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1.
J Pediatr Orthop B ; 2019 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-31305365

RESUMO

Overcoverage of the femoral head by the acetabulum, increased acetabular depth and retroversion have been associated with the etiology of slipped capital femoral epiphysis (SCFE). However, limited evidence exists about the impact of the acetabular morphology on the development of a contralateral slip following an initial presentation of unilateral SCFE. We aimed to investigate whether acetabular overcoverage as assessed by an increased lateral center-edge angle (LCEA) and low Tönnis angle, increased acetabular depth assessed by the acetabular depth-width ratio (ADR) and the presence of coxa profunda; and acetabular retroversion assessed by the presence of the crossover sign were associated with a contralateral slip in patients presenting with unilateral SCFE. We evaluated 250 patients with initial diagnosis of unilateral SCFE (average age, 12.5 ± 1.7 years), who had not undergone prophylactic fixation on the contralateral hip for a median follow-up of 49 months (interquartile range: 25-76 months). Endpoints were the development of a contralateral slip (70 patients, 28%) or skeletal maturity assessed by complete closure of the proximal femoral growth plate (180 patients, 72%). We measured the LCEA, Tönnis angle, ADR, and the coxa profunda sign on an anteroposterior pelvic radiograph. The crossover sign was assessed in 208 hips who had a secondary ossification center in the posterior acetabular rim. For each additional degree of LCEA, the odds of contralateral slip decreased 8% [odds ratio = 0.92; 95% confidence interval (CI), 0.87-0.98; P = 0.009]. Tönnis angle (P = 0.11), ADR (P = 0.20) and coxa profunda (p = 0.37) had no association with a contralateral slip. The presence of crossover sign increased two and half times the odds for a contralateral slip (odds ratio = 2.5; 95% CI = 1.12-5.64; P = 0.03). Acetabular retroversion, but not acetabular overcoverage or increased acetabular depth, was associated with contralateral SCFE development in patients with unilateral SCFE. Level of evidence: prognostic level II.

3.
Arq. bras. oftalmol ; 82(3): 225-232, May-June 2019. tab, graf
Artigo em Inglês | LILACS-Express | ID: biblio-1001296

RESUMO

ABSTRACT Purpose: To study the efficacy and safety of treatments with ranibizumab and bevacizumab for exudative age-related macular degeneration. Methods: A parallel randomized clinical trial was conducted to compare the efficacy and safety of three regimens (bevacizumab every month, bevacizumab every 2 weeks, and ranibizumab every month), followed by as-needed retreatments, for 1 year, in previously untreated individuals with age-related macular degeneration. The primary outcome was change in visual acuity and in central macular thickness after 1 year of follow-up. Subjects were assigned randomly to one of the three groups in a 1:1:1 ratio, and investigators and examiners were blinded to the randomization results. Results: We included 15 patients in each group. After 1 year of follow-up, we found statistically significant improvements in visual acuity and central macular thickness reduction in all groups. However, we found no statistically significant differences between the three groups. Conclusions: The bi-weekly follow-up was effective and we found no significant differences in efficacy or safety between the treatments with ranibizumab and bevacizumab.


RESUMO Objetivo: Estudar a eficácia e segurança dos tratamentos com ranibizumabe e bevacizumabe para a degeneração macular relacionada à idade exsudativa. Métodos: Ensaio clínico paralelo randomizado foi conduzido para comparar a eficácia e segurança de três regimes (bevacizumabe a cada mês, bevacizumabe a cada 2 semanas e ranibizumabe todos os meses), seguidos por retratamentos conforme necessidade, durante 1 ano, em indivíduos previamente não tratados com degeneração macular relacionada à idade. O desfecho primário foi alteração na acuidade visual e na espessura macular central após um ano de seguimento. Os indivíduos foram designados aleatoriamente para um dos 3 grupos em uma proporção de 1:1:1, e os investigadores e examinadores foram mascarados para os resultados da randomização. Resultados: Foram incluídos 15 pacientes em cada grupo. Após um ano de seguimento, encontramos melhorias estatisticamente significativas na acuidade visual e na redução da espessura macular central em todos os grupos. No entanto, não encontramos diferenças estatisticamente significativas entre os 3 grupos. Conclusões: O seguimento quinzenal foi eficaz e não encontramos diferenças significativas na eficácia ou segurança entre os tratamentos com bevacizumabe e ranibizumabe.

4.
Clin Orthop Relat Res ; 477(5): 1036-1052, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30998632

RESUMO

BACKGROUND: The time-consuming and user-dependent postprocessing of biochemical cartilage MRI has limited the use of delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). An automated analysis of biochemical three-dimensional (3-D) images could deliver a more time-efficient and objective evaluation of cartilage composition, and provide comprehensive information about cartilage thickness, surface area, and volume compared with manual two-dimensional (2-D) analysis. QUESTIONS/PURPOSES: (1) How does the 3-D analysis of cartilage thickness and dGEMRIC index using both a manual and a new automated method compare with the manual 2-D analysis (gold standard)? (2) How does the manual 3-D analysis of regional patterns of dGEMRIC index, cartilage thickness, surface area and volume compare with a new automatic method? (3) What is the interobserver reliability and intraobserver reproducibility of software-assisted manual 3-D and automated 3-D analysis of dGEMRIC indices, thickness, surface, and volume for two readers on two time points? METHODS: In this IRB-approved, retrospective, diagnostic study, we identified the first 25 symptomatic hips (23 patients) who underwent a contrast-enhanced MRI at 3T including a 3-D dGEMRIC sequence for intraarticular pathology assessment due to structural hip deformities. Of the 23 patients, 10 (43%) were male, 16 (64%) hips had a cam deformity and 16 (64%) hips had either a pincer deformity or acetabular dysplasia. The development of an automated deep-learning-based approach for 3-D segmentation of hip cartilage models was based on two steps: First, one reader (FS) provided a manual 3-D segmentation of hip cartilage, which served as training data for the neural network and was used as input data for the manual 3-D analysis. Next, we developed the deep convolutional neural network to obtain an automated 3-D cartilage segmentation that we used as input data for the automated 3-D analysis. For actual analysis of the manually and automatically generated 3-D cartilage models, a dedicated software was developed. Manual 2-D analysis of dGEMRIC indices and cartilage thickness was performed at each "full-hour" position on radial images and served as the gold standard for comparison with the corresponding measurements of the manual and the automated 3-D analysis. We measured dGEMRIC index, cartilage thickness, surface area, and volume for each of the four joint quadrants and compared the manual and the automated 3-D analyses using mean differences. Agreement between the techniques was assessed using intraclass correlation coefficients (ICC). The overlap between 3-D cartilage volumes was assessed using dice coefficients and means of all distances between surface points of the models were calculated as average surface distance. The interobserver reliability and intraobserver reproducibility of the software-assisted manual 3-D and the automated 3-D analysis of dGEMRIC indices, thickness, surface and volume was assessed for two readers on two different time points using ICCs. RESULTS: Comparable mean overall difference and almost-perfect agreement in dGEMRIC indices was found between the manual 3-D analysis (8 ± 44 ms, p = 0.005; ICC = 0.980), the automated 3-D analysis (7 ± 43 ms, p = 0.015; ICC = 0.982), and the manual 2-D analysis.Agreement for measuring overall cartilage thickness was almost perfect for both 3-D methods (ICC = 0.855 and 0.881) versus the manual 2-D analysis. A mean difference of -0.2 ± 0.5 mm (p < 0.001) was observed for overall cartilage thickness between the automated 3-D analysis and the manual 2-D analysis; no such difference was observed between the manual 3-D and the manual 2-D analysis.Regional patterns were comparable for both 3-D methods. The highest dGEMRIC indices were found posterosuperiorly (manual: 602 ± 158 ms; p = 0.013, automated: 602 ± 158 ms; p = 0.012). The thickest cartilage was found anteroinferiorly (manual: 5.3 ± 0.8 mm, p < 0.001; automated: 4.3 ± 0.6 mm; p < 0.001). The smallest surface area was found anteroinferiorly (manual: 134 ± 60 mm; p < 0.001, automated: 155 ± 60 mm; p < 0.001). The largest volume was found anterosuperiorly (manual: 2343 ± 492 mm; p < 0.001, automated: 2294 ± 467 mm; p < 0.001). Mean average surface distance was 0.26 ± 0.13 mm and mean Dice coefficient was 86% ± 3%. Intraobserver reproducibility and interobserver reliability was near perfect for overall analysis of dGEMRIC indices, thickness, surface area, and volume (ICC range, 0.962-1). CONCLUSIONS: The presented deep learning approach for a fully automatic segmentation of hip cartilage enables an accurate, reliable and reproducible analysis of dGEMRIC indices, thickness, surface area, and volume. This time-efficient and objective analysis of biochemical cartilage composition and morphology yields the potential to improve patient selection in femoroacetabular impingement (FAI) surgery and to aid surgeons with planning of acetabuloplasty and periacetabular osteotomies in pincer FAI and hip dysplasia. In addition, this validation paves way to the large-scale use of this method for prospective trials which longitudinally monitor the effect of reconstructive hip surgery and the natural course of osteoarthritis. LEVEL OF EVIDENCE: Level III, diagnostic study.

5.
J Pediatr Orthop ; 2019 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-30969198

RESUMO

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is one of the most common hip disorders. The vascularity of the lateral epiphyseal vessels supplying the femoral head in patients with healed SCFE has not been well defined. The purpose of this study was to characterize the location and number of lateral epiphyseal vessels in young adults with healed SCFE. METHODS: This was a retrospective study of 17 patients (18 hips) with a diagnosis of SCFE and a matched control group of 17 patients (17 hips) with developmental dysplasia of the hip. All patients underwent high-resolution contrast-enhanced magnetic resonance imaging to visualize the path of the medial femoral circumflex artery and the lateral epiphyseal arterial branches supplying the femoral head. RESULTS: There were 5 unstable SCFEs and 13 stable SCFEs with an average slip angle of 31 degrees. (All patients had been treated with in situ pinning and screw removal). Average age at time of magnetic resonance imaging was 24.5 years (range, 15 to 34 y). The lateral epiphyseal vessels reliably inserted on the posterior-superior aspect of the femoral neck from the superior-anterior to the superior-posterior position in both the SCFE and control groups. An average of 2 (±0.8) retinacular vessels were identified in the SCFE group compared with 5.2 (±0.7) retinacular vessels in the control group (P<0.001). CONCLUSIONS: In healed SCFE, the lateral epiphyseal vessels reliably insert in the same anatomic region as patients with hip dysplasia; however, the overall number of vessels is significantly lower.

6.
J Orthop Res ; 37(7): 1571-1579, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30908729

RESUMO

Epiphyseal tubercle and peripheral cupping can influence the development of slipped capital femoral epiphysis (SCFE) and Cam morphology. During normal skeletal growth, epiphyseal tubercle shrinks while the peripheral cupping grows. We hypothesized that epiphyseal tubercle act as the primary stabilizer of the head-neck junction at early stages and this role is gradually transferred to epiphyseal cupping as the tubercle shrinks and cupping grows. From a cohort of 80 boys and girls (8-15 years old) with normal hips, CT scans of 5 subjects corresponding to minimum, 25th percentile, median, 75th percentile and maximum relative tubercle and cupping height were used to develop 3D finite element models. In vivo measured hip loads were used to study load sharing between the tubercle and peripheral cupping under combined and uniaxial loads exerted on femoral head during a range of daily activities. Lower epiphyseal tubercle height, larger epiphyseal cupping height and bigger differences in tubercle and cupping heights were strongly associated with increased epiphyseal cupping to epiphyseal tubercle stress ratios (R2 > 0.7). We found lower peripheral cupping stresses relative to the tubercle (cupping to tubercle stress ratio <1) in hips with larger tubercle and smaller cupping. The relative decreases in tubercle size along with increased in peripheral cupping in our models gradually shifted the load distribution to higher stresses in the periphery compared to the epiphyseal tubercle area (cupping to tubercle stress ratio >1). Both tubercle and cupping play a substantial role in sharing the generated stresses across the head-neck junction under all tested loading conditions. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1571-1579, 2019.

7.
Artigo em Inglês | MEDLINE | ID: mdl-30864075

RESUMO

PURPOSE OF REVIEW: To review slipped capital femoral epiphysis (SCFE), with a focus on new insights into its etiology and evolving methods of operative fixation. RECENT FINDINGS: The epiphyseal tubercle and its size during adolescence are paramount to understanding the mechanism of SCFE. In chronic stable SCFE, the epiphysis rotates about the tubercle protecting the lateral epiphyseal vessels from disruption. In an acute unstable SCFE, the tubercle displaces, increasing the risk of osteonecrosis, also known as avascular necrosis (AVN). Intraoperative stability suggests that stable and unstable SCFE based on ambulation may be inaccurate. For stable SCFE, in situ pinning remains the most accepted treatment for mild slips with delayed symptomatic femoroacetabular impingement (FAI) management. Treatment of moderate to severe stable slips with realignment osteotomy leads to less femoral deformity and potentially better outcomes. However, it has a higher risk of complications, including AVN and chondrolysis. Our knowledge of the etiology for SCFE is evolving. The optimal technique for operative treatment of moderate to severe SCFE is controversial and varies by center. Well-controlled studies of these patients are needed to understand the best treatment for this difficult problem. Furthermore, increasing the awareness about SCFE is paramount to allow for early recognition and treatment of deformity at its early stages and avoiding severe SCFE deformity which has been associated with worse long-term outcomes.

8.
Arq Bras Oftalmol ; 82(3): 225-232, 2019 May-Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30810619

RESUMO

PURPOSE: To study the efficacy and safety of treatments with ranibizumab and bevacizumab for exudative age-related macular degeneration. METHODS: A parallel randomized clinical trial was conducted to compare the efficacy and safety of three regimens (bevacizumab every month, bevacizumab every 2 weeks, and ranibizumab every month), followed by as-needed retreatments, for 1 year, in previously untreated individuals with age-related macular degeneration. The primary outcome was change in visual acuity and in central macular thickness after 1 year of follow-up. Subjects were assigned randomly to one of the three groups in a 1:1:1 ratio, and investigators and examiners were blinded to the randomization results. RESULTS: We included 15 patients in each group. After 1 year of follow-up, we found statistically significant improvements in visual acuity and central macular thickness reduction in all groups. However, we found no statistically significant differences between the three groups. CONCLUSIONS: The bi-weekly follow-up was effective and we found no significant differences in efficacy or safety between the treatments with ranibizumab and bevacizumab.

9.
Am J Sports Med ; 47(1): 112-122, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30781992

RESUMO

BACKGROUND:: Controversy surrounds the classification and treatment of hips with a lateral center-edge angle (LCEA) between 18° and 25°. It remains undetermined as to whether periacetabular osteotomy (PAO) or arthroscopic surgery is best used to treat this patient population. HYPOTHESIS:: Patients with hip pain and mild or borderline acetabular dysplasia defined by an LCEA between 18° and 25° have different features of acetabular and femoral morphology, as determined by other relevant radiographic measures assessing the anterior and posterior acetabular walls, anterior coverage of the femoral head by the acetabulum, and femoral head and neck junction sphericity. STUDY DESIGN:: Cross-sectional study; Level of evidence, 3. METHODS:: A retrospective review of patients who had an LCEA between 18° and 25° undergoing hip preservation between January 2010 and December 2015 with either PAO or hip arthroscopic surgery was performed. Anteroposterior, Dunn lateral, and false profile radiographs were used to measure the LCEA, Tönnis angle, anterior center-edge angle (ACEA), anterior wall index (AWI) and posterior wall index (PWI), femoral epiphyseal acetabular roof (FEAR) index and posterior to anterior wall index, and alpha angle and femoral neck-shaft angle. An agglomerative hierarchical clustering analysis was then performed on the continuous radiographic variables to identify different subtypes of hip pathomorphology among the study cohort. There were sex-specific trends in hip morphology. Therefore, we proceeded to perform separate cluster analyses for each sex. Multivariate logistic regression was used to identify radiographic parameters for distinguishing between female patients who underwent hip arthroscopic surgery versus PAO. RESULTS:: Ninety-eight patients with hip pain and an LCEA between 18° and 25° underwent surgery in the study period, 77 (78%) were female, and 81 (82%) had complete radiographs for cluster analyses. The mean age was 22.6 years. Hip arthroscopic surgery was performed in 40 (41%) patients, and PAO was performed in 58 (59%) patients. The ACEA (45%), FEAR index (34%), and AWI (30%) were the most commonly abnormal radiographic parameters among all patients. In female patients, the ACEA (55%), FEAR index (42%), and AWI (34%) were the most commonly abnormal radiographic parameters. In male patients, the PWI (48%) was the most common radiographic abnormality. For female patients, 3 clusters representing different patterns of hip morphology were identified: acetabular deficiency with cam morphology, lateral acetabular deficiency, and anterolateral acetabular deficiency. For male patients, 3 clusters were also identified: posterolateral acetabular deficiency with global cam morphology, posterolateral acetabular deficiency with focal cam morphology, and lateral acetabular deficiency without cam morphology. The ACEA (odds ratio [OR], 47.7 [95% CI, 9.6-237.6]; P < .001) and AWI (OR, 3.9 [95% CI, 1.0-15.0]; P = .049) were identified as independent factors predicting which procedure was performed in female patients. CONCLUSION:: A comprehensive evaluation of radiographic parameters in patients with an LCEA between 18° and 25° identified sex-specific trends in hip morphology and showed a large proportion of dysplastic features among these patients. An isolated assessment of the LCEA is an oversimplistic approach that may jeopardize appropriate classification and may provide insufficient data to guide the treatment of hips with additional features of dysplasia and instability.

10.
J Bone Joint Surg Am ; 101(3): 209-217, 2019 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-30730480

RESUMO

BACKGROUND: Femoral morphology may influence the etiology of slipped capital femoral epiphysis (SCFE). We investigated whether radiographic parameters of femoral head-neck morphology are associated with a subsequent contralateral slip in patients presenting with unilateral SCFE. METHODS: We evaluated 318 patients treated for unilateral SCFE between 2000 and 2017. There were 145 males (46%), and the mean age in the series was 12.4 ± 1.7 years. The patients were followed for a minimum of 18 months or until the development of a contralateral slip (70 patients, 22%). We measured the epiphyseal tilt, epiphyseal extension ratio, alpha angle, and epiphyseal angle of the uninvolved, contralateral hip at initial presentation. Multivariable logistic regression analysis was used to assess whether femoral measurements were associated with the occurrence of a contralateral slip. Receiver operating characteristic (ROC) curves were used to determine optimal thresholds of radiographic measures to determine an increased risk of a contralateral slip. A number-needed-to-treat (NNT) analysis was conducted to evaluate the effectiveness of the femoral measurement thresholds in preventing a contralateral slip. RESULTS: Multivariable analysis, controlling for triradiate cartilage status, identified the lateral tilt angle and the superior epiphyseal extension ratio as independent factors associated with the likelihood of a contralateral slip. For each additional degree of posterior tilt, the odds of a contralateral slip increase by 8% (odds ratio [OR] = 1.08; 95% confidence interval [CI] = 1.02 to 1.14; p = 0.008), and for each 0.01 increase in the superior epiphyseal extension ratio, the odds of a contralateral slip decrease by 6% (OR = 0.94; 95% CI = 0.88 to 0.99; p = 0.03). A threshold for the epiphyseal tilt of 10° corresponded to a predicted probability of a contralateral slip of 54% in patients with open triradiate cartilage and an NNT of 3.3. CONCLUSIONS: In patients presenting with unilateral SCFE, a higher posterior tilt of the epiphysis increases the risk while an increased superior extension of the epiphysis reduces the risk of a contralateral slip. Our findings may assist the discussion about contralateral prophylactic pinning in patients with unilateral SCFE. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

11.
Clin Orthop Relat Res ; 477(5): 1138-1144, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30676406

RESUMO

BACKGROUND: Periacetabular osteotomy (PAO) is an established treatment for acetabular dysplasia in the skeletally mature individual. Fluoroscopy is used intraoperatively for osteotomy completion and to judge fragment correction. However, a comprehensive study validating fluoroscopy to judge anterior, lateral, and posterior coverage in PAO has not been reported. QUESTIONS/PURPOSES: (1) Are radiographic and fluoroscopic measures of anterior, lateral, and posterior acetabular coverage reliable? (2) Do fluoroscopic measures of fragment correction accurately measure anterior, lateral, and posterior coverage when compared with postoperative radiographs? METHODS: We performed a retrospective study of patients undergoing PAO with a primary diagnosis of acetabular dysplasia. Between 2012 and 2014 two surgeons performed 287 PAOs with fluoroscopy. To be included in this retrospective study, patients had to be younger than 35 years old, have a primary diagnosis of dysplasia (not retroversion, Perthes, or skeletal dysplasia), have adequate radiographic and fluoroscopic imaging, be a primary PAO (not revision), and in the case of bilateral patients, only the first hip operated on in the study period was included. Based on these criteria, 46% of the PAOs performed were included here (133 of 287). A total of 109 (82%) of the patients were females (109 of 133), and the mean age of the patients represented was 24 years (SD, 7 years). Pre- and postoperative standing radiographs as well as intraoperative fluoroscopic images were reviewed and lateral center-edge angle (LCEA), Tönnis angle (TA), anterior center-edge angle (ACEA), anterior wall index (AWI), and posterior wall index (PWI) were measured. Two fellowship-trained hip preservation surgeons completed all measurements with one reader performing a randomized sample of 49 repeat measurements 4 weeks after the initial reading for purposes of calculating intraobserver reliability. Intra- and interrater reliability was assessed using an intraclass correlation coefficient (ICC) model. Agreement between intraoperative fluoroscopic and postoperative radiographic measures was determined by estimating the ICC with 95% confidence intervals and by Bland-Altman analysis. RESULTS: Intrarater reliability was excellent (ICC > 0.75) for all measures and good for postoperative AWI (ICC = 0.72; 95% confidence interval [CI], 0.48-0.85). Interrater reliability was excellent (ICC > 0.75) for all measures except intraoperative TA (ICC = 0.72; 95% CI, 0.48-0.84). Accuracy of fluoroscopy was good (0.60 < ICC < 0.75) for LCEA (ICC = 0.73; 95% CI, 0.55-0.83), TA (ICC = 0.66; 95% CI, 0.41-0.79), AWI (ICC = 0.63; 95% CI, 0.48-0.74), and PWI (ICC = 0.72; 95% CI, 0.35-0.85) and excellent (ICC > 0.75) for ACEA (ICC = 0.80; 95% CI, 0.71-0.86). Bland-Altman analysis for systematic bias in the comparison between intraoperative fluoroscopy and postoperative radiography found the effect of such bias to be negligible (mean difference: LCEA 2°, TA 2°, ACEA 1°, AWI 0.02, PWI 0.11). CONCLUSIONS: Fluoroscopy is accurate in measuring correction in PAO. However, surgeons should take care not to undercorrect the posterior wall. Based on our study, intraoperative fluoroscopy may be used as an alternative to an intraoperative AP pelvis radiograph to judge final acetabular fragment correction with an experienced surgeon. However, more studies are needed including a properly powered direct comparative study of intraoperative fluoroscopy and intraoperative radiographs. Moreover, the impact of radiographic correction achieved during surgery should be studied to determine the implications for patient-reported outcomes and long-term survival of the hip. LEVEL OF EVIDENCE: Level IV, diagnostic study.

12.
Graefes Arch Clin Exp Ophthalmol ; 257(3): 517-528, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30607553

RESUMO

PURPOSE: To test the applicability of the acai dye at a 25% concentration for identifying the posterior hyaloids and internal limiting membranes (ILMs) during pars plana vitrectomy (PPV) in human eyes with macular holes (MHs). METHODS: This study included 25 patients with chronic idiopathic MHs. The exclusion criteria included glaucoma, previous significant ocular conditions, and previous ocular surgeries except uncomplicated cataract. Ten surgeons performed 23-gauge four-port PPV, phacoemulsification, posterior hyaloid detachment, ILM peeling guided by dye staining, and perfluoropropane injection. The patients remained prone for 5 days postoperatively. The patients were evaluated postoperatively after 1, 30, and 180 days. The surgeons completed a questionnaire regarding the dye's staining abilities. RESULTS: The posterior hyaloids and ILMs stained purple in all eyes. The final best-corrected visual acuity improved significantly (p < 0.001) from preoperatively (1.37 ± 0.29) to 180 days postoperatively (1.05 ± 0.43). The MHs closed in 76% of eyes. CONCLUSION: The acai dye at a 25% concentration identified posterior hyaloids and ILMs during PPVs in humans. Dye toxicity was unlikely.


Assuntos
Antocianinas/farmacologia , Euterpe , Angiofluoresceinografia/métodos , Perfurações Retinianas/diagnóstico , Tomografia de Coerência Óptica/métodos , Vitrectomia/métodos , Corpo Vítreo/diagnóstico por imagem , Idoso , Doença Crônica , Corantes/farmacologia , Feminino , Seguimentos , Fundo de Olho , Humanos , Período Intraoperatório , Masculino , Perfurações Retinianas/cirurgia , Coloração e Rotulagem/métodos , Fatores de Tempo , Corpo Vítreo/cirurgia
13.
Clin Orthop Relat Res ; 477(5): 1086-1098, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30531425

RESUMO

BACKGROUND: Hip microinstability has gained attention recently as a potential cause of hip pain. Currently there is a lack of evidence-based objective diagnostic criteria surrounding this diagnosis. Previous studies have shown translation of the femoral head during extreme hip positions. However, reliable assessment of femoral head translation is lacking. QUESTIONS/PURPOSES: (1) How precise is musculoskeletal ultrasound for measuring anterior femoral head translation during the hip anterior apprehension test? (2) What is the intra- and interrater reliability of dynamic ultrasonography in assessing anterior femoral head translation? METHODS: We recruited 10 study participants (20 hips) between the ages of 22 and 50 years with no history of hip pain or functional limitations. Test-retest methodology was used. Seven females and three males were enrolled. The mean age of study participants was 27 years (SD 8.7 years); mean body mass index was 22.6 kg/m (SD 2.2 kg/m). All study participants underwent dynamic hip ultrasonography by three different physicians 1 week apart. Each hip was visualized in two neutral positions (neutral and neutral with the contralateral hip flexed [NF]) and two dynamic positions, which sought to replicate the apprehension test, although notably study participants had no known hip pathology and therefore no apprehension. The first maintained the hip in extension and external rotation off to the side of the examination table (EER1), and the second held the hip off of the bottom of the examination table (EER2). One hundred twenty ultrasound scans (480 images) were performed. Mean and SD were calculated using absolute values of the difference in ultrasound measurements (mm) between positions NF and EER1 and NF and EER2 calculated for each physician as well as an average of all three physicians. Intraclass correlation coefficient (ICC) analysis was used to examine intra- and interrater reliability. RESULTS: The mean absolute difference for NF and EER1 was 0.84 mm (SD 0.93 mm) and for NF and EER2 0.62 mm (SD 0.40 mm) on Study Day 1. Similarly, on Study Day 2, the mean absolute difference for NF and EER1 position was 0.90 mm (SD 0.74 mm) and for NF and EER2 1.03 mm (SD 1.18 mm). Cumulative values of ICC analysis indicated excellent intrarater reliability in all four positions: neutral 0.794 (95% confidence interval [CI], 0.494-0.918), NF 0.927 (95% CI, 0.814-0.971), EER1 0.929 (95% CI, 0.825-0.972), and EER2 0.945 (95% CI, 0.864-0.978). Similarly, interrater ICC analysis cumulative values were excellent for NF, EER1, and EER2 and fair to good for the neutral position: neutral 0.725 (95% CI, 0.526-0.846), NF 0.846 (95% CI, 0.741-0.913), EER1 0.812 (95% CI, 0.674-0.895), and EER2 0.794 (95% CI, 0.652-0.884). CONCLUSIONS: This study offers the first ultrasound protocol of which we are aware for measuring anterior femoral head translation. Hip dynamic ultrasound may assist in providing precise objective clinical-based diagnostic evidence when evaluating complex hip pain and suspected microinstability. Musculoskeletal ultrasound is a reliable office-based method of measuring anterior femoral head translation that can be utilized by physicians with varying experience levels. Future studies are needed to investigate ultrasound anterior femoral head translation taking into account sex, prior hip surgery, hip osseous morphology, and ligamentous laxity. LEVEL OF EVIDENCE: Level III, diagnostic study.

14.
Clin Orthop Relat Res ; 477(5): 1111-1122, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30550402

RESUMO

BACKGROUND: Prophylactic pinning of the asymptomatic and normal-appearing contralateral hip in patients with unilateral slipped capital femoral epiphysis (SCFE) remains controversial. Understanding the minimal 10-year clinical, functional, and radiographic outcomes of the contralateral asymptomatic hip in unilateral SCFE may be helpful in the decision regarding whether the benefits associated with potentially preventing a SCFE are outweighed by the risk of additional surgery. QUESTIONS/PURPOSES: Among patients with SCFE treated with prophylactic pinning of the asymptomatic and contralateral hip, we sought (1) to determine the complications and reoperations; (2) to evaluate the development of cam deformities and the frequency and severity of osteoarthritis progression; and (3) to characterize hip pain and function as measured by the Harris hip score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS) at minimal 10-year followup. METHODS: Between 1998 and 2005 all patients with SCFE seen at our institution were treated with the modified Dunn procedure and all were offered prophylactic pinning of the contralateral asymptomatic hip. Of the 41 patients who underwent the unilateral modified Dunn procedure and who had an asymptomatic contralateral hip, 37 patients (90%) underwent pinning of that contralateral hip. Of those, 33 patients (80%) were available for clinical and radiographic evaluation for this retrospective study at a minimum of 10 years (mean followup 12 ± 2 years) after surgery. Three patients of the 37 patients only had 10-year clinical followup, including questionnaires sent by mail and telephone, because they refused further radiographic followup and one patient was lost to followup. The group included 19 males and 17 females whose age at surgery was a mean of 13 ± 2 years. Medical charts were reviewed and patients were asked about complications and additional surgical procedures. Most recent postoperative radiographs were evaluated for measurement of the alpha angle, head-neck offset, epiphysis orientation, and osteoarthritis grading according to Tönnis classification and minimum joint space width. The presence of a cam deformity was defined by an alpha angle measurement > 60° on the AP radiograph and/or > 55° on the lateral radiograph. Hip function and pain were assessed by the HHS and HOOS outcome measures. RESULTS: No complications with prophylactic in situ pinning were recorded. Four of 36 (11%) patients underwent subsequent surgical treatment for cam-type femoroacetabular impingement (FAI), and hardware removal was performed in four hips (11%). The mean alpha angle was 53° ± 8° on the AP radiograph and 49° ± 8° on the lateral view at followup. In total, 10 of 33 hips (30%) had a cam morphology at the femoral head-neck junction and four (12%) were symptomatic and underwent FAI surgery. Six of 33 patients (18%) developed an asymptomatic cam morphology at the femoral head-neck junction; in three of 33 hips (9%), the cam deformity instead of lesion were visible only on the lateral projection, and 9% were visible on both the AP and lateral projections. The preoperative offset of the femoral head-neck junction was 10 ± 3 mm on the AP view and 11 ± 4 mm on the lateral view. At followup, the AP offset was 7 ± 3 mm and the lateral offset was 6 ± 3 mm, and on the lateral view, the offset was < 10 mm in eight hips (22%). No patient had radiographic signs of hip osteoarthritis (Tönnis Grade 0). The mean minimum joint space width was 4 ± 0.4 mm. The mean HHS for the 32 patients who did not undergo subsequent surgery was 97 ± 5 at latest followup. The mean postoperative HOOS was 94 ± 8 for the 32 patients at latest followup. CONCLUSIONS: At a minimum followup of 10 years after prophylactic pinning of a contralateral asymptomatic hip, most patients achieve excellent hip scores; however, a substantial proportion will develop a symptomatic cam deformity despite prophylactic pinning. No patient had signs of osteoarthritis at a minimum of 10 years, but almost one-third of the patients who underwent prophylactic pinning developed a cam deformity. LEVEL OF EVIDENCE: Level IV, therapeutic study.

15.
Ophthalmologica ; : 1-9, 2018 Oct 17.
Artigo em Inglês | MEDLINE | ID: mdl-30332674

RESUMO

OBJECTIVE: To compare two different laser strategies of panretinal photocoagulation for diabetic retinopathy. METHODS: Single-center, randomized study including 41 eyes treated with 577-nm multispot laser with a 20-ms pulse duration (group 1) or a 532-nm single-spot laser with a 100-ms pulse duration (group 2). The outcomes included best-corrected visual acuity (BCVA) and imaging changes at baseline, 6 and 12 months, laser parameters, and results of subjective pain analysis. RESULTS: At 12 months, the treatments did not differ significantly in BCVA, central retinal thicknesses (CRTs), improved macular edema, vitreomacular interface changes, patient-reported pain scores, or angiographic responses. Group 1 had significantly fewer treatment sessions but used more laser spots (p < 0.001). CONCLUSION: The multispot laser required fewer applications with more spots delivered to compensate for lower fluency, showing similar patient tolerance to single-spot laser. Both groups maintained the initial visual acuities and CRTs; about 50% of cases had vitreomacular interface changes and improved macular edema, with similar angiographic improvements after 12 months.

16.
Artigo em Inglês | MEDLINE | ID: mdl-30272610

RESUMO

BACKGROUND: Leverage of the femoral head against the acetabular rim may lead to posterior hip dislocation during sports activities in hips with femoroacetabular impingement (FAI) deformity. Abnormal concavity of the femoral head and neck junction has been well described in association with posterior hip dislocation. However, acetabular morphology variations are not fully understood. QUESTIONS/PURPOSES: The purpose of this study was to compare the acetabular morphology in terms of acetabular version and coverage of the femoral head in adolescents who sustained a posterior hip dislocation during sports and recreational activities with a control group of patients without a history of hip disease matched by age and sex. METHODS: In this case-control study, we identified 27 adolescents with posterior hip dislocation sustained during sports or recreational activities who underwent a CT scan of the hips (study group) and matched them to patients without a history of hip disease being evaluated with CT for possible appendicitis (control group). Between 2001 and 2017, we treated 71 adolescents (aged 10-19 years old) for posterior hip dislocations. During the period in question, we obtained CT scans or MR images after closed reduction of a posterior hip dislocation. One patient was excluded because of a diagnosis of Down syndrome. Twenty-one patients who were in motor vehicle-related accidents were also excluded. Twelve patients were excluded because MRI was obtained instead of CT. Finally, three patients with no imaging after reduction and seven patients with inadequate CT reformatting were excluded. Twenty-seven patients (38%) had CT scans of suitable quality for analysis, and these 27 patients constituted the study group. We compared those hips with 27 age- and sex-matched adolescents who had CT scans for appendicitis and who had no history of hip pain or symptoms (control group). One orthopaedic surgeon and one pediatric musculoskeletal radiologist, not invoved in the care of the patients included in the study, measured the lateral center-edge angle, acetabular index, acetabular depth/width ratio, acetabular anteversion angle (10 mm from the dome and at the level of the center of the femoral heads), and the anterior and posterior sector angles in the dislocated hip; the contralateral uninvolved hip of the patients with hip dislocations; and both hips in the matched control patients. Both the study and control groups had 25 (93%) males with a mean age of 13 (± 1.7) years. Inter- and intrarater reliability of measurements was assessed with intraclass correlation coefficient (ICC). There was excellent reliability (ICC > 0.90) for the acetabular anteversion angle measured at the center of the femoral head, the acetabular version 10 mm from the dome, and the posterior acetabular sector angle. RESULTS: The mean acetabular anteversion angle (± SD) was lower in the study group at 10 mm from the acetabular dome (-0.4° ± 9° versus 4° ± 4°; mean difference -5°; 95% confidence interval [CI], -9 to -0.3; p = 0.015) and at the center of the femoral heads (10° ± 5° versus 14° ± 4°; mean difference -3°; 95% CI, -6 to -0.9; p = 0.003). A higher proportion of acetabula was severely retroverted in the study group (14 of 27 [52%]; 95% CI, 33%-71% versus four of 27 [15%]; 95% CI, 1%-28%; p = 0.006). The mean posterior acetabular sector angle was lower in the study group (82° ± 8° versus 90° ± 6°; mean difference -8°; 95% CI, -11 to -4; p < 0.001), whereas no difference was found for the anterior acetabular sector angle (65° ± 6° versus 65° ± 7°; mean difference 0.3°; 95% CI, -3 to 4; p = 0.944). There was no difference for the lateral center-edge angle (27° ± 6° versus 26° ± 5°; p = 0.299), acetabular index (5° ± 3° versus 6 ± 4°; p = 0.761), or acetabular depth/width ration (305 ± 30 versus 304 ± 31; p = 0.944) between groups. Acetabular anteversion angle at the center of the femoral heads (11° ± 4° versus 14° ± 4°; p = 0.006) and the posterior acetabular sector angle (86° ± 7 ° versus 91° ± 6°; p = 0.007) were lower in the contralateral uninvolved hips compared with control hips. CONCLUSIONS: Decreased acetabular anteversion angle and posterior acetabular coverage of the femoral head were associated with posterior dislocation of the hip in adolescents with sports-related injury even in the absence of a high-energy mechanism. Further studies are necessary to clarify whether a causative effect exists between acetabular and femoral morphology and the dislocation of the hip in patients with sports-related injuries. LEVEL OF EVIDENCE: Level III, prognostic study.

17.
Artigo em Inglês | MEDLINE | ID: mdl-30272611

RESUMO

BACKGROUND: The treatment of mild or borderline acetabular dysplasia is controversial with surgical options including both arthroscopic labral repair with capsular closure or plication and periacetabular osteotomy (PAO). The degree to which improvements in pain and function might be achieved using these approaches may be a function of acetabular morphology and the severity of the dysplasia, but detailed radiographic assessments of acetabular morphology in patients with a lateral center-edge angle (LCEA) of 18° to 25° who have undergone PAO have not, to our knowledge, been performed. QUESTIONS/PURPOSES: (1) Do patients with an LCEA of 18° to 25° undergoing PAO have other radiographic features of dysplasia suggestive of abnormal femoral head coverage by the acetabulum? (2) What is the survivorship free from revision surgery, THA, or severe pain (modified Harris hip score [mHHS] < 70) and proportion of complications as defined by the modified Dindo-Clavien severity scale at minimum 2-year followup? (3) What are the functional patient-reported outcome measures in this cohort at minimum 2 years after surgery as assessed by the UCLA Activity Score, the mHHS, the Hip disability and Osteoarthritis Outcome Score (HOOS), and the SF-12 mental and physical domain scores? METHODS: Between January 2010 and December 2014, a total of 91 patients with hip pain and LCEA of 18° to 25° underwent a hip preservation surgical procedure at our institution. Thirty-six (40%) of the 91 patients underwent hip arthroscopy, and 56 hips (60%) were treated by PAO. In general, patients were considered for hip arthroscopy when symptoms were predominantly associated with femoroacetabular impingement (that is, pain aggravated by sitting and hip flexion activities) and physical examination showed a positive anterior impingement test with negative signs of instability (negative anterior apprehension test). In general, patients were considered for PAO when symptoms suggested instability (that is, pain with upright activities, abductor fatigue now aggravated by sitting) and clinical examinations demonstrated a positive anterior apprehension test. Bilateral surgery was performed in six patients and only the first hip was included in the study. One patient was excluded because PAO was performed to address dysplasia caused by surgical excision of a proximal femoral tumor associated with multiple epiphyseal dysplasia during childhood yielding a total of 49 patients (49 hips). There were 46 of 49 females (94%), the mean age was 26.5 years (± 8), and the mean body mass index was 24 kg/m (± 4.5). Radiographic analysis of preoperative films included the LCEA, Tönnis acetabular roof angle, the anterior center-edge angle, the anterior and posterior wall indices, and the Femoral Epiphyseal Acetabular Roof index. Thirty-nine of the 49 patients (80%) were followed for a minimum 2-year followup (mean, 2.2 years; range, 2-4 years) and were included in the analysis of survivorship after PAO, complications, and functional outcomes. Kaplan-Meier modeling was used to calculate survivorship defined as free from revision surgery, THA, or severe pain (mHHS < 70) at minimum 2 years after surgery. Complications were graded according to the modified Dindo-Clavien severity. Patient-reported outcomes were collected preoperatively and at minimum 2 years after surgery and included the UCLA Activity Score, the mHHS, the HOOS, and the SF-12 mental and physical domain scores. RESULTS: Forty-six of 49 hips (94%) had at least one other radiographic feature of dysplasia suggestive of abnormal femoral head coverage by the acetabulum. Seventy-three percent of the hips (36 of 49) had two or more radiographic features of hip dysplasia aside from a LCEA of 18° to 25°. The survivorship of PAO at minimum 2 years for the 39 of 49 (80%) patients available was 94% (95% confidence interval, 80%-90%). Three of 39 patients (8%) developed a complication. At a mean of 2.2 years of followup, there was improvement in level of activity (preoperative UCLA score 7 ± 2 versus postoperative UCLA score 6 ± 2; p = 0.02). Hip symptoms and function improved postoperatively, as reflected by a higher mean mHHS (86 ± 13 versus 64 ± 19; p < 0.001) and mean HOOS (386 ± 128 versus 261 ± 117; p < 0.001). Quality of life and overall health assessed by the physical domain of the SF-12 improved (47 ± 11 versus 39 ± 12; p < 0.001). However, with the numbers available, no improvement was observed for the mental domain of the SF-12 (52 ± 8 versus 51 ± 11; p = 0.881). CONCLUSIONS: Hips with LCEA of 18° to 25° frequently have other radiographic features of dysplasia suggestive of abnormal femoral head coverage by the acetabulum. These hips may be inappropriately labeled as "borderline" or "mild" dysplasia on consideration of LCEA alone. A more comprehensive imaging analysis in these hips by the radiographic features of dysplasia included in this study is recommended to identify hips with abnormal coverage of the femoral head by the acetabulum and to plan treatment accordingly. Patients with LCEA of 18° to 25° showed improvement in hip pain and function after PAO with minimal complications and low proportions of persistent pain or reoperations at short-term followup. Future studies are recommended to investigate whether the benefits of symptomatic and functional improvement are sustained long term. LEVEL OF EVIDENCE: Level IV, therapeutic study.

18.
Ophthalmic Surg Lasers Imaging Retina ; 49(8): 603-610, 2018 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30114305

RESUMO

BACKGROUND AND OBJECTIVE: To illustrate how optical coherence tomography (OCT) angiography (OCTA) can be misinterpreted if not evaluated along with structural en face OCT to analyze the signal intensity. PATIENTS AND METHODS: Patients with different macular diseases associated with suspicious flow impairment in the choriocapillaris were recruited to be imaged on the RTVue XR Avanti device (Optovue, Fremont, CA) with the Angio Retina mode. En face OCT angiograms, structural en face OCT, and corresponding OCT B-scans with flow signal overlaid were compared to evaluate the correspondence of signal strength to areas of flow reduction in the choriocapillaris. RESULTS: Six eyes from six patients were enrolled. Macular lesions evaluated in this study included acute central serous chorioretinopathy, paracentral acute middle maculopathy, age-related macular degeneration, adult-onset foveomacular vitelliform dystrophy, and branch retinal vein occlusion. In all cases, areas of suspicious flow decrement in the choriocapillaris corresponded to hyporeflective areas in the intensity en face OCT. Thus, a precise confirmation of choriocapillaris flow impairment was not possible. CONCLUSION: It is essential to be aware of the importance of analyzing the structural image alongside with the flow image to interpret flow impairment. This is more important in subretinal pigment epithelial structures such as choriocapillaris and choroid. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:603-610.].

19.
Retina ; 2018 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30074522

RESUMO

PURPOSE: To compare the sensitivity of detection and the measured size of choroidal neovascularization (CNV) on two commercially available spectral domain optical coherence tomography angiography (OCTA) devices, the Optovue RTVue XR Avanti with AngioVue and the Zeiss Cirrus HD-OCT with AngioPlex. METHODS: Patients with CNV lesions were imaged consecutively on both OCTA devices on the same day of their visit. 3 × 3 mm and 6 × 6 mm scans centered at the fovea were obtained. Two independent masked readers evaluated the OCTA images for CNV identification and its area measurements. RESULTS: No significant differences were observed between the 2 OCTA devices in CNV area measurements on their 3 × 3 mm and 6 × 6 mm scans. However, there was suboptimal performance of their automated segmentation algorithms as compared to manually adjusted segmentation for visualizing CNV lesions. CONCLUSION: There was no significant difference in the size of the CNV lesion as measured on either commercially available spectral domain OCTA device. Both devices were comparable in their detection of CNV lesions on manual adjustment of segmentation lines. However, their automated segmentation algorithms need improvement to allow for accurate measurement of CNV lesions for routine clinical application.

20.
Orthop J Sports Med ; 6(6): 2325967118781579, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30090833

RESUMO

Background: Understanding the development of the capital femoral epiphysis is essential to identify pathologic variations that may lead to cam morphology. Purpose/Hypothesis: The purpose of this study was to investigate the development of the capital femoral epiphysis during childhood and adolescence, with specific morphologic analysis of the peripheral growth and the metaphyseal surface of the growth plate. We hypothesized that age- and sex-dependent morphologic variations of the peripheral growth (cupping) and surface anatomy (epiphyseal tubercle) of the epiphysis would be evident with increasing age. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Pelvic computed tomography scans of 80 children and adolescents (range, 8-15 years; n = 10 per age group; 50% male), imaged because of suspected appendicitis, were used to reformat the proximal femur. All patients had asymptomatic hips with no signs or history of hip disorder. We measured the peripheral cupping of the epiphysis and the epiphyseal tubercle dimensions from 3-dimensional models. All measurements were normalized to the epiphyseal diameter. The effect of age on these parameters was evaluated by use of linear regression analysis. A 2-way analysis of variance (ANOVA) was used to compare these parameters between males and females. Results: The mean epiphyseal cupping increased with increasing age (R2 = 0.54; P < .001). The mean normalized epiphyseal cupping was consistently higher in the anterior and posterior directions compared with the inferior and superior locations. Male patients aged 10 and 11 years had lower (P = .002) mean epiphyseal cupping compared with female patients of the same age. We observed no difference between male and female participants after 12 years of age (P > .3). The normalized epiphyseal tubercle height (R2 = 0.08; P = .009), width (R2 = 0.13; P = .001), and length (R2 = 0.45; P < .001) decreased with increasing age, with no differences between male and female patients. On average, a 2.6-fold increase was found in epiphyseal cupping from 8 to 15 years of age, whereas normalized tubercle height decreased by 0.4-fold. Conclusion: Peripheral cupping of the epiphysis over the metaphysis increases with age, while the relative epiphyseal tubercle dimensions decrease. Females have an earlier onset of rapid increase in the peripheral cupping compared with males; however, no differences in epiphyseal tubercle dimensions were found between male and female patients. These findings may guide future studies investigating the development of cam morphology, which should consider the surface morphologic characteristics of the capital femoral epiphysis, the growth plate, and the differences in morphologic characteristics according to age and sex.

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