Joint Procedures Research Articles

Prevalence of pain 6months after surgery: a prospective observational study.

BackgroundPain after surgery is a major issue for patient discomfort and often associated with delayed recovery. The aim of the present study was to evaluate the prevalence of pain and requirement for analgesics up to 6 months after elective surgery, independent if new pain symptoms occurred after surgery or if preoperative pain persisted in the postoperative period.MethodsA prospective observational single center cohort study was conducted between January 2012 and August 2013. Eligible patients were scheduled to undergo elective surgical interventions including joint (hip, knee arthroplasty), back (nucleotomy, spondylodesis), or urological surgery (cystectomy, prostatectomy, nephrectomy). Pain was assessed on an 11-point numerical rating scale (NRS) before, on postoperative day 2 and 6 months after surgery. Clinical information was collected with structured questionnaires and by telephone interview.ResultsSix hundred and forty-four patients gave informed consent, including 54.4 % men (mean age 62.2, SD 14.3). Higher preoperative pain scores were found in patients undergoing joint (mean 7.6; 95 % confidence interval [CI]: 7.2–8.0) and back surgery (mean 7.1, CI: 6.8–7.5) than in patients prior to urological surgery (mean 2.3; CI: 1.8–2.8). After 6 months, about 50 % of patients after joint or back surgery indicated pain levels ≥3/10, compared to 15.9 % of patients after urological surgery (p < .001). 35.3 % of the patients after joint surgery and 41.3 % after back surgery still use pain medication 6 months postoperatively, in contrast to 7.3 % of patients after urological surgery. 13.6 % of patients who underwent back surgery indicated the regular intake of opioids.ConclusionsOur results reveal that a significant percentage of patients undergoing procedures in joint or back surgery still need pain medication up to 6 months postoperatively due to ongoing pain symptoms. Improved monitoring of pain management is warranted, especially after discharge from hospital, to improve long-term results.Trial registrationClinicaltrials.gov (Identifier: NCT01488617); date of registration December 6th 2011.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0261-7) contains supplementary material, which is available to authorized users.

Temporal trends of β-haemolytic streptococcal osteoarticular infections in western Norway.

BackgroundBeta-haemolytic streptococci are important contributors to the global burden of osteoarticular infections (OAI). Knowledge on the disease traits specific for streptococcal OAI, however, remains scarce. We wished to explore temporal trends of OAI caused by Group A Streptococci (GAS), Group B Streptococci (GBS) and Group C and G Streptococci (GCGS), and furthermore, to describe the associated host and pathogen characteristics.MethodsAll cases of microbiologically verified β-haemolytic streptococcal OAI in Health Region Bergen, Norway, in the period 1999–2013 were retrospectively identified. Clinical data were extracted from medical records. Microbial isolates were submitted to antibiotic susceptibility testing and molecular typing.ResultsA total of 24 GAS, 45 GBS and 42 GCGS acute OAI were identified. The cumulative incidence of GCGS OAI, but not GAS or GBS OAI, increased significantly from the first to the last 5-year period (IRR 5.7, p = 0.0003), with the annual incidence peaking at 1.9/100 000 in 2013. GAS OAI generally produced the most acute and severe clinical presentation, whereas GBS and GCGS predominantly affected the elderly, and were significantly associated with the presence of host risk factors of systemic and focal origin, respectively.ConclusionsWe found a significantly increasing incidence of GCGS OAI, likely related to the presence of host susceptibility factors, including prosthetic material and pre-existing joint disease. With an increasing application of therapeutic and diagnostic bone and joint procedures, the rising trend of OAI caused by GCGS is likely to continue. Sustained epidemiological attentiveness to GCGS seems warranted.

Trends in Complication Rates Following Ankle Arthrodesis and Total Ankle Replacement.

This study provides an updated comparison of the reoperation rates following primary ankle arthrodesis and total ankle replacement on the basis of observational, population-based data from California. We previously reported data from 1995 to 2004, and our current study includes new data from 2005 to 2010. Our hypothesis was that total ankle replacement would demonstrate increasing utilization and lower complication rates given advances in implant design and growth in surgeon experience. California's hospital discharge database was used to identify patients who had undergone primary ankle arthrodesis or total ankle replacement between 1995 and 2010. Short-term outcomes examined were based on Centers for Medicaid & Medicare Services (CMS) surgical quality measures and included readmission for any cause, death, and readmission for 7 common surgical complications (acute myocardial infarction, pneumonia, sepsis, pulmonary embolism, mechanical complications, surgical-site bleeding, and periprosthetic joint infection or wound infection). Long-term outcomes analyzed included rates of major revision surgery (ankle arthrodesis or ankle replacement, adjacent joint procedures (subtalar arthrodesis, triple arthrodesis, tarsometatarsal arthrodesis, and total knee replacement), and below-the-knee amputation. Logistic and proportional hazard regression models were used to estimate the impact of ankle arthrodesis or total ankle replacement on the rates of adverse outcomes, with adjustment for patient factors such as age, sex, race, type of health insurance, and comorbidities. We also compared patients in the 2005 to 2010 cohort with those in the earlier cohort. In all, 8,491 ankle arthrodesis and 1,280 total ankle replacement cases were identified. Patients managed with ankle replacement were more likely to be female, white, and older and to have Medicare or private health insurance. Short-term complication risk was low for both procedures, and patients managed with total ankle replacement had significantly lower rates of readmission (p < 0.0001) and periprosthetic joint infection/wound infection (p = 0.02) compared with patients managed with ankle arthrodesis. The inclusion of new data on patients who underwent surgery between 2005 and 2010 demonstrates increasing utilization and lower complication rates for total ankle replacement compared with ankle arthrodesis. These findings suggest that there have been improvements in the clinical safety of total ankle replacement over time. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hemimandibular Elongation: Is the Corrected Occlusion Maintained Long-Term? Does the Mandible Continue to Grow?

The purpose of this study was to assess for the maintenance of a corrected occlusion and ongoing mandibular growth in a group of patients younger than 26years with hemimandibular elongation (HME) who underwent bimaxillary orthognathic reconstruction. We conducted a retrospective cohort study of HME patients operated on by a single surgeon at 1 institution between 1999 and 2013. At a minimum, all patients underwent Le Fort I and bilateral sagittal ramus osteotomies. Study exclusions included patients aged 26years or older; those with clefts, craniofacial disorders, or tumors; and those with a history of temporomandibular joint or orthognathic surgery. The study variables included age, gender, side of condylar hyperactivity, premolar extractions, extent of mandibular deformity and malocclusion, planned surgical change, and longitudinal follow-up. The outcome variables studied were the achievement and maintenance of a corrected occlusion and the occurrence of continued mandibular growth after surgery. We compared the occlusion atintervals including the following: before surgery (T1), 5weeks postoperatively (T2), and either 6to24months after surgery (T3) or more than 2years after surgery (T4). Anterior occlusion assessment included evaluation of overjet, overbite, and dental midline position. Posterior occlusion assessment included the Angle classification, first molar vertical position, and first molar transverse position. If the corrected anterior occlusion remained stable and no posterior open bite occurred, then no clinically significant condylar hyperactivity and/or ongoing mandibular growth was judged to have occurred. Seventy-six consecutive patients met the inclusion criteria. Age at operation averaged 18years (range, 14.5 to 25years), and the study included 44 female patients (58%). T3 patients (10 of 76, 13%) had documentation of occlusion at a mean of 19months after surgery. T4 patients (66 of 76, 87%) had documentation of occlusion at a mean of 5years 8months after surgery. Only 1 of the 76 study patients (1%) was judged to have clinically significant ongoing mandibular growth after reconstruction. For all other patients, a corrected anterior occlusion was maintained long-term, and a posterior open bite did not develop in any. In 7 of the 76 patients (9%), there was a recurrent posterior crossbite by 1year after completion of orthodontics but without the need for retreatment. An association was confirmed between mandibular setback and long-term posterior malocclusion even with simultaneous maxillary advancement (P= .05). In HME, a favorable occlusion can be reliably achieved and maintained long-term in most cases using standard bimaxillary orthognathic technique. The need for mandibular setback, even in the presence of simultaneous maxillary advancement, proved to be a factor in the recurrence of long-term posterior malocclusion, although the risk remains low. The results clarify that in patients with HME, by use of the described techniques and timing for surgery, there is no need for an ablative open joint procedure to arrest condylar growth.

Dynamic parameter sensitivity in numerical modelling of cyclone-induced waves: a multi-look approach using advanced meta-modelling techniques

The knowledge and prediction of cyclones as well as wave models experienced significant improvements in this last decade, opening the perspective of a better understanding of the wave sensitivity to the cyclone characteristics (e.g. track angle of approach θ, forward speed V f, radius of maximum wind R m, landfall position x o, etc.). Physically, waves are strongly linked to the time-varying evolution of the relative cyclone position. Thus, even assuming the main cyclone characteristics to be stationary, exploring the role played by each of them should necessarily be conducted in a dynamic manner. This problem is investigated using the advanced statistical tools of variance-based global sensitivity analysis (VBSA) in different ways to provide an overall view of wave height sensitivity to cyclone characteristics: (1) step-by-step: by computing the time series of sensitivity measures; (2) aggregated: by summarising the time-varying information into a single sensitivity indicator; (3). mode-based: by studying the sensitivity with respect to the occurrence of specific temporal patterns (e.g. up-down translation of the overall series). Yet, applying this multi-look dynamic sensitivity analysis faces two major difficulties: (1) VBSA requires a large number of simulations (typically > 10,000), which appears to be incompatible with the large computation time cost of numerical codes (>several hours for a single run); (2) integrating the time dimension imposes to process a large amount of information via vectors of large size (e.g. series of significant wave height H S discretised over several hundreds of time steps). In this study, we propose a joint procedure combining kriging meta-modelling (to overcome the 1st issue) and principal component analysis techniques (to overcome the 2nd issue by summarising the time information into a limited number of components). The applicability of this strategy is tested and demonstrated on a real case (Sainte-Suzanne city, located at Reunion Island) using a set of 100 cyclone-induced H S series, each of them being computed for different scenarios of cyclone characteristics, i.e. using only 100 long-running simulations. The key role of R m over the whole evolution of H S is shown by means of the aggregated option, with a more specific influence in the vicinity of Sainte-Suzanne (when the cyclone eye is located less than 200 km away from the site) as highlighted by the step-by-step option. The step-by-step option also highlights the influence of the landfall position on the H S peak reached in strong interaction with θ and R m. Finally, the role of V f in the occurrence of a turning point marking a shift near landfall between regimes of low-to-high H S values is also identified. The above results provide guidelines for future research efforts on cyclone characteristics prediction.

Subtalar Arthrodesis in Patients With Avascular Necrosis of the Talus

Category: Hindfoot Introduction/Purpose: Avascular necrosis (AVN) of the talus can lead to subtalar arthritis, pain, and decreased function. Isolated subtalar arthrodesis has been attempted in these patients, potentially allowing re-vascularization of the talus from calcaneal bone ingrowth while preserving the tibiotalar joint. The purpose of this study is to determine the union rate and complications of subtalar arthrodesis in patients with AVN of the talus. Methods: After obtaining IRB approval, a retrospective review of subtalar arthrodeses performed at a single academic institution, from 2000 to 2014, was conducted. Patients were included if they had a preoperative diagnosis of avascular necrosis of the talus, underwent subtalar arthrodesis and had a minimum follow up of 12 months. Exclusion criteria include: age younger of 18 years, incomplete clinical and radiological data or those whom underwent a concomitant tibiotalar arthrodesis. Results: Twelve patients with a mean age of 46.6 ± 13.9 years were included in the study. The fusion rate was 58% with a mean time to fuse of 35 weeks (range, 14-146). Seventeen percent of the patients had diabetes or vascular disease and an additional 17% had a positive history for tobacco use. The overall complication rate was 67% (8 patients). Five patients progressed to non-union (42%) and three of them underwent revision to tibiotalocalcaneal arthrodesis. Two patients (17%) had progression of AVN, one of which necessitated a tibiotalocalcaneal arthrodesis. Two patients (17%) developed a wound dehiscence that healed uneventfully with local wound care and oral antibiotics administration. One patient (8%) underwent hardware removal. Conclusion: With a fusion rate as low as 58% and a 67% complication rate, caution should be exhibited when considering an isolated subtalar arthrodesis in the setting of AVN of the talus. In selected cases, consideration should be given to extending the arthrodesis site to include the tibiotalar or talonavicular joint or revascularization procedures such as concomitant vascularized bone grafts.

A procedure to detect, construct, quantify, numerically simulate and validate fracture networks in coal blocks

Coal mass is a typical sedimentary rock mass with three approximately orthogonal discontinuity sets: bedding planes, face cleats and butt cleats. The mechanical anisotropy of coal masses is dependent on this fabric to a large extent. In this paper, a framework incorporating X-ray computed tomography (CT) scanning, statistical analysis, the fracture tensor based methodology and a numerical stress analysis technique is proposed to detect, construct, quantify and simulate the fracture networks in coal blocks. The CT scanning was first used to obtain the geometric information of the fractures in cubic coal blocks. Then a statistical numerical procedure was proposed to estimate and construct the locations, orientations and sizes of the fractures. An overall assessment of the constructed fracture networks was next made using the fracture tensor based methodology to incorporate all the important features: number of joint sets, joint density, joint orientation and joint size. The fracture networks in cubic blocks were then numerically simulated through a proposed modified fictitious joint procedure to accommodate a large quantity of non-persistent joints with an acceptable numerical stress analysis effort. The framework was validated at different stages to evaluate the reliability. Finally, the implementation of this framework is shown by a numerical investigation of the influence of the fracture networks and confining stresses on the jointed coal mass strength. The proposed framework provides a systematic and innovative method to tackle the fracture network induced mechanical anisotropy of the fractured rock masses.

Dislocation of the Temporomandibular Joint and Relocation Procedures.

Dislocation of the Temporomandibular Joint and Relocation Procedures.

Dislocation of the Temporomandibular Joint and Relocation Procedures.

Temporomandibular joint (TMJ) dislocation requires prompt medical attention due to the crucial impact of airway, nutrition acquisition, and communication. Recognition of this injury by the practitioner, based on clinical presentation and history, is paramount for identification of accurate diagnosis and prompt treatment of TMJ dislocation. Relocation or reduction methods vary on the basis of the severity of the injury and whether it is an acute or chronic dislocation.

Multiple joint procedures in haemophilia: benefit of self-reported activities

Abstract This paper presents a long-term follow-up (mean 6 years) of three cases, providing insight into individual changes in self-reported activities of persons with haemophilia (PWH) who underwent multiple joint procedures (MJP). The procedures include one bilateral ankle pan arthrodesis by means of an ankle arthrodesis nail (case 1) and two times bilateral total knee arthroplasty (TKA), both type Genesis II (cases 2 and 3). MJP are defined as any combination of total hip arthroplasty (THA), total knee arthroplasty (TKA) and ankle arthrodesis (AA) during one hospital admission (one session or staged). The results of MJP need meticulous long-term follow-up, including tools with the capacity to provide detailed measurements for levels of activity. Measurements performed before and after surgery included active range of motion (AROM), the Hemophilia Activities List (HAL) sub-scores for basic and complex lower extremity and the McMaster Toronto Arthritis patient disability questionnaire (MACTAR). Pain scores were only available post-surgery and were by means of a visual analogue scale (VAS), 0 indicating no pain and 10 maximum pain. Post-operative VAS scores were 0.3 on average (range 0-1), indicating only minimal pain. Pre-operative pain was the actual indication for MJP. However, it was measured with a different score, the WFH score. Regarding post-operative AROM, case 1 showed a decreased ankle plantar flexion averaging 15˚ (range 10-20˚) and dorsiflexion averaging 7.5˚ (range 5-10˚), results expected after surgical fixation of the tibiotalar joint. Cases 2 and 3 showed an increased active flexion of both knee joints, on average 6° (range 5-10˚), and extension of 11° (range 0-20˚). From these two cases the HAL showed improvement in both basic (Δ 40 and Δ 30) and complex lower extremity (Δ 40 and Δ 3,5) activities. When considering the standard deviations of the HAL normalised total score of 18, it can be appreciated that these improvements are clinically relevant (effect size Δ 1). The MACTAR showed individual progress, with emphasis on walking, standing, riding a bicycle and walking stairs. These MJP cases provide insight on the benefits of self-reported activities, as well as the relationship between body and activity of the ICF. For the long-term follow-up of this very specific population, self-reported activities should be included.

Disparities in Discharge Destination After Lower Extremity Joint Arthroplasty: Analysis of 7924 Patients in an Urban Setting

BackgroundDischarge destination is an important factor to consider to maximize care coordination and manage patient expectations after total joint arthroplasty (TJA). It also has significant impact on the cost-effectiveness of these procedures given the significant cost of post-acute inpatient care. Therefore, understanding factors that impact discharge destination after TJA is critical. MethodsAn evaluation of socioeconomic, geographic, and racial/ethnic factors associated with discharge destination to either home or institution (ie, rehabilitation, skilled nursing facility, and so forth) following joint arthroplasty of the lower extremity was conducted. We analyzed data on patients admitted between 2011 and 2014 for primary or revision hip or knee arthroplasty at a single institution. Bivariate and multivariate statistical techniques were applied to determine associations. ResultsIncluded in the analysis were 7924 cases of lower extremity joint procedures, of which 4836 (61%), 785 (10%), and 2770 (35%) were of female gender, low socioeconomic status, and nonwhite race/ethnicity, respectively. A total of 5088 (64%) and 2836 (36%) cases were discharged to home and institution, respectively. Significant predictors of discharge to an institution in the multivariate analysis include SES (low and middle SES [odds ratio {OR}: 1.27, 95% confidence interval {CI}: 1.02-1.57, P = .029; and OR: 1.26, 95% CI: 1.10-1.44, P = .001]), age (OR: 1.05, 95% CI: 1.049-1.060, P < .001), female gender (OR: 1.69, 95% CI: 1.52-1.89, P < .001) and TKA procedure (OR: 1.48, 95% CI: 1.33-1.64, P < .001). Patients of nonblack race/ethnicity were more likely to be discharged home (white OR: 0.84, 95% CI: 0.72-0.98, P = .027; other OR: 0.80, 95% CI: 0.67-0.95, P = .009). ConclusionSocioeconomic status and race/ethnicity are important factors related to discharge destination following TJA. Thoroughly understanding and addressing these factors may help increase the rates of discharge to home as opposed to institution.

Climate setting in sourcing teams: Developing a measurement scale for team creativity climate

Creative sourcing strategies, designed to extract more value from the supply base, have become a competitive, strategic differentiator. To fuel creativity, companies install sourcing teams that can capitalize on the specialized knowledge and expertise of their employees across the company. This article introduces the concept of a team creativity climate (TCC) - team members' shared perceptions of their joint policies, procedures, and practices with respect to developing creative sourcing strategies – as a means to address the unique challenges associated with a collective, cross-functional approach to develop value-enhancing sourcing strategies. Using a systematic scale development process that validates the proposed concept, the authors confirm its ability to predict sourcing team performance, and suggest some research avenues extending from this concept.

Processing of signals from land-based radio emission sources in a monostatic air-borne monitoring system

The problem of processing of signals from fixed land-based radio emission sources (RESs) measured in a monostatic air-borne radio monitoring system is considered. On the basis of the Bayesian approach, an optimal joint procedure for RES identification from radio measurements, estimation of RES state coordinates, and RES type recognition is developed. Relationships obtained in the synthesis of the joint procedure are analyzed. The results of application of the joint procedure are compared with the results obtained by independently synthesized algorithms for RES identification, estimation of RES state coordinates, and RES type recognition.

Mechanical and Electrical Characteristics of a Bridge-Type Mechanical Lap Joint of HTS STARS Conductors

Segmented fabrication of high-temperature superconducting (HTS) coils has been proposed for the helical fusion reactor FFHR-d1; the joint-winding and “remountable” (demountable) helical coils concept are the primary and advanced options, respectively. This paper introduces recent research activities on a bridge-type mechanical lap joint of HTS Stacked Tapes Assembled in Rigid Structure (STARS) conductors, particularly to be used for joint winding of the helical coils, and also discusses some technical issues to develop a reliable joint. First, the required joint performance is discussed from the viewpoints of operation cost and mechanical behavior, taking the present design of joint winding of the helical coils for the FFHR-d1 into consideration. Then, mechanical and electrical characteristics of a prototype STARS conductor joint, which achieved a joint resistance of 1.8 nΩ at a current of 100 kA, are analyzed based on small- and largescale joint tests. It is suggested that the joint performance of the prototype joint can be improved more, according to tests of small-scale conductor joints. Finally, the study introduces a fabrication procedure for a reliable joint. We need to develop nondestructive testing for a joint at room temperature. For this purpose, we also perform an X-ray computed tomography inspection as a first step. The inspection can roughly judge whether a fabricated joint is acceptable.

Clostridium difficile-associated diarrhoea in primary joint arthroplasty in Aneurin Bevan University Health Board South.

The choice of perioperative antibiotics to reduce the prevalence of infection after joint arthroplasty should be considered carefully to minimise the risk of nosocomial infections. Dramatic increases in the incidence and severity of healthcare-associated Clostridium difficile infection with Clostridium difficile-associated diarrhoea (CDAD) have occurred since 2000. A retrospective audit of patients who underwent total hip and total knee replacement between 1 January 2005 and 31 December 2007 was undertaken in Aneurin Bevan University Health Board South (ABHBS). Stool samples from patients who had diarrhoea <12 months of surgery were recorded. Positive samples for CDAD <1 month of surgery were identified. After the change in practice in June 2010, a re-audit linked joint-replacement patients between 1 July 2010 and 26 June 2013 with infection control-records for CDAD-positive cases. In the first audit cycle, 1900 joint procedures were carried out in 1845 patients. There were 4 cases of CDAD <1 month of surgery (0.22%). In the re-audit period, 2591 joint procedures were undertaken in 2400 patients: no cases of CDAD <1 month of surgery were recorded. Fisher's exact test gave a two-tailed p=0.036. The significant reduction in CDAD cases after the change in perioperative antibiotic regimen for primary joint arthroplasty mirrored a 66% reduction in overall CDAD cases in the ABUHBS between 2008 and 2012. This reduction was accompanied by financial savings in antibiotics and nursing hours.

Preoperative Head and Neck Surgical Planning with Computer-Assisted Design and Modeling

Virtual surgical planning (VSP) has significantly impacted modern head and neck surgery. Over the past decade, advancements in computer-assisted design (CAD) software have been applied to high-resolution three-dimensional imaging technology to generate powerful tools for planning complex craniofacial resections and reconstructions. These virtual surgical plans incorporate the design of intraoperative surgical guides that are generated through the process of computer-assisted manufacturing (CAM). Virtually planned procedures are then translated to the operating room where they are carried out with unparalleled precision and efficiency. This process allows for accurate operative design that reliably achieves predicted results. Surgical teams are now able to formulate single-staged ablative/reconstructive procedures all the way through to prosthetic dentition and expected soft-tissue outcomes. Recent studies have demonstrated the benefits of preoperative CAD/CAM surgical planning for oncologic resections with immediate reconstructions, severe facial trauma, complex orthognathic and temporomandibular joint procedures, esthetic surgery, and composite tissue allotransplantation. We provide an overview of CAD/CAM applications in head and neck surgery and review the evidence to date regarding the use of preoperative VSP in complex craniofacial reconstruction.

Involvement of the MAPK pathway in the pressure-induced synovial metaplasia procedure for the temporomandibular joint.

Abnormal pressure is an important factor that contributes to bone adaptation in the temporomandibular joint (TMJ). We determined the effect of the mitogen-activated protein kinases (MAPK) pathway on the pressure-induced synovial metaplasia procedure for the TMJ, both in vitro and in vivo. Synovial fibroblasts (SFs) were exacted from rat TMJs and exposed to different hydrostatic pressures. The protein extracts were analyzed to determine the activation of ERK1/2, JNK, and p38. Surgical anterior disc displacement (ADD) was also performed on Japanese rabbits, and the proteins of TMJ were isolated to analyze pressure-induced MAPK activation after 1, 2, 4, and 8 weeks. The results showed that the activation of ERK1/2 and JNK in SFs significantly changed with increasing hydrostatic pressure, whereas p38 activation did not change. Moreover, p38 was activated in animals 1 week after surgical ADD. The levels of p38 gradually increased after 2 and 4 weeks, and then slightly decreased but remained higher than in the control 8 weeks after surgical ADD. Nevertheless, JNK was rarely activated after the ADD treatment. Our findings suggest the involvement of MAPK activation in the pressure-induced synovial metaplasia procedure with pressure loading in TMJ.

Experience with conservative rehabilitation in patients with juvenile chronic arthritis

Objective: to estimate a need for conservative rehabilitation treatment in patients with juvenile chronic arthritis (JCA). Material and methods. Data on the principles and procedures of rehabilitation treatment were analyzed in patients with JCA on the basis of 25- year experience. The need for these packages of measures in 1999, 2008, and 2014 was compared. Standard procedures for joints at different sites were described. According to the degree of joint functions, there were rehabilitation treatment packages: corrective, mobilization, and general health-improving. Results and discussion. All patients with juvenile arthritis need rehabilitation (physical, psychological, and social). Comparison of the total number of patients who had received rehabilitation treatment in 1999, 2008, and 2014 showed a small trend towards its reduction. This is due to the smaller number of patients with dysfunctions and to the larger number of those without movement disorders who had received adequate treatment in early periods of the disease. The high percentage of patients having limited joint functions needs a mobilization package. Analysis of the data available in the literature and the authors' experience may lead to the conclusion that all patients with JCA need exercise therapy. The latter is a major procedure for physical rehabilitation and should be included in the standards for adjuvant treatment during basic medical therapy. Emphasis is laid on the importance of the early initiation of treatment to prevent incapacitating deformity at early stages of the disease.

Morphometric Characteristics of C1-C2 Vertebrae to Perform Anterior Transarticular Crossing Screw Fixation.

In unique clinical situations where C1-C2 posterior fixation is not available or has previously failed, an anterior transarticular screw (ATAS) may be a viable alternative. However, there are no previous reports that investigate possible screw angles, screw entry points, and screw length based on computed tomography (CT) multiplanar reconstruction images in Turkish patients. The aim of this study was to determine the morphometric characteristics C1-C2 vertebrae in order to perform anterior transarticular crossing screw fixation. Patients who underwent a complete CT scan of the cervical spine for causes other than an investigation of cervical spine malformation or congenital anomaly between the years 2013 and 2015 were included in this study. The anterior transarticular C1-C2 screw angles, screw entry point, and screw length were measured on coronal and sagittal CT multiplanar reconstruction images. Twenty-five male and 14 female patients were included in the study. The mean maximum screw angle for ATAS was found to be 41.18°±4.49°. The minimum and maximum screw lengths were 27.46±3.39 mm and 28.46±3.60 mm, respectively. Preoperatively, performing a calculation of the possible screw angles, screw entry point, and screw length based on CT multiplanar reconstruction images for ATAS is a safe and applicable method. In cases in which ATAS fixation across the atlantoaxial joint procedure should be performed without performing a measurement, a screw angle not more than 41.18°±4.49° on the coronal plane does not damage the vertebral artery. Furthermore, using screws shorter than 28.46±3.60 mm doesn"t purchase the atlantoaxial joint.

Rheumatologic skills development: what are the needs of internal medicine residents?

Given the burden of rheumatic disease in our society and the anticipated future shortage of rheumatologists, all internal medicine (IM) residencies need to train internists who are capable of caring for patients with rheumatic diseases. The objective of this study was to perform a targeted needs assessment of the self-confidence of IM residents in the evaluation and care of patients with rheumatologic diseases. A 16-item, web-based, self-assessed confidence survey tool was administered to participating post graduate year (PGY)1 (N = 83) and PGY3 (N = 37) residents. The categories of questions included self-confidence in performing a rheumatologic history and exam, performing common rheumatologic procedures, ordering and interpreting rheumatologic laboratory tests, and caring for patients with common rheumatologic diseases. Resident demographics, prior rheumatology exposure, and career plans were also queried. PGY3 residents had higher self-assessed confidence than PGY1 residents in all categories. Self-assessed confidence in joint procedures was consistently low in both groups and when compared to other categories. Prior exposure to a rheumatology course or elective was not consistently associated with higher self-assessed confidence ratings across all categories. PGY3 residents showed less interest in rheumatology as a career than PGY1 residents, although the interest in the topic of rheumatology was not statistically different. Our needs assessment shows a low level of self-assessed confidence in rheumatology knowledge and skills among IM residents. Despite improvement with PGY year of training, self-assessed confidence remains low. To improve resident's skills and self-confidence in rheumatology, more curricular innovations are needed. Such innovations should be assessed for overall effectiveness.