Efficacy of suprascapular nerve block compared with subacromial injection: a randomized controlled trial in patients with rotator cuff tears.

HYPOTHESIS: We aimed to compare the clinical efficacy of a suprascapular nerve block (SSNB) versus subacromial injection (SA) for outpatient treatment of patients with symptomatic rotator cuff tears in a double-blinded, randomized controlled trial using sealed-envelope randomization. METHODS: A total of 42 participants with symptomatic partial- and full-thickness rotator cuff tears quantified by ultrasound or magnetic resonance imaging received either an ultrasound-guided SSNB or SA. The primary outcome measure was shoulder function measured by the modified Constant-Murley (CM) score and the secondary outcome was the pain score measured by a visual analog scale at 2, 6, and 12 weeks after injection. RESULTS: We analyzed 43 shoulders (27 in male patients, 62.2%). The mean age was 65.2 years (standard deviation [SD], 11.9 years). Of the shoulders, 22 (51.2%) underwent SAs and 21 (48.8%) underwent SSNBs. Continuous variables were analyzed by an independent t test (2 tailed), and nominal data were analyzed by the Fisher exact test (1 sided). At 6 weeks, the mean change from the baseline CM score was significantly higher in the SSNB group than in the SA group (14.3 [SD, 18.1] vs 3.0 [SD, 12.8]; P = .048). At 12 weeks' follow-up, the SSNB group had a significantly higher CM score than the SA group (57.6 [SD, 10] vs 44.6 [SD, 16]; P = .023) and greater improvement from the baseline CM score (23.4 [SD, 17.5] vs 7.8 [SD, 16.5]; P = .014). At 12 weeks, the visual analog scale score was significantly better in the SSNB group than in the SA cohort (9.9 [SD, 3.3] vs 7.3 [SD, 4.3]; P = .03). CONCLUSIONS: This study demonstrates that an SSNB resulted in better pain and functional results than an SA at 6 and 12 weeks for symptomatic rotator cuff tears.

Thrombus volume is associated with cardiovascular events and aneurysm growth in patients who have abdominal aortic aneurysms.

BACKGROUND: Patients with abdominal aortic aneurysms (AAA) are predisposed to cardiovascular events and often experience continual expansion of their aneurysm. Cardiovascular events and expansion rates are positively correlated with aneurysm size. AAA is usually associated with intraluminal thrombus, which has previously been implicated in AAA pathogenesis. This study prospectively assessed the association of infrarenal abdominal aortic thrombus volume with cardiovascular events and AAA growth. METHODS: Ninety-eight patients with AAAs underwent computed tomography angiography (CTA). The volume of infrarenal aorta thrombus was measured by a previously validated technique. Patients were monitored prospectively for a median of 3 years (interquartile range [IQR], 2.0-3.6 years), and cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, coronary revascularization, amputation, and cardiovascular death) were recorded. Of the original patients, 39 underwent repeat CTA a median of 1.5 years (IQR, 1.1-3.3 years) after entry to the study. Kaplan-Meier and Cox proportional analysis were used to examine the association of aortic thrombus with cardiovascular events and average weighted AAA growth. RESULTS: There were 28 cardiovascular events during follow-up. The incidence of cardiovascular events was 23.4% and 49.2% for patients with small (smaller than the median) and large (median or larger) volumes of aortic thrombus, respectively, at 4 years (P = .040). AAA thrombus volume of median or larger was associated with increased cardiovascular events (relative risk [RR] 2.8, 95% confidence interval [CI], 1.01-5.24) independent of other risk factors, including initial AAA diameter, but was only of borderline significance when patients were censored at the time of AAA repair (RR, 2.35; 95% CI, 0.98-5.63). In the subset of patients with CTA follow-up, the median annual increase in AAA volume was 5.1 cm³ (IQR, 0.8-10.3 cm³). Annual AAA volume increase was positively correlated with initial AAA diameter (r = 0.44, P = .006) and thrombus volume (r = 0.50, P = .001). Median or larger aortic thrombus volume was associated with rapid AAA volume increase (≥ 5 cm/y), independent of initial aortic diameter (RR, 15.0; 95% CI, 1.9-115.7; P = .009). CONCLUSION: In this small cohort, infrarenal aortic thrombus volume was associated with the incidence of cardiovascular events and AAA progression. These results need to be confirmed and mechanisms underlying the associations clarified in large further studies.

Paediatric scoliosis: Update on assessment and treatment.

BACKGROUND: Paediatric scoliosis is a common condition seen by general practitioners. Structural scoliosis is characterised by axial rotation at the apex. Several new operative treatments have recently been developed. OBJECTIVE: The aim of this article is to give an overview of scoliosis diagnosis, assessment and management. DISCUSSION: Scoliosis assessment should identify structural curves, underlying causes, severity and growth potential. Atypical curves and red flags must be excluded. Observation is appropriate for curves <20° in patients with high growth potential (Risser 0-2) and curves <40° in patients with minimal growth potential (Risser 3-5). Bracing is appropriate for patients with a curve of 20-40° with high growth potential. Indications for surgery vary depending on patient and curve factors; however, surgery can be indicated when the curve is >40°. Surgery can be divided into three groups: growth modulation, instrumentation without fusion and instrumentation with fusion. Early diagnosis and referral to a paediatric spine service can improve outcomes.

Non-radicular low back pain: Assessment and evidence-based treatment.

BACKGROUND: Low back pain (LBP) is a common presentation in general practice. Clinical workup must exclude sinister underlying diseases. Treatment of central LBP is difficult given the numerous treatment options available. OBJECTIVE: The aim of this article is to help clinicians assess patients with LBP and formulate evidence-based treatment decisions. DISCUSSION: Patient presentations can be stratified according to the presence of red flags and pain type (ie non-spinal, radicular, non­organic and central). The vast majority of patients with acute central back pain experience improvement of their symptoms. Treatment options include education, lifestyle modification, heat, massage, graduated return to early activity, nonsteroidal anti-inflammatory medications and muscle relaxants when appropriate. Chronic LBP treatment can also include paracetamol and physiotherapy. Second-line treatment can include psychological therapy, multidisciplinary rehabilitation, targeted injections and antidepressants. Tapentadol is a safe and effective medication for treating severe LBP. Pain specialist referral should be considered if patients require controlled analgesia. Surgical treatment has narrow indications in central non-radicular back pain and is considered as a last-line treatment in selected patients.

What happens to our amputees? The Darling Downs experience.

BACKGROUND: Major lower limb amputation is occasionally required in the management of end-stage pathology where other treatment options have failed. The primary aim of this study was to determine the 30-day and 1-year mortality rates of patients undergoing nontraumatic major lower limb amputation. Secondary aims were to investigate risk factors for poor outcomes, incidence of previous minor amputation, and the rate of subsequent major amputation. METHODS: All nontraumatic, major lower limb amputations performed at Toowoomba Hospital during an 18-year period were retrospectively reviewed. Mortality data were obtained from the Queensland Registry of Births, Deaths and Marriages. Kaplan-Meier analysis was performed to determine survival after amputation. RESULTS: A total of 147 patients were included in the study, with 104 undergoing below knee and 43 undergoing above knee amputations. Ten patients identified as having an Aboriginal and Torres Strait Islander background. For all patients, the 30-day mortality was 4.1% and 1-year mortality was 21.1%. For Indigenous patients, 30-day mortality was 10%. Previous minor amputation had occurred in 40 patients. Twenty-nine patients underwent further minor surgery after their initial major amputation, with thirteen requiring subsequent major amputation. Factors that increased mortality risk were the presence of peripheral vascular disease, an American Society of Anesthesiologists score of four and age greater than 65 years. CONCLUSION: The morbidity and mortality following major lower limb amputation is significant. The findings of this study highlight the importance of preventative measures to minimize the incidence of lower limb amputations in the future.

Three Cycles of Radiofrequency Ablation Are More Efficacious Than Two in the Management of Morton's Neuroma.

BACKGROUND: Morton's neuroma is a common cause of forefoot pain. Outcomes of conservative therapy are mixed and many patients undergo operative intervention. Radiofrequency ablation has recently gained favor as a treatment option, although the optimal regime is unknown. This study investigates the effectiveness of 2 versus 3 cycles of radiofrequency ablation for the treatment of Morton's neuroma. METHODS: We surveyed a cohort of patients with Morton's neuroma who had progressed to radiofrequency ablation after failed conservative treatment. Patients received either 2 or 3 cycles of radiofrequency ablation by a single surgeon. We assessed patients based on their change in numerical pain rating scale, symptom improvement, complications, and progression to surgical excision through a series of telephone interviews. Outcomes between the 2 treatment arms were compared by parametric tests. RESULTS: Twenty-eight patients were included in the study. Eighteen patients with 21 neuromas received 2 cycles and 10 patients with 11 neuromas received 3 cycles. Mean time of follow-up was 12.9 months. Overall, 88% of patients were either very or moderately satisfied with their outcome. In patients who received 2 cycles mean numerical pain scores decreased from 7.9 ± 1.1 to 3.4 ± 2.4 postprocedure. Three patients progressed to operative excision. In patients who received 3 cycles, numerical pain scores decreased from 8.0 ± 1.0 to 1.5 ± 2.0 postprocedure. One patient progressed to operative excision. Patients who received 3 cycles had reduced medium-term pain postoperatively compared with 2 cycles (3.4 ± 2.4 vs 1.5 ± 2.0, P = .011). CONCLUSION: Radiofrequency ablation provides a high rate of patient satisfaction in the treatment of Morton's neuroma with few side effects. It appears that 3 cycles may be superior to 2 cycles but a randomized controlled trial will be required to confirm these results. LEVELS OF EVIDENCE: Intervention, Level III: Comparative study without concurrent controls.

Humidity a potential risk factor for prosthetic joint infection in a tropical Australian hospital.

BACKGROUND: Many pathogens of importance, including the staphylococcal species of concern in orthopaedics, demonstrate seasonal variations influenced by environmental factors. The aim of this study was to investigate the role of humidity as a risk factor for deep prosthetic joint infection following total knee arthroplasty (TKA) in a tropical Australian hospital. METHODS: A retrospective cohort study of all TKAs performed over a 13-year period was conducted at the author's institution. Univariate analysis was used to individually assess for a range of risk factors including humidity >60% and apparent temperature >30°C (86°F). Odds ratios (ORs) were reported. P-values <0.25 were considered as potentially important risk factors and P-values <0.05 were considered statistically significant. RESULTS: A total of 1058 primary TKAs were performed with a deep prosthetic joint infection incidence of 2.7%. Four potential risk factors were identified with P-values <0.25: (i) humidity >60% (OR 1.4; 95% confidence interval (CI) 0.68-3.04; P = 0.221); (ii) apparent temperature >30°C (86°F) (OR 2.4; 95% CI 0.56-10.1; P = 0.174); (iii) male gender (OR 2.2; 95% CI 1.02-4.81; P = 0.057); and (iv) American Society of Anesthesiologists score of III or IV (OR 2.1; 95% CI 1.00-4.49; P = 0.064). CONCLUSION: Humidity and apparent temperature may be potentially important risk factors for infection following TKA.

Scedosporium prolificans Septic Arthritis and Osteomyelitis of the Hip Joints in an Immunocompetent Patient: A Case Report and Literature Review.

Scedosporium prolificans, also known as Scedosporium inflatum, is a fungus widespread in soil, sewage, and manure. This species is highly virulent and is an emerging opportunistic pathogen found in penetrating injuries in immunocompromised patients. Here we report on an immunocompetent patient with bilateral hip S. prolificans-associated osteomyelitis and septic arthritis caused by intentional penetrating trauma. The condition was refractory to initial antimicrobial suppression and surgical irrigation and debridement. Successful outcome was achieved after incorporating a bilateral two-stage total-hip-arthroplasty with Voriconazole-loaded cement and spacer.

Comparison of volume and diameter measurement in assessing small abdominal aortic aneurysm expansion examined using computed tomographic angiography.

AIM: First we aimed to assess the reproducibility of a computer tomography angiography (CTA) based technique for measuring infra-renal aortic volume and diameter. Second we sought to investigate whether changes in aortic volume and diameter were similar during follow-up. MATERIALS AND METHODS: A prospective series of 57 patients, with aortic diameter initially measuring between 25 and 55 mm, were assessed with 2 CTAs a median of 14 months apart. Aortic volume and maximum diameter (both axial and orthogonal) were measured by a semi-automated workstation protocol based on previously defined techniques. Intra- and inter-observer reproducibility were assessed by repeat assessment of the initial CTA images of the first 33 patients included in the study, in order to estimate the 95% limits of agreements. Changes in aortic dimensions between the first and follow-up CTA, were defined for volume and diameter separately as changes greater than their respective 95% limits of agreement. RESULTS: Reproducibility of aortic volume and diameter was excellent with an average coefficient of variation <4%. The median (inter-quartile range) increases in total volume, orthogonal and axial diameters were 4.9 cm(3) (0.01-14.18), 1.2mm (0.40-3.50) and 1.4mm (-0.15 to 3.55) respectively. Forty-two percent of patients who had increased aortic volume above the 95% limit of agreement did not display corresponding axial or orthogonal diameter changes. CONCLUSIONS: Infra-renal total aortic volume, axial and orthogonal diameter can all be measured reproducibly from CTA. Aortic volume changes are not always reflected by similar changes in diameter and therefore provide complementary information when assessing AAA expansion over time.

Relation of infra-renal abdominal aortic calcific deposits and cardiovascular events in patients with peripheral artery disease.

In patients with peripheral artery disease, aortic calcific deposits are a common finding. The aim of this study was to assess the association of infrarenal abdominal aortic calcific deposits with prospective cardiovascular events in patients with peripheral artery disease. A consecutive series of 213 patients who presented for investigation of abdominal aortic aneurysm or intermittent claudication were assessed using computed tomographic angiography. Infrarenal abdominal aortic calcific deposits were estimated using a previously defined highly reproducible semiautomated program. Patients were followed prospectively for a median of 2.8 years (interquartile range 1.7 to 3.6), and cardiovascular events were recorded. Kaplan-Meier and Cox proportional-hazards analysis were used to examine the association of calcific deposits with cardiovascular events. A total of 45 cardiovascular events occurred during follow-up, including nonfatal myocardial infarction (n = 23), coronary revascularization (n = 6), stroke (n = 3), below-knee amputation (n = 2), and cardiovascular death (n = 11). The incidence of cardiovascular events was 21.7%, 33.0%, and 36.9% for patients with mild (<400 mm(3)), intermediate (400 to 1,700 mm(3)), and severe (>1,700 mm(3)) abdominal aortic calcific deposits, respectively (p = 0.039). Calcific deposit volume >400 mm(3) (relative risk 2.8, 95% confidence interval 1.2 to 6.6) and coronary artery disease (relative risk 2.8, 95% confidence interval 1.4 to 5.6) were independently associated with increased cardiovascular events during follow-up. In conclusion, abdominal aortic calcific deposits are prognostic for cardiovascular events in patients with peripheral artery disease.

Osteocalcin positive mononuclear cells are associated with the severity of aortic calcification.

OBJECTIVE: To assess the association of circulating bone marrow-derived osteo-progenitors with vascular calcification in mouse models and patients with peripheral artery disease. METHODS: We estimated the percentage of circulating mononuclear cells expressing osteocalcin in 2 mouse models of aortic calcification developed in osteoprotegerin-deficient mice (OPG(-/-)) using flow cytometry. Aortic calcification was assessed in mice principally by a bioassay of harvested aortas. In patients with peripheral artery disease osteocalcin-positive cells (estimated by flow cytometry) were related to aortic calcification volume assessed from computed tomography. RESULTS: The amount of extractable aortic calcium was increased in both mouse models used in comparison to controls. The percentage of circulating mononuclear cells expressing osteocalcin was correlated to the amount of extractable aortic calcium in male (r=0.525, p=0.02) and female OPG(-/-) (r=0.564, p=0.02) mice and also in animals in which calcification was accelerated using calcitriol (r=0.64, p=0.01). Patients with more severe aortic calcification had a greater percentage of circulating OCN(+) MNCs (median 4.07%, IQR 3.76-4.39, n=12) than those with less severe aortic calcification (median 3.10%, IQR 2.32-3.60, n=11, p=0.05). CONCLUSIONS: This study demonstrates that aortic calcification can be robustly quantified in 2 mouse models. In these models and patients with peripheral artery disease circulating osteocalcin positive mononuclear cells are associated with the severity of aortic calcification.

Diagnosis and monitoring of abdominal aortic aneurysm: current status and future prospects.

Abdominal aortic aneurysm (AAA) remains an important cause of morbidity and mortality in elderly men, and prevalence is predicted to increase in parallel with a global aging population. AAA is commonly asymptomatic, and in the absence of routine screening, diagnosis is usually incidental when imaging to assess unrelated medical complaints. In the absence of approved diagnostic and prognostic markers, AAAs are monitored conservatively via medical imaging until aortic diameter approaches 50-55 mm and surgical repair is performed. There is currently significant interest in identifying molecular markers of diagnostic and prognostic value for AAA. Here we outline the current guidelines for AAA management and discuss modern scientific techniques currently employed to identify improved diagnostic and prognostic markers.

Role of homocysteine in aortic calcification and osteogenic cell differentiation.

BACKGROUND: The role of homocysteine in atherosclerosis is unclear. We examined the relationship between plasma homocysteine and infrarenal aortic calcification, the presence of homocysteine in human atheroma and the influence of homocysteine on osteogenic differentiation in vitro. METHODS AND RESULTS: In 194 patients with symptomatic peripheral artery disease or abdominal aortic aneurysm, fasting plasma total homocysteine was independently associated with the severity of infrarenal aortic calcification measured by Computer Tomography Angiography (odds ratio 1.91, 95% confidence interval 1.17-3.21 for calcification >or=median). Homocysteine was identified in all 60 atheroma biopsies from 16 patients undergoing endarterectomy, and concentrations were significantly greater in the calcified biopsies (p=0.003). In vitro studies demonstrated that 100 micromol/L homocysteine doubled the calcium deposition by mesenchymal stem cells during 16 days incubation in osteogenic medium (74+/-4 compared to 42+/-5 microg calcium/well without homocysteine, p<0.001). Homocysteine also stimulated monocytic THP1 cells to promote aortic smooth muscle cell calcification as evidenced by significant higher calcium deposition and alkaline phosphatase activity compared to incubation without homocysteine (p

Measurement and determinants of infrarenal aortic thrombus volume.

Intra-luminal thrombus has been suggested to play a role in the progression of abdominal aortic aneurysm (AAA). The aims of this study were twofold. Firstly, to assess the reproducibility of a computer tomography (CT)-based technique for measurement of aortic thrombus volume. Secondly, to examine the determinants of infrarenal aortic thrombus volume in a cohort of patients with aortic dilatation. A consecutive series of 75 patients assessed by CT angiography with maximum aortic diameter > or = 25 mm were recruited. Intra-luminal thrombus volume was measured by a semi-automated workstation protocol based on a previously defined technique to quantitate aortic calcification. Intra- and inter-observer reproducibility were assessed using correlation coefficients, coefficient of variation and Bland-Altman plots. Infrarenal aortic thrombus volume percentage was related to clinical, anatomical and blood characteristics of the patients using univariate and multivariate tests. Infrarenal aortic thrombus volume was related to the severity of aortic dilatation assessed by total aortic volume (r = 0.87, P < 0.0001) or maximum aortic diameter (r = 0.74, P < 0.0001). We therefore examined the clinical determinates of aortic thrombus expressed as a percentage of total aortic volume. Aortic thrombus percentage was negatively correlated with serum high density lipoprotein (HDL, r = -0.31). By ordinal multiple logistic regression analysis serum HDL below median (< or = 1.2 mM: ) was associated with aortic thrombus percentage in the upper quartile adjusting for other risk factors (odds ratio 5.3, 95% CI 1.1-25.0). Infrarenal aortic thrombus volume can be measured reproducibly on CT. Serum HDL, which can be therapeutically raised, may play a role in discouraging aortic thrombus accumulation with implications in terms of delaying progression of AAA.

Relationship between CT anthropometric measurements, adipokines and abdominal aortic calcification.

BACKGROUND: Visceral obesity and aortic calcification are both associated with cardiovascular events. The purpose of this study was to examine if visceral obesity was associated with the severity of abdominal aortic calcification. METHODS: One hundred and forty eight patients with peripheral artery disease were assessed by CT angiography. The severity of infrarenal abdominal aortic calcification was measured using a validated technique. The size of the visceral and subcutaneous compartments was estimated from anthropometric measurements made from the same CT. Calcification and anthropometric measurements were compared with Spearman's correlation and multiple logistic regression (adjusting for age, gender, hypertension, diabetes, smoking and cholesterol). RESULTS: The relative size of the visceral compartment estimated from CT diameter ratios was correlated with abdominal aortic calcification severity, r=0.27, p=0.001 and independently associated with calcification allowing for other cardiovascular risk factors (OR 6.63, 95% CI 1.90-23.14). The relative size of the visceral compartment was associated with serum osteoprotegerin levels, suggesting a possible mechanism underlying the detrimental influence of visceral adiposity. CONCLUSION: The association of visceral adiposity and arterial calcification suggests one mechanism, which may contribute to the detrimental effects of central obesity.

The outcome of endovascular repair of small abdominal aortic aneurysms.

OBJECTIVE: To assess the outcome of endovascular repair (EVAR) of small abdominal aortic aneurysms (AAA,