Complication Rates Following Total Ankle Arthroplasty in Inpatient versus Outpatient Populations: A Systematic Review & Meta-Analysis.

Total ankle arthroplasty (TAA) is used as an alternative to ankle arthrodesis for adults with severe ankle arthritis. Numerous orthopedic centers have entered the healthcare market offering fast-tracked joint replacement protocols, meanwhile, TAA has been excluded from these joint centers, and is primarily performed in the inpatient setting. The purpose of this study is to examine short-term complications in the inpatient and outpatient settings following TAA using a systematic review and quantitative analysis. We considered all studies examining short-term complications following TAA performed in the inpatient versus outpatient setting occuring within 1 year of the index operation. We summarized data using a pooled relative risk and random effects model. A pooled sensitivity analysis was performed for studies with data on complication rates for inpatient or outpatient populations, which did not have a control group. The quality of included studies was assessed using the Cochrane risk of bias tool. Nine studies were included in the quantitative analysis, with 4 studies in the final meta-analysis. Subjects undergoing inpatient surgery experienced a 5-times higher risk of short-term complications compared to the outpatient group (risk ratio 5.27, 95% confidence interval 3.31, 8.42). Results did not change after sensitivity analysis (inpatient weighted mean complication rate: 9.62% vs outpatient weighted mean 5.02%, p value <.001). The overall level of evidence of included studies was level III, with a moderate to high risk of bias. Outpatient TAAs do not appear to pose excess complication risks compared to inpatient procedures, and may therefore be a reasonable addition to experienced centers that have established a fast-track outpatient total joint protocol.

Mechanisms, screening modalities and treatment options for individuals with non-alcoholic fatty liver disease and type 2 diabetes.

Non-alcoholic fatty liver disease (NAFLD) exists as a spectrum of disease ranging from excessive accumulation of fat within the liver (simple steatosis), inflammation (non-alcoholic steatohepatitis) through to fibrosis, cirrhosis and end-stage liver disease. There is also an increased risk of hepatocellular carcinoma. The principal risk factor for NAFLD is overweight or obesity, along with type 2 diabetes, and NAFLD itself is also a risk factor for incident type 2 diabetes. Overweight/obesity is synergistic with alcohol consumption in causing progressive and insidious liver damage. Recent consensus advocates a change in nomenclature from NAFLD to 'metabolic associated fatty liver disease' (MAFLD), reflective of the associated metabolic abnormalities (insulin resistance/type 2 diabetes and metabolic syndrome components). Additional extra-hepatic manifestations of NAFLD include cardiovascular disease, chronic kidney disease and certain cancers. Unlike other micro- and macrovascular complications of type 2 diabetes, systematic screening or surveillance protocols have not been widely adopted in routine diabetes care to assess for presence/severity of NAFLD. Various screening tools are available (non-invasive tests and biochemical indices) combined with imaging techniques (e.g. transient elastography) to detect steatosis and more importantly advanced fibrosis/cirrhosis to facilitate appropriate surveillance. Liver biopsy may be sometimes necessary. Treatment options for type 2 diabetes, including lifestyle interventions (dietary change and physical activity), glucose-lowering therapies and metabolic surgery, can modulate hepatic steatosis and to a lesser extent fibrosis. Awareness of the impact of liver disease on the choice of glucose-lowering medications in individuals with type 2 diabetes is also critical.

Amnion: The Ideal Scaffold for Treating Full-Thickness Wounds of the Lower Extremity.

Amnion and amniotic tissue has been studied for more than 100 years in the treatment of acute and chronic wounds. Recent studies have focused on the use of amnion tissue in the management of full-thickness diabetic wounds, particularly of the lower extremities. With new harvesting, processing, and distribution technologies, amnion is increasingly available in treating these wounds. Current data and research show increased healing potential and decreased healing times, pain, drainage, and infection in wounds treated with amnion products. There are a variety of amnion products with varying differences and purposes, requiring additional research and comparison trials.

Radiographic Union Scoring Scale for Determining Consolidation Rates in the Calcaneus.

The reliable evaluation of osseous consolidation after hindfoot osteotomy can be difficult. Concomitant hindfoot osteotomies often dictate the advancement of weightbearing, and radiographs are the mainstay imaging tool owing to cost, efficiency, and radiation exposure. Understanding the radiographic parameters that can be used to reliably determine osseous healing is paramount. However, currently, no reliable or validated method is available to determine osseous healing of hindfoot osteotomies in irregular bones of the foot. The purpose of the present study was to develop a radiographic healing scoring system that would enhance the diagnostic healing assessment after elective calcaneal osteotomy. We adapted existing orthopedic scales validated for healing in the leg for application in the irregular bones of the foot. A total of 168 cases were evaluated by 6 blinded assessors to test the interrater reliability of subjective healing assessment compared with the proposed scoring system. The radiographs were classified by postoperative period: ≤4 weeks, 5 to 12 weeks, and >12 weeks. The proposed scale had high interrater reliability but was burdensome. Using a priori item reduction protocols, a limited 6-item scale further improved internal consistency and reduced the burden. The result was excellent interrater reliability (α = 0.98, standard deviation 0.02, 95% confidence interval 0.91 to 0.96) among all assessors when using the scoring scale compared with unacceptable reliability (α = 0.438) for subjective osteotomy healing. The reliability of our system appeared superior to that of subjective assessment of osseous healing alone, even in the absence of clinical correlates after osteotomy of the calcaneus.

Development of a Radiographic Union Score for Determining Osteotomy Union Rates in Long Bones of the Foot.

Determining the status of bone healing after osteotomy can be challenging and has implications ranging from clinical decision-making to standardization of research outcomes without the use of computed tomography. To date, no method has been validated for determining osseous healing of an osteotomy site of the long bones of the foot. The purpose of the present study was to develop a radiographic union scoring system that would enhance the diagnostic healing assessment. We adapted existing orthopedic scales that had been validated for healing in the leg for application in the long bones of the foot. One hundred cases were evaluated by 6 blinded assessors to test the inter- and intrarater reliability of the subjective healing assessment compared with the proposed scoring system. The radiographs were classified by postoperative period: ≤4, 5 to 12, and >12 weeks. The proposed scale had a high interrater reliability but was burdensome. Using a priori item reduction protocols, the scale was limited to the 5 items with the best internal consistency, which significantly reduced the burden. The result was excellent interrater reliability (α = 0.87) among all assessors compared with acceptable reliability (α = 0.66) for the subjective osteotomy healing assessment. The intrarater reliability during the subsequent retest phase demonstrated similar relationships, with low agreement (r = 0.38) for subjective healing. Each of the items included in the final scoring scale had moderate to good agreement across all assessors (r = 0.51 to 0.63). The reliability of this system appeared superior to the subjective assessment of osseous healing alone, even in the absence of clinical correlates after an osteotomy in the foot.

Healing in the new millennium: bone stimulators: an overview of where we've been and where we may be heading.

Electromagnetic fields and their uses in bone healing have been fairly well studied, with most results showing improvement in healing of both bone and cartilage. Most supportive data are found in relation to the spine, femur, and tibia, but there is increasing evidence for its use in the foot and ankle for treatment of nonunions and as an adjunctive device in arthrodeses, particularly in high-risk populations. There are varying data and a significant variety of quality in the current research and publications concerning the use of electrical bone stimulation in the treatment of the foot and ankle. Thus, there is a definite need for further investigation and high-quality study designs to determine the most effective treatment modalities and pathologies best used with bone stimulation. Bone stimulation should be viewed as an adjunctive procedure in which the surgeon optimizes the high-risk patient both medically or surgically whenever possible. But when used appropriately, bone stimulation has the potential to influence outcomes and aid in bone healing when complications arise and in high-risk populations.

Fractures of the talus: a comprehensive review.

The talus, a highly specialized bone with a unique anatomic design, is crucial for normal ambulation. Although uncommon, talar fractures can be potentially devastating to the patient. Although all talar fractures require appropriate diagnosis and treatment, some require surgical skill for appropriate correction. This article reviews the literature on talar fractures and their treatments.

Overview of concepts and treatments in open fractures.

Open fractures are one of the few lower extremity surgical emergencies. These injuries require immediate treatment. If untreated, severe cases of open fracture can be limb threatening. This article is a review of the literature of open fractures and the current treatment guidelines.

A comparison of inpatient and outpatient ASCT.

Outpatient high-dose chemotherapy and autologous stem cell transplantation (ASCT) has been shown to be feasible in terms of physical morbidity and mortality outcomes, but few data exist on the psychosocial impact of delivering such aggressive therapy in this manner. The purpose of this observational study was to compare effects of inpatient (n = 20) and outpatient (n = 21) modes of care on physical status, psychological well-being, quality of life, personal finances and caregiver burden. Most patients were treated according to their preference for inpatient or outpatient care. Those choosing outpatient care were screened for eligibility according to established criteria for ambulatory management. Measures were taken at baseline, then at days 4-6, 12-16 and 30 post ASCT. Results showed that overall, the psychological, physical, social and financial outcomes of the outpatient ASCT group were comparable, to or better than inpatients. Factors that seem to be important for successful outpatient management are previous experience with cancer treatment, a satisfying quality of life, physical well-being, patient's preference for a particular mode of care and physical proximity to the treatment centre. The study results suggest that outpatient ASCT is an efficient, effective and acceptable form of care for motivated patients and caregivers who have the physical and psychological capability and desire to receive cancer treatment in this manner.

A study on dust emission, particle size distribution and formaldehyde concentration during machining of medium density fibreboard.

A study to characterise the quantity, particle size distribution and morphology of dust created during the machining of MDF was carried out. Four different types of MDF boards were included in this study, including a 'zero-formaldehyde' board that contains isocyanate-based resin, rather than urea-formaldehyde resin. In addition, natural softwood (pine) and natural hardwood (oak) were included in the study, for comparison with MDF. The results show that in general, the dust generated by machining MDF is comparable in terms of particle size distribution and morphology with the dust generated by similarly machining hardwood or softwood. The quantity of dust generated during sanding is higher for sanding MDF compared with sanding either hardwood or softwood. However, for sawing there is no significant difference between MDF and natural woods, in terms of the quantity of dust generated. Free formaldehyde in the air was less than 0.17mg m(-3) during machining of the Class B (higher formaldehyde potential) MDF board. There was no measurable isocyanate in the dust generated from the boards.

Analysis of sperm chromosome complements before, during, and after chemotherapy.

Sperm chromosomal abnormalities were assessed in testicular cancer patients before, during, and after BEP (bleomycin, etoposide, cisplatin) chemotherapy (CT). Multicolor fluorescence in situ hybridization (FISH) analysis was employed to detect aneuploidy for chromosomes 1, 12, X, and Y, and diploidy. Sperm samples were cryopreserved and coded before analysis to facilitate "blind" analysis. Complete results at all time points was available for only one patient. A total of 60,400 sperm were analyzed: 20,004 before CT, 20,005 during CT, and 20,391 after CT. There was a significant increase in the frequency of 24,XY sperm during (0.33%) and post-CT (0.34%) compared to pre-CT (0.14%). This study suggests that there may be a significantly increased risk of chromosomal abnormalities in sperm of CT patients during and immediately post-CT, similar to that shown in animal models.

Effectiveness of megestrol acetate in patients with advanced cancer: a randomized, double-blind, crossover study.

PURPOSE: To evaluate the effect of megestrol acetate at a lower dose than previously investigated on the symptoms of cachexia in patients with advanced cancer. METHODS: A total of 84 patients with advanced, solid tumours not responsive to hormone therapy were enrolled in this double-blind, crossover study. During phase 1, patients were randomly assigned to receive megestrol acetate (160 mg 3 times daily) for 10 days or placebo. During phase 2, after a 2-day washout period, patients received the alternate treatment for 10 days. Patients underwent daily assessments of activity, nausea, appetite and well-being by means of a visual analogue scale (VAS). In addition, nutritional status (weight, tricep skinfold measure, arm muscle circumference), energy intake, fatigue (Piper Fatigue Scale) and quality of life (Functional Living Index-Cancer [FLIC]) were assessed. RESULTS: Among the 53 evaluable patients megestrol acetate resulted in a significant improvement in appetite (p = 0.005), activity (p = 0.007) and well-being (p = 0.03). There was no significant change in the intensity of nausea, nutritional parameters, energy intake or FLIC scores. There was a significant improvement in 2 of the 3 factors measured by the Piper Fatigue Scale and in the overall fatigue score. Upon completion of the study, while still blind to the treatment condition, 30 patients indicated that they felt better overall after megestrol, 15 said they felt better after placebo, and 10 indicated no preference (p = 0.001). CONCLUSION: Treatment with megestrol acetate results in rapid and significant improvement of symptoms in terminally ill patients at lower doses than previously reported. The effects are not secondary to nutritional changes. The FLIC quality-of-life questionnaire was unable to detect these changes.

Compliance of clinical stage I nonseminomatous germ cell tumor patients with surveillance.

PURPOSE: We evaluate compliance and its effect on the outcome of patients with clinical stage I nonseminomatous germ cell tumor who underwent post-orchiectomy surveillance at the Tom Baker Cancer Centre. MATERIALS AND METHODS: From 1980 to 1994, 76 evaluable patients underwent surveillance at the Tom Baker Cancer Centre. The surveillance protocol consisted of clinical evaluation, chest x-ray and serum tumor marker measurements monthly in year 1, every 2 months in year 2, every 6 months in years 3 to 5 and yearly in years 6 to 10. Abdomen and pelvic computerized tomography (CT) were scheduled every 2 months in year 1 and every 4 months in year 2. Noncompliance was defined as missing 2 or more consecutive clinic visits, tumor marker measurements or chest x-rays or 1 or more CT scans. RESULTS: Compliance with clinical evaluations was 61.5% in year 1 and 35.5% in year 2, whereas compliance with CT was only 25% and 11.8% in years 1 and 2, respectively. By univariate analysis diagnosis before 1990 predicted noncompliance, while age, marital status and distance from the center did not. Recurrent disease was detected in 28 patients (37%) at a median of 5.5 months after orchiectomy (range 1 to 49.5). Among the 47 compliant patients 23 had relapse and none died. Among the 29 noncompliant patients 5 had relapse and 2 died with central nervous system disease. CONCLUSIONS: Overall compliance with this surveillance program was poor but this study was too small to demonstrate whether poor compliance adversely affects overall survival.

Chromosomal abnormalities in sperm from testicular cancer patients before and after chemotherapy.

Sperm chromosome abnormalities were assessed in testicular cancer patients before and after treatment with BEP (bleomycin, etoposide, cisplatin). The frequencies of disomy for chromosomes 1, 12, X, Y and XY were assessed along with diploid frequencies and sex ratios by multicolour fluorescence in situ hybridization (FISH). For each cancer patient, a minimum of 10,000 sperm was assessed for each chromosome probe before and after chemotherapy (CT). Data was analysed "blindly" by coding the slides. A total of 161097 sperm were analyzed, 80,445 before and 80,642 after treatment. The mean disomy frequencies were 0.11% pre-CT vs 0.06% post-CT for chromosome 1, 0.18% vs 0.15% for chromosome 12, 0.10% vs 0.9% for the X chromosome, 0.13% vs 0.10% for the Y chromosome and 0.25% vs 0.20% for XY sperm. There was no significant difference in the frequency of disomy pre-CT vs post-CT for any chromosome except that chromosome 1 demonstrated a significant decrease after CT. The "sex ratios" and frequency of diploid sperm were also not significantly different in pre and post-CT samples with 50.2% X-bearing sperm pre-CT and 50.5% X post-CT and 0.14% diploid sperm pre-CT vs 0.15% diploid sperm post-CT. There was no significant donor heterogeneity among the cancer patients. None of the values in the cancer patients differed significantly from 10 normal control donors. Thus our study suggests that BEP chemotherapy does not increase the risk of numerical chromosomal abnormalities in human sperm.

Analysis of human sperm karyotypes in testicular cancer patients before and after chemotherapy.

Sperm karyotype analysis was performed on testicular cancer patients before and after treatment with BEP (bleomycin, etoposide, and cisplatin). A total of 788 sperm chromosome complements was studied, 236 before chemotherapy (CT) and 552 post-CT. There was no significant difference in the total frequency of sperm chromosomal abnormalities pre-CT (10.2%) compared to post-CT (10.7%). Similarly, there were no significant differences in the frequencies of numerical abnormalities (2.5% pre-CT vs. 2.4% post-CT) or structural abnormalities (6.4% pre-CT vs. 7.4% post-CT). The percentage of X-bearing sperm was also not significantly different before (46.3%) and after CT (50.1%). The results in cancer patients were not significantly different from those in control donors. This study corroborates results from our previous analysis of these same men using multicolor fluorescence in situ hybridization for assessment of aneuploidy for chromosomes 1, 12, X, Y, and XY. Together, these two studies suggest that the sperm of men receiving BEP chemotherapy are not at increased risk of chromosomal abnormalities two or more years after treatment.