Bulletin of the NYU hospital for joint diseases最新文献

A 75-year-female with a history of Isoniazid (INH) therapy for latent tuberculosis, was admitted with a 4-week duration of dyspnea, cough, and pleuritic chest pain. She was treated with intravenous antibiotics for a diagnosis of pneumonia. Her stay was complicated by development of recurrent, exudative eosinophilic pleural effusions (EPEs). When symptoms continued to worsen and she developed joint pain and anasarca and did not respond to the antibiotics, a rheumatologic work-up was performed. She was found to have positive anti-double stranded-DNA antibodies and anti-histone antibodies; thus, a diagnosis of drug-induced lupus, secondary to INH, was made. INH was discontinued, and the patient was started on prednisone; within weeks her symptoms resolved. This case illustrates a unique side effect of INH that caused exudative EPEs and drug-induced lupus with positive anti-dsDNA.

The standard method for the evaluation of arthritis and postoperative assessment of arthroplasty treatment is observation and measurement from plain films, using the flm edge for orientation. A more recent employment of an anatomical landmark, the ischial tuberosity, has come into use as orientation for evaluation and is called the ischio-lateral method. In this study, the use of this method was evaluated as a first report to the literature on acetabular component measurement using a skeletal reference with lateral radiographs. Postoperative radiographs of 52 hips, with at least three true lateral radiographs taken at different time periods, were analyzed. Component position was measured with the historical method (using the flm edge for orientation) and with the new method using the ischio-lateral method. The mean standard deviation (SD) for the historical approach was 3.7° and for the ischio-lateral method, 2.2° (p < 0.001). With the historical method, 19 (36.5%) hips had a SD greater than ± 4°, compared to six hips (11.5%) with the ischio-lateral method. By using a skeletal reference, the ischio-lateral method provides a more consistent measurement of acetabular component position. The high intra-class correlation coefficients for both intra- and inter-observer reliability indicate that the angle measured with this simple method, which employs no further technology, increased time, or cost, is consistent and reproducible for multiple observers.

The causes of brachial plexus palsy in neonates should be classified according to their most salient associated feature. The causes of brachial plexus palsy are obstetrical brachial plexus palsy, familial congenital brachial plexus palsy, maternal uterine malformation, congenital varicella syndrome, osteomyelitis involving the proximal head of the humerus or cervical vertebral bodies, exostosis of the first rib, tumors and hemangioma in the region of the brachial plexus, and intrauterine maladaptation. Kaiser Wilhelm syndrome, neonatal brachial plexus palsy due to placental insufficiency, is probably not a cause of brachial plexus palsy. Obstetrical brachial plexus palsy, the most common alleged cause of neonatal brachial plexus palsy, occurs when the forces generated during labor stretch the brachial plexus beyond its resistance. The probability of obstetrical brachial plexus palsy is directly proportional to the magnitude, acceleration, and cosine of the angle formed by the direction of the vector of the stretching force and the axis of the most vulnerable brachial plexus bundle, and inversely proportional to the resistance of the must vulnerable brachial plexus bundle and of the shoulder girdle muscles, joints, and bones. Since in most nonsurgical cases neither the contribution of each of these factors to the production of the obstetrical brachial plexus palsy nor the proportion of traction and propulsion contributing to the stretch force is known, we concur with prior reports that the term of obstetrical brachial plexus palsy should be substituted by the more inclusive term of birth-related brachial plexus palsy.

In total joint arthroplasty, it is often necessary to formulate decisions that are not clearly evidence-based. This review presents some current controversial topics in total joint arthroplasty, including preoperative autologous blood donation versus erythropoietin (EPO) usage, preoperative screening and treatment for methicillin resistant Staphylococcus aureus (MRSA), and the use of continuous passive motion (CPM) following total knee arthroplasty, providing an evidence-based guide for the treating orthopaedic surgeon. Our review shows that preoperative autologous blood donation is over utilized, with EPO being under utilized. Surgeons are encouraged to develop patient-specific strategies, which have been shown to decrease transfusion rates, reduce wasted autologous blood, and increase EPO use. Definitive conclusions regarding MRSA screening for orthopaedic patients cannot be drawn; but due to the significant cost and morbidity associated with a postoperative MRSA infection, we believe a screen and treat protocol should be considered for all patients being admitted to the hospital for elective or emergent surgery. Short-term (3 to 5 days) inpatient use of CPM is recommended at this time. It is low-cost, has minimal risk, and may be a factor in decreasing the length of stay, potentially leading to significant cost savings. However, no long-term benefits of CPM use have been established.

Three major advances over the last decade have impacted the way we treat rheumatoid arthritis; early and aggressive treatment, use of disease activity measures leading to treat to target, and availability of biologic agents. No oral biologic agents are available at this time but promising data is emerging for two drugs, tofacitinib and fostamatinib, inhibitors of JAK and Syk kinases, respectively. This paper will review some of the relevant published data for these agents and discuss where they may be placed in our treatment options for RA.

Juvenile idiopathic arthritis (JIA) consists of a collection of all forms of chronic arthritis in childhood with no apparent cause. JIA is the most common rheumatic disease in children and may result in significant pain, joint deformity, and growth impairment, with persistence of active arthritis into adulthood. The extra-articular features of JIA, such as anterior uveitis or macrophage activation syndrome, are often the greater focus of therapy. Prior to the mid 1990s, the therapeutic armamentarium for JIA was more limited, utilizing non-specific agents, many with significant adverse effects. In the current era of target-specific biologic therapy, it is possible to better tailor therapy for patients. Through continued translational research and clinical trials, the biology mediating disease is better understood, and there is the hope of safer, more effective medicine and potential cure. This review will outline the clinical features of JIA as well as provide the latest updates in current and future pharmacotherapy.

"Treat-to-target" of rheumatoid arthritis (RA) is similar in many respects to hypertension and diabetes. All three diseases involve a dysregulation of normal physiologic functions, which results in long-term organ damage if not treated. "Treat-to-target" strategies, based on values of specific quantitative measures, lead to improved outcomes, including longer survival. However, RA differs from hypertension and diabetes in at least five important respects: 1. the absence of a single "gold standard" measure in RA for all individual patients necessitates indices; 2. the rarity of acute emergency situations in RA leads to underestimation of its natural history, which includes increased mortality rates similar to hypertension and diabetes; 3. the patient with hypertension or diabetes goes to the doctor to learn how she or he is doing, based on a "gold standard" quantitative measure, while the patient with RA goes to the doctor to tell the doctor how she or he is doing; 4. the history and physical examination in hypertension or diabetes may be recorded as narrative, nonquantitative information, as a vital sign or laboratory test provides the crucial information for clinical care but should be recorded as quantitative, standardized "scientific" data on patient questionnaires and formal joint counts because of their importance in RA; and 5. patient mood or distress may impact directly RA indices used as quantitative measures in a "treat-to-target" strategy, which is not seen in hypertension or diabetes. These matters may be addressed through three global scales completed by health professionals concerning inflammation, damage, or neither inflammation nor damage as a basis for symptoms.

There are certain thought barriers involved in making diagnostic-classification criteria in diseases of unknown origin. Among these are a lack of appreciation of the issue of circular logic, the basic oneness of diagnostic and classification criteria, the lack of appreciation as to why we make such criteria in the first place, and the lack of importance informing our patients that we do as well as should treat them without a frm diagnosis in many instances. The relevance of these thought barriers to the new American College of Rheumatology/European Union League Against Rheumatism (ACR/EULAR) Rheumatoid Arthritis (RA) classification criteria are also discussed.

Unlabelled: Hip resurfacing arthroplasty has had excellent clinical outcomes from multiple centers. However, controversy exists regarding the most appropriate patient selection criteria. Many proponents of hip resurfacing believe that narrowing the patient indications with strict inclusion and exclusion criteria may lead to improved outcomes and decreased complication rates. The purpose of this study was to review the results of resurfacing performed by an experienced surgeon to determine if implant survival and complication rates were different between subgroups of patients with different demographic factors.

Materials and methods: We evaluated 311 patients who had a hip resurfacing arthroplasty performed after the initial learning curve and who had a minimum follow-up of 5 years (mean, 93 months). These patients were compared to a group of 93 patients (96 hips) who underwent resurfacings, with newer selection criteria based on the findings of the first cohort.

Results: Overall, there were 10 failures in the first patient cohort (97% survivorship), compared to no failures in the second cohort. Higher revision rates were associated with patients who had osteonecrosis or rheumatoid arthritis. Patients who had femoral component sizes larger than 50 millimeters had lower revision rates. There were no revisions in patients who were under 50 years of age, had head sizes greater than 50 millimeters, and who had a primary diagnosis of osteoarthritis.

Discussion: After evaluating our initial experience after the learning curve, the ideal patient selection criteria was determined to be young males who have femoral head sizes greater than 50 millimeters. The early results are encouraging in that, although resurfacing may not be appropriate for all patients, it can provide predictable, excellent survivorship in these patients.

The incidence of isthmic spondylolysis is approximately 3% to 6% in the general population. Spondylolytic defects involving multiple vertebral levels, on the other hand, are extremely rare. Only a handful of reports have examined the outcomes of surgical treatment of multi-level spondylolysis. Here, we present one case of bilateral pars defects at L3, L4, and L5. The patient, a 46-year-old female, presented with lower back pain radiating into the left lower extremity. Radiographs and CT scans of the lumbar spine revealed bilateral pars defects at L3-L5. The patient underwent lumbar discectomy and interbody fusion of L4-S1 as well as direct repair of the pars defect at L3. There were no postoperative complications, and by seven months the patient had improved clinically. While previous reports describe the use of either direct repair or fusion in the treatment of spondylolysis, we are unaware of reports describing the use of both techniques at adjacent levels.