Adiposity, hormone replacement therapy use and breast cancer risk by age and hormone receptor status: a large prospective cohort study.

INTRODUCTION Associations of hormone-receptor positive breast cancer with excess adiposity are reasonably well characterized; however, uncertainty remains regarding the association of body mass index (BMI) with hormone-receptor negative malignancies, and possible interactions by hormone replacement therapy (HRT) use. METHODS Within the European EPIC cohort, Cox proportional hazards models were used to describe the relationship of BMI, waist and hip circumferences with risk of estrogen-receptor (ER) negative and progesterone-receptor (PR) negative (n = 1,021) and ER+PR+ (n = 3,586) breast tumors within five-year age bands. Among postmenopausal women, the joint effects of BMI and HRT use were analyzed. RESULTS For risk of ER-PR- tumors, there was no association of BMI across the age bands. However, when analyses were restricted to postmenopausal HRT never users, a positive risk association with BMI (third versus first tertile HR = 1.47 (1.01 to 2.15)) was observed. BMI was inversely associated with ER+PR+ tumors among women aged ≤49 years (per 5 kg/m2 increase, HR = 0.79 (95%CI 0.68 to 0.91)), and positively associated with risk among women ≥65 years (HR = 1.25 (1.16 to 1.34)). Adjusting for BMI, waist and hip circumferences showed no further associations with risks of breast cancer subtypes. Current use of HRT was significantly associated with an increased risk of receptor-negative (HRT current use compared to HRT never use HR: 1.30 (1.05 to 1.62)) and positive tumors (HR: 1.74 (1.56 to 1.95)), although this risk increase was weaker for ER-PR- disease (Phet = 0.035). The association of HRT was significantly stronger in the leaner women (BMI ≤22.5 kg/m2) than for more overweight women (BMI ≥25.9 kg/m2) for, both, ER-PR- (HR: 1.74 (1.15 to 2.63)) and ER+PR+ (HR: 2.33 (1.84 to 2.92)) breast cancer and was not restricted to any particular HRT regime. CONCLUSIONS An elevated BMI may be positively associated with risk of ER-PR- tumors among postmenopausal women who never used HRT. Furthermore, postmenopausal HRT users were at an increased risk of ER-PR- as well as ER+PR+ tumors, especially among leaner women. For hormone-receptor positive tumors, but not for hormone-receptor negative tumors, our study confirms an inverse association of risk with BMI among young women of premenopausal age. Our data provide evidence for a possible role of sex hormones in the etiology of hormone-receptor negative tumors.

Official Positions for FRAX(®) clinical regarding glucocorticoids: the impact of the use of glucocorticoids on the estimate by FRAX(®) of the 10 year risk of fracture from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX(®).

Given the significant impact the use of glucocorticoids can have on fracture risk independent of bone density, their use has been incorporated as one of the clinical risk factors for calculating the 10-year fracture risk in the World Health Organization's Fracture Risk Assessment Tool (FRAX(®)). Like the other clinical risk factors, the use of glucocorticoids is included as a dichotomous variable with use of steroids defined as past or present exposure of 3 months or more of use of a daily dose of 5 mg or more of prednisolone or equivalent. The purpose of this report is to give clinicians guidance on adjustments which should be made to the 10-year risk based on the dose, duration of use and mode of delivery of glucocorticoids preparations. A subcommittee of the International Society for Clinical Densitometry and International Osteoporosis Foundation joint Position Development Conference presented its findings to an expert panel and the following recommendations were selected. 1) There is a dose relationship between glucocorticoid use of greater than 3 months and fracture risk. The average dose exposure captured within FRAX(®) is likely to be a prednisone dose of 2.5-7.5 mg/day or its equivalent. Fracture probability is under-estimated when prednisone dose is greater than 7.5 mg/day and is over-estimated when the prednisone dose is less than 2.5 mg/day. 2) Frequent intermittent use of higher doses of glucocorticoids increases fracture risk. Because of the variability in dose and dosing schedule, quantification of this risk is not possible. 3) High dose inhaled glucocorticoids may be a risk factor for fracture. FRAX(®) may underestimate fracture probability in users of high dose inhaled glucocorticoids. 4) Appropriate glucocorticoid replacement in individuals with adrenal insufficiency has not been found to increase fracture risk. In such patients, use of glucocorticoids should not be included in FRAX(®) calculations.

Measurements of three-dimensional glenoid erosion when planning the prosthetic replacement of osteoarthritic shoulders.

The three-dimensional (3D) correction of glenoid erosion is critical to the long-term success of total shoulder replacement (TSR). In order to characterise the 3D morphology of eroded glenoid surfaces, we looked for a set of morphological parameters useful for TSR planning. We defined a scapular coordinates system based on non-eroded bony landmarks. The maximum glenoid version was measured and specified in 3D by its orientation angle. Medialisation was considered relative to the spino-glenoid notch. We analysed regular CT scans of 19 normal (N) and 86 osteoarthritic (OA) scapulae. When the maximum version of OA shoulders was higher than 10°, the orientation was not only posterior, but extended in postero-superior (35%), postero-inferior (6%) and anterior sectors (4%). The medialisation of the glenoid was higher in OA than normal shoulders. The orientation angle of maximum version appeared as a critical parameter to specify the glenoid shape in 3D. It will be very useful in planning the best position for the glenoid in TSR.

Total ankle replacement for rheumatoid arthritis of the ankle.

Rheumatoid arthritis is an autoimmune disease that may affect multiple joints, both small and large, and leads to numerous complications. The standard surgical treatment for a rheumatoid arthritic ankle has been an arthrodesis. The ideal candidate for an ankle replacement in a rheumatoid patient is one who is moderately active, has a well-aligned ankle and heel, and a fair range of motion in the ankle joint. Good surgical technique and correction of any hindfoot deformity will result in satisfactory alignment of the ankle with regard to the mechanical axis, and this will lead to increased prosthetic longevity.

Infection after total ankle replacement : A 5-year retrospective analysis of 92 implanted ankle prostheses (2004-2008).

Objectives: Total ankle replacement (TAR) is increasingly used for treatment of primary or posttraumatic arthritis of the ankle joint, if joint movement is intended to be preserved. Data on characteristics and treatment of ankle prosthetic joint infection (PJI) is limited and no validated therapeutic algorithm exist. Therefore, we analyzed all infections, which occurred in a cohort of implanted ankle prostheses during a 5-year-period.Methods: Between 06/2004 and 12/2008, all patients with an implanted ankle prosthesis at our institution were retrospectively reviewed. All patients were operated by the same surgical team. Ankle PJI was defined as visible purulence, acute inflammation on histopathology, sinus tract, or microbial growth in periprosthetic tissue or sonication fluid of the removed prosthesis. The surgery on the infected ankle prosthesis and the follow-up were performed by the surgical team, who implanted the prosthesis. A specialized septic team consisting of an orthopaedic surgeon and infectious diseases consultant were included in the treatment.Results: During the study period, 92 total ankle prostheses were implanted in 90 patients (mean age 61 years, range 28-80 years). 78 patients had posttraumatic arthritis, 11 rheumatoid arthritis and 3 other degenerative disorder. Ankle PJI occurred in 3 of 92 TAR (3.3%), occurring 1, 2 and 24 months after implantation; the causative organisms were Enterobacter cloacae, Streptococcus pyogenes and Staphylococcus epidermidis, respectively. The ankle prosthesis was removed in all infected patients, including debridement of the surrounding tissue was debrided and insertion of an antibiotic loaded spacer. Provisional arthrodesis was performed by external fixation in two patients and by plaster cast in one. A definitive ankle arthrodesis with a retrograde nail was performed 6 to 8 weeks after prosthesis removal. One patient needed a flap coverage. All 3 patients received intravenous antibiotic treatment for 2 weeks, followed by oral antibiotics for 4-6 weeks. At follow-up visit up to 18 months after start of treatment, all patients were without clinical or laboratory signs of infection.Conclusions: The infection incidence after TAR was 3.3%, which is slightly higher than reported after hip (<1%) or knee arthroplasty (<2%). A two-step approach consisting of removal of the infected prosthesis, combined with local and systemic antibiotic treatment, followed by definitive ankle arthrodesis shows good results. Larger patient cohort and longer follow-up evaluation is needed to define the optimal treatment approach for ankle PJI.

Outcome after proximal femoral fractures during primary total hip replacement by the direct anterior approach.

BACKGROUND: The literature suggests that intraoperative fractures of the greater trochanter and the metaphysis are increased with uncemented stems and the direct anterior approach. This study aims to determine the incidence and assess the functional and radiological outcome after such fractures. METHODS: 484 consecutive total hip replacements (THR) (64 ± 12 years) were analyzed. We treated trochanteric fractures conservatively without any further denuding, and secured metaphyseal fissures with cerclages. Postoperative X-rays and at the latest follow-up were compared to assess secondary fracture displacement and stem subsidence. Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores after 1 year were analyzed. For each patient sustaining a fracture, two patients without fractures were matched in terms of age, body mass index and gender. RESULTS: 13 (2.7 %, 5 male, 68 ± 9 years) patients with intraoperative fractures of the greater trochanter (n = 8) or the metaphysis (n = 5) were analyzed. Consolidation was observed in 7/8 patients sustaining a trochanteric fracture while secondary displacement of the fragment occurred in one case. Stem subsidence was observed in 2/5 cases (5 and 7 mm). Patients who sustained a fracture showed a trend towards poorer WOMAC scores at 1 year postoperatively, compared to patients without fractures. A significantly increased joint stiffness was also observed. CONCLUSION: The intraoperative fracture risk in this series of THR through a direct anterior approach was 2.7 %. Trochanteric fractures do heal without primary fixation. Metaphyseal fractures heal well if immediately stabilized with a cerclage.

Negative emotions affect postoperative scores for evaluating functional knee recovery and quality of life after total knee replacement

This study aimed to determine whether psychological factors affect health-related quality of life (HRQL) and recovery of knee function in total knee replacement (TKR) patients. A total of 119 TKR patients (male: 38; female: 81) completed the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), State Trait Anxiety Inventory (STAI), Eysenck Personality Questionnaire-revised (EPQR-S), Knee Society Score (KSS), and HRQL (SF-36). At 1 and 6 months after surgery, anxiety, depression, and KSS scores in TKR patients were significantly better compared with those preoperatively (P<0.05). SF-36 scores at the sixth month after surgery were significantly improved compared with preoperative scores (P<0.001). Preoperative Physical Component Summary Scale (PCS) and Mental Component Summary Scale (MCS) scores were negatively associated with extraversion (E score) (B=-0.986 and -0.967, respectively, both P<0.05). Postoperative PCS and State Anxiety Inventory (SAI) scores were negatively associated with neuroticism (N score; B=-0.137 and -0.991, respectively, both P<0.05). Postoperative MCS, SAI, Trait Anxiety Inventory (TAI), and BAI scores were also negatively associated with the N score (B=-0.367, -0.107, -0.281, and -0.851, respectively, all P<0.05). The KSS function score at the sixth month after surgery was negatively associated with TAI and N scores (B=-0.315 and -0.532, respectively, both P<0.05), but positively associated with the E score (B=0.215, P<0.05). The postoperative KSS joint score was positively associated with postoperative PCS (B=0.356, P<0.05). In conclusion, for TKR patients, the scores used for evaluating recovery of knee function and HRQL after 6 months are inversely associated with the presence of negative emotions.

Preoperative education and its influence on perception of recovery for clients awaiting total hip and total knee replacement surgery /

The puqjose of this study was to examine the manner in which an inviting approach to a preoperative teaching and learning educational experience influenced the perception and subsequent recovery of clients who were awaiting total hip and total knee replacement surgery. An in-depth review of the internal and external factors that shape client perceptions was undertaken in this study. In addition, this study also explored whether or not the Prehab Program was preparing clients physically, socially, and psychologically for surgery. Data for this qualitative case study research were collected through preoperative interviews with 4 participants awaiting total hip replacement surgery and 1 participant awaiting total knee replacement surgery. Four postoperative interviews were conducted with the participants who had received total hip replacement surgery. The occupational therapist and physical therapist who were the coleaders of the Prehab Program at the time of this study were also interviewed. The results of this study suggest that while individuals may receive similar educational experiences, their perceptions of the manner in which they benefited from these experiences varied. This is illustrated in the research findings, which concluded that while clients benefited physically from the inviting approach used during the practical teaching session, not all clients perceived the psychological benefits of this practice session, especially clients with preexisting high levels of anxiety. In addition to increasing the understanding of the internal as well as external factors that influence the perceptions of clients, this study has also served as an opportunity for reflection on practice for the Prehab therapists and other healthcare educators.

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts (R) total joint prostheses Part IV - Soft tissue response

The purpose of this Study was to evaluate Soft tissue response to rnaxillo-mandibular counter-clockwise rotation, with TMJ reconstruction and mandibular advancement using TMJ Concepts (R) total joint prostheses, and maxillary osteotomies in 44 females. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one Surgeon (Wolford). Eighteen patients had genioplasties with either porous block hydroxyapatite or hard tissue replacement implants (Group 2) 26 had no genioplasty (Group 1). Surgically, the maxilla moved forward and upward by counter-clockwise maxillo-mandibular rotation with greater horizontal movement in Group 2. Vertically, both groups showed diversity of maxillo-mandibular mean movement. Group I showed a consistent 1:0.97 ratio of hard to soft tissue advancement at pogonion; Group 2 results were less consistent, with ratios between 1:0.84 and 1:1.02. Horizontal changes in upper lip morphology after maxillary advancement/impaction, VY closure, and alar base cinch sutures showed greater movement in both groups, than observed in hard tissue. Counter-clockwise rotation of the maxillo-mandibular complex using TMJ Concepts total joint prostheses resulted in similar soft tissue response as previously reported for traditional maxillo-mandibular advancement without counter-clockwise rotation of the occlusal plane. The association of chin implants, in the present sample, showed higher variability of soft tissue response.

Evaluation of temporomandibular joint noise in partially edentulous patients.

In order to evaluate the presence of TMD (temporomandibular disorder), dissatisfaction related to the use of removable partial dentures (RPD) and the effect of the treatment on temporomandibular joint noises, 13 female patients with Kennedy class I and II mandibular arch were selected. Another 13 young, asymptomatic, dentate patients, also female, were used as reference. After four years, 38.4% were found to have a moderate or severe degree of TMD. Over the four years, the degree of TMD increased in 46.15% of the patients, was not affected in 20.07%, while in 15.38% it decreased or the patients remained free from signs and symptoms. About 30% of the patients at the second year and 46% after the fourth year, had complaints regarding retention and stability. It was concluded that there is no relationship between TMD and the condition of partially edentulous Kennedy class I and II, but patient dissatisfaction increased after the second year and temporomandibular joint noise was reduced significantly with the replacement of the teeth.

Maxillo-mandibular counter-clockwise rotation and mandibular advancement with TMJ Concepts (R) total joint prostheses Part I - Skeletal and dental stability

The purpose of this study was to evaluate skeletal and dental stability in patients who had temporomandibular joint (TMJ) reconstruction and mandibular counterclockwise advancement using TMJ Concepts total join, prostheses (TMJ Concepts Inc. Ventura, CA) with maxillary osteotomies being performed at the same operation. All patients were operated at Baylor University Medical Center, Dallas TX, USA, by one surgeon (Wolford). Forty-seven females were studied; the average post-surgical follow-up was 40.6 months. Lateral cephalograms were analyzed to estimate surgical and post-surgical changes. During surgery, the occlusal plane angle decreased 14.9 +/- 8.0 degrees. The maxilla moved forward and upward. The posterior nasal spine moved downward and forward. The mandible advanced 7.9 +/- 3.5 mm at the lower incisor tips, 12.4 +/- 5.4 mm at Point B, 17.3 +/- 7.0 mm at menton, 18.4 +/- 8.5 mm at pogonion, and 11.0 +/- 5.3 mm at gonion. Vertically, the lower incisors moved upward -2.9 +/- 4.0 mm. At the longest follow-up post surgery, the maxilla showed minor horizontal changes while all mandibular measurements remained stable. TMJ reconstruction and mandibular advancement with TMJ Concepts total joint prosthesis in conjunction with maxillary osteotomies for counter-clockwise rotation of the rnaxillo-mandibular complex was a stable procedure for these patients at the longest follow-up.

International survey of primary and revision total knee replacement

Purpose Total knee arthroplasty (TKA) is currently the international standard of care for treating degenerative and rheumatologic knee joint disease, as well as certain knee joint fractures. We sought to answer the following three research questions: (1) What is the international variance in primary and revision TKA rates around the world? (2) How do patient demographics (e.g., age, gender) vary internationally? (3) How have the rates of TKA utilization changed over time? Methods The survey included 18 countries with a total population of 755 million, and an estimated 1,324,000 annual primary and revision total knee procedures. Ten national inpatient databases were queried for this study from Canada, the United States, Finland, France, Germany, Italy, the Netherlands, Portugal, Spain, and Switzerland. Inpatient data were also compared with published registry data for eight countries with operating arthroplasty registers (Denmark, England & Wales, Norway, Romania, Scotland, Sweden, Australia, and New Zealand). Results The average and median rate of primary and revision (combined) total knee replacement was 175 and 149 procedures/100,000 population, respectively, and ranged between 8.8 and 234 procedures/100,000 population. We observed that the procedure rate significantly increased over time for the countries in which historical data were available. The compound annual growth in the incidence of TKA ranged by country from 5.3% (France) to 17% (Portugal). We observed a nearly 27-fold range of TKA utilization rates between the 18 different countries included in the survey. Conclusion It is apparent from the results of this study that the demand for TKA has risen substantially over the past decade in countries around the world.

Impact of complications in total ankle replacement and ankle arthrodesis analyzed with a validated outcome measurement

Major modifications in the design and techniques of total ankle replacement have challenged the perception that ankle arthrodesis is the treatment of choice for end-stage ankle arthritis. High complication and revision rates have been reported after both procedures.

Effects of glenoid component version on humeral head displacement and joint reaction forces: an experimental study

The purpose of this study was to determine whether changes in glenoid version are associated with humeral head displacement and changes in the joint reaction forces, as these might contribute to instability or loosening in total shoulder replacement. A total shoulder prosthesis was implanted in neutral version in 6 cadaveric shoulders. Glenoid version was then changed in steps of 4 degrees toward more anteversion and retroversion. An increase in anteversion resulted in anterior translation of the humeral head and in eccentric loading of the anterior part of the glenoid. Retroversion was associated with posterior displacement and posterior loading of the glenoid. A change in rotation of the humeral component did not compensate for altered version of the glenoid component. These results suggest that both instability and glenoid component loosening may be related to the version of the glenoid component. Therefore, assessment of loosening and instability justifies precise assessment of glenoid component version.