Comparison of Efficacy and Safety of Transdermal Buprenorphine Patch and Conventional Analgesics in Intra-capsular Femur Neck Fracture Post Hemiarthroplasty.

Background: One of the most common fractures in the elderly population is a fracture of the neck of femur. Effective post-operative analgesia is a major challenge. Age-related co-morbidities restrict the choice of analgesics. The purpose of this study was to compare the efficacy and safety of transdermal buprenorphine [TDB] patch and conventional analgesics following hemiarthroplasty for intra-capsular fracture neck of femur. Materials and methods: This was a prospective, randomized control study done in 60 patients undergoing hemiarthroplasty for intra-capsular fracture neck of femur over a period of 2 years. Patients were randomized in 2 groups. Group A received a combination of IV paracetamol and tramadol for first 48 h followed by oral formulation. In Group B patients, a transdermal buprenorphine patch of 5 mcg/h was applied at the beginning of surgery and was continued 2 weeks post-operative.Pain score by VAS was observed both at rest and on movement and followed up till 14 days post-operative. Primary target was to maintain a VAS ≤ 4. Rescue analgesic was given if the VAS was ≥ 6. Secondary targets were number of rescue analgesics required, adverse reactions and complications if any. Results: Group B had significantly lower pain scores at rest and during movement [p value 0.0012 to ≤ 0.0001], so was rescue analgesia requirement. No significant side effects were seen in TDB group. Conclusion: TDB patch is safe and provides superior analgesia and compliance as compared to conventional analgesics in the post-operative period in proximal femur fracture surgeries.

Discrepant histological diagnoses: A cause of early low FJS-12 score and if untreated, unhappy Total Knee Arthroplasty patient.

PURPOSE: Total Knee Arthroplasty (TKA) is one of the most successful operations in orthopedics. Still, a sizable percentage of patients (20%) remain dissatisfied after a well-executed TKA. The study aims to examine the excised synovium from the suprapatellar region in osteoarthritic knees during TKA and evaluate the histopathology (HP) report to know whether discrepant diagnoses affect the Forgotten Joint Score-12 at various time intervals. METHODS: This is a prospective cohort study. Two hundred (160 female; 40 male) end-stage osteoarthritis patients who underwent primary TKA were studied. An inclusion criterion was patient with end-stage osteoarthritis. Clinically and serologically proven rheumatoid arthritis patients were excluded from the study. The synovium excised during the TKA procedure was sent for the HP examination. The statistical significance was measured with the Chi-square test and two-sample t-test. RESULTS: A total of 184 out of the 200 patients (92%) knee synovium showed HP features of osteoarthritis. The discordant diagnoses and discrepant diagnosis rate was 8% and 7%, respectively, which is statistically significant by Chi-square test (p value < 0.0001 and p value = 0.0001). 14 of the patients (12 F:2 M) showed histological features of inflammatory/rheumatoid arthritis who were treated, two patients (all female) showed HP features of villonodular synovitis. The mean (SD) improvement in FJS-12 at six weeks in the concordant group (25.3 [17.6]) is significantly more than the discrepant group (15.3 [12.5]), p-value 0.0385. CONCLUSION: 8% of our patients exhibited unexpected results. The study showed a 7% rate of discrepant diagnosis. This discrepant diagnosis if missed and untreated, would have affected the function and long-term survival of the implanted TKA.

Using the semitendinosus tendon to stabilize sternoclavicular joints in a patient with Ehlers-Danlos syndrome: a case report.

Symptomatic recurrent anterior dislocation of the sternoclavicular joint is a rare but sometimes painful condition. A novel technique of extrathoracic reconstruction using tendon autograft is presented in this case report. When spontaneous ankylosis of an anterior dislocation of the sternoclavicular joint does not occur, and the patient remains symptomatic, surgical reconstruction using this procedure may be a viable alternative.

Long-term results of total joint arthroplasty in elderly patients who are frail.

Many studies of joint replacement in the aged population include a wide spectrum of geriatric patients ranging from relative healthy and otherwise vigorous younger-elderly to small numbers of much older patients with many comorbid problems. To clarify the latter patient subset we assessed the results of total hip and knee arthroplasties done on a group of frail elderly patients. We retrospectively reviewed the preoperative and postoperative charts and radiographs of 130 patients who were at least 80 years when they had a total joint arthroplasty. One hundred arthroplasties (70 hips, 30 knees) were done. On a subjective grading scale, 95% of the patients were very satisfied, 5% reported satisfactory outcomes and no patients considered their results poor. After surgery, 90% of the patients became community walkers without assistance. The level of independent living was maintained in 97% of patients at long-term followup. Causes of morbidity included two infections, one dislocation, and one leg-length discrepancy. This study specifically addresses the outcomes of total joint replacement in elderly patients who are frail. We show that satisfactory and cost-effective health outcomes can be anticipated after total joint arthroplasties in this age group.

Activation of p38 and Smads mediates BMP-2 effects on human trabecular bone-derived osteoblasts.

The bone morphogenetic proteins (BMPs) are potent osteoinductive factors that accelerate osteoblast maturation, accompanied by increased cell-substrate adhesion. BMP-2 treatment of osteoblastic cells increases phosphorylation of the cytoplasmic BMP-2 signaling molecules, Smad1 and Smad5. We have previously reported that BMP-2 treatment increase cytoskeletal organization of human trabecular bone-derived osteoblast-like cells (osteoblasts), which is also accompanied by an activation of the focal adhesion kinase p125(FAK). We report here that activation of p125(FAK) occurs with the same kinetics as the phosphorylation of Smad1, suggesting that BMP-2 initiates cross-talk between Smad signaling and the adhesion-mediated signaling pathway. As an adjunct to these effects, we examined activation of mitogen-activated protein (MAP) kinase family members in response to focal adhesion contact formation. Although phosphorylated forms of all three kinases were apparent, only SAPK2alpha/p38 (p38) was activated in response to BMP-2 treatment. Inhibition of p38 kinase activity suppressed BMP-2 induced Smad1 phosphorylation, as well as its translocation to the nucleus, suggesting the integration of p38 activation with Smad1 signaling. Finally, inhibition of p38 in osteoblasts also led to the complete abrogation of BMP-2 induced osteocalcin gene expression and matrix mineralization. These findings suggest that BMP-2 must activate p38 in order to mediate osteogenic differentiation and maturation.

Algorithms for the treatment of femoral neck fractures.

Worldwide prevalence of femoral neck fractures is increasing, doubling for patients older than 50 years. Age of the patient, prefracture activity level, and associated comorbidities must be considered when determining treatment. It seems that hemiarthroplasty is best suited for an elderly patient who is a household ambulator with low demands on the prosthesis. Younger patients, and those with minimally displaced fractures, should be treated with internal fixation in an attempt to preserve the natural hip. Proximal femur fractures in the pediatric population are associated with high complication rates. Because of vascular vulnerability, avascular necrosis of the femoral head continues to be the most frequent and serious complication after hip trauma in children. Femoral neck fractures in children also differ from those in adults because a child can tolerate immobilization much more readily than can an adult. As healthcare resources become more limited and their use becomes scrutinized more closely, cost-effective treatment algorithms for femoral neck fractures will dictate orthopaedic treatment. For some fractures, closed treatment is evolving toward interventional approaches to minimize late sequelae. With the availability of viable treatment options, the potential risks and benefits of individual treatment modalities as related to each fracture pattern must be reviewed.