Highlights • This paper provides a comprehensive review of literature on the detriments to healing of diabetic foot ulcers. • This paper will assist in guiding physicians on effective treatment of ...diabetic foot ulcers. • This paper will highlight areas of research potential for treatment of diabetic foot ulcers.
There are several types of prostheses available to surgeons when performing a total ankle arthroplasty (TAA). The main objective of this study was to summarize the clinical and functional outcomes of ...4 TAA prostheses: the Hintegra implant (Integra LifeSciences), the Agility implant (DePuy), the Mobility implant (DePuy), and the Scandinavian Total Ankle Replacement (STAR) implant (Small Bone Innovations SBi).
Patients were prospectively recruited. A total of 451 TAAs with a mean follow-up (and standard deviation) of 4.5 ± 2.0 years were included. Patients were assessed annually and completed self-reported outcome measures at these visits. Complications and revisions were reported at the time of incident. Mean improvements are reported by prosthesis. Linear mixed-effects models were used to obtain adjusted comparisons of scores across prostheses. Survivorship curves were generated by prosthesis and type of complication.
Mean improvement in the Ankle Osteoarthritis Scale (AOS) total score was less among patients with the Mobility implant (19.5; 95% confidence interval CI, 15 to 24) than it was among patients with the Agility implant (29.1; 95% CI, 24 to 34), Hintegra implant (29.7; 95% CI, 27 to 33), and STAR implant (28.5; 95% CI, 23 to 34). Patients in the Mobility group also had less mean improvement in the AOS pain score (21.3; 95% CI, 17 to 26) compared with patients in the Hintegra (29.0; 95% CI, 26 to 32), Agility (29.8; 95% CI, 25 to 35), and STAR (29.1; 95% CI, 23 to 35) groups. The Mobility group also had less mean improvement in the AOS disability score (17.3; 95% CI, 12 to 23) compared with the Hintegra (30.4; 95% CI, 27 to 34), Agility (28.8; 95% CI, 23 to 34), and STAR (27.8; 95% CI, 21 to 34) groups. Survival results among the 4 prostheses are reported.
This study demonstrated acceptable outcomes of 4 modern TAA prostheses. Outcome results from patient-reported scores were comparable between at least 3 of the 4 prostheses (the Hintegra, STAR, and Agility implants). The rates of complications and revisions found in this study are within the limits reported in the literature for similar prostheses and methods of reporting.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Summary Background Intimate partner violence (IPV) is the leading cause of non-fatal injury to women worldwide. Musculoskeletal injuries, which are often seen by orthopaedic surgeons, are the second ...most common manifestation of IPV. We aimed to establish the 12-month and lifetime prevalence of IPV in women presenting to orthopaedic fracture clinics. Methods The PRAISE team of 80 investigators did a cross-sectional study of a consecutive sample of 2945 female participants at 12 orthopaedic fracture clinics in Canada, the USA, the Netherlands, Denmark, and India. Participants who met the eligibility criteria anonymously answered direct questions about physical, emotional, and sexual IPV, and completed two previously developed questionnaires (Women Abuse Screening Tool WAST and Partner Violence Screen PVS). We did a multivariable logistic regression analysis to investigate the risk factors associated with IPV. Findings The overall response rate was 85% (2344 of 2759 patients provided informed consent). One in six women (455/2839, 16·0%, 95% CI 14·7–17·4%) disclosed a history of IPV within the past year, and one in three (882/2550, 34·6%, 32·8–36·5%) had experienced IPV in their lifetime. 49 women (1·7%, 1·3–2·2%) attended their clinic visit as a direct consequence of IPV, only seven of whom (14%) had ever been asked about IPV in a health-care setting. Women in short-term relationships (OR 0·584, 99% CI 0·396–0·860, p=0·0001) were at increased risk of IPV and physical abuse in the past 12 months in this study. Compared with women in Canada and the USA, those in the Netherlands and Denmark were at reduced risk of any abuse in the past 12 months, physical abuse in lifetime, and any abuse in lifetime (OR 0·595, 99% CI 0·427–0·830, p<0·0001; 0·630, 0·445–0·890, p=0·001; and 0·464, 0·352–0·612, p<0·0001, respectively). Interpretation PRAISE is the largest prevalence study done so far in orthopaedics. Orthopaedic surgeons should be confident in the assumption that one in six women have a history of physical abuse, and that one in 50 injured women will present to the clinic as a direct result of IPV. Our findings warrant serious consideration for fracture clinics to improve identification of, respond to, and provide referral services for, victims of IPV. Funding Orthopaedic Trauma Association, Canadian Orthopaedic Foundation, and the McMaster University Surgical Associates. MB is partly funded by a Canada Research Chair.
Chronic, non-cancer pain affects approximately 20-30% of the population in North America, Europe, and Australia, with surgery and trauma frequently cited as inciting events. Prospective studies of ...fracture patients have demonstrated an association between somatic pre-occupation, poor coping, and low recovery expectations following surgery with persistent pain, functional limitations, and lower rates of return to work. Psychological interventions, such as cognitive behavioural therapy (CBT), that are designed to modify unhelpful beliefs and behaviours have the potential to reduce persistent post-surgical pain and its associated effects among trauma patients.
To determine whether online CBT, versus usual care, reduces the prevalence of moderate to severe persistent post-surgical pain among participants with an open or closed fracture of the appendicular skeleton.
The Cognitive Behavioural Therapy to Optimize Post-Operative Fracture Recovery (COPE) protocol will be followed to conduct a multi-centre randomized controlled trial. Participants undergoing surgical repair of a long bone fracture will be randomized to receive either (1) online CBT modules with asynchronous therapist feedback or (2) usual care. The primary outcome will be the prevalence of moderate to severe persistent post-surgical pain over 12 months post-fracture. Secondary outcomes include the Short Form-36 Physical and Mental Component Summary scores, return to function, pain severity and pain interference over 12 months post-fracture, and the proportion of patients prescribed opioid class medications (and average dose) at 6 and 12 months post-fracture. The COPE trial will enroll 1000 participants with open and closed fractures of the appendicular skeleton from approximately 10 hospitals in North America.
If CBT is effective in improving outcomes among patients with traumatic fractures, our findings will promote a new model of care that incorporates psychological barriers to recovery.
ClinicalTrials.gov Identifier: NCT04274530. Registered on 14 February 2020.
Extremity fractures are common, and most are managed operatively; however, despite successful reduction, up to half of patients report persistent post-surgical pain. Furthermore, psychological ...factors such as stress, distress, anxiety, depression, catastrophizing, and fear-avoidance behaviors have been associated with the development of chronic pain. The purpose of this pilot study was to examine the feasibility of a randomized controlled trial to determine the effect of in-person cognitive behavioral therapy (CBT) vs. usual care on persistent post-surgical pain among patients with a surgically managed extremity fracture.
Eligible patients were randomized to either in-person CBT or usual care. We used four criteria to judge the composite measure of feasibility: 1) successful implementation of CBT at each clinical site, 2) 40 patients recruited within 6 months, 3) treatment compliance in a minimum 36 of 40 participants (90%), and 4) 32 of 40 participants (80%) achieving follow-up at one year. The primary clinical outcome was persistent post-surgical pain at one year after surgery.
Only two of the four participating sites were able to implement the CBT regimen due to difficulties with identifying certified therapists who had the capacity to accommodate additional patients into their schedule within the required timeframe (i.e., 8 weeks of their fracture). Given the challenges associated with CBT implementation, only one site was able to actively recruit patients. This site screened 86 patients and enrolled 3 patients (3.5%) over a period of three months. Participants were unable to comply with the in-person CBT, with no participants attending an in-person CBT session. Follow-up at one year could not be assessed as the pilot study was stopped early, three months into the study, due to failure to achieve the other three feasibility criteria.
Our pilot trial failed to demonstrate the feasibility of a trial of in-person CBT versus usual care to prevent persistent pain after surgical repair of traumatic long-bone fractures and re-enforces the importance of establishing feasibility before embarking on definitive trials. Protocol modifications to address the identified barriers include the delivery of our intervention as a therapist-guided, remote CBT program.
ClinicalTrials.gov (Identifier NCT03196258); Registered June 22, 2017, https://clinicaltrials.gov/ct2/show/NCT03196258.
Abstract
β2 (CD18) integrins (CD11a,b,c,d) are important adhesion molecules necessary for leukocyte migration, homing, and cell to cell interactions. CD18-deficiency in humans is characterized by ...recurrent bacterial infections and poor wound healing, due to defects in leukocyte activation and migration. However, the in vivo role of each of the individual β2 family members is poorly understood. CD11a, CD11b and CD11c are all upregulated on activated CD8 T cells. In order to study the potential role of β2 integrins in host defense, CD11a, CD11b and CD11c deficient and wildtype mice were infected with Listeria monocytogenes (LM). Our results indicate that the absence of CD11b and CD11c had no effect on antigen specific CD8 T cells in response to infection with LM. On the contrary, after infection, antigen specific CD8 T cells in CD11a -/- mice exhibited diminished proliferation and activation resulting in significantly reduced numbers at the peak of the response. Moreover, CD11a KO mice exhibited a reduced differentiation of short lived effectors subset (KLRG1 hi CD127 lo) although cytokine and granzyme B production was unaffected. Interestingly, upon secondary infection with LM, antigen specific memory CD8 T cells in CD11a KO responded robustly. Overall, these results suggest that CD11a plays a crucial role in regulation of primary CD8 T cell effector differentiation, but may be dispensable for secondary responses to Listeria infection.
The initial engagement of the TCR through interaction with cognate peptide-MHC is a requisite for T cell activation and confers Ag specificity. Although this is a key event in T cell activation, the ...duration of these interactions may affect the proliferative capacity and differentiation of the activated cells. In this study, we developed a system to evaluate the temporal requirements for antigenic stimulation during an immune response in vivo. Using Abs that target specific Ags in the context of MHC, we were able to manipulate the duration of Ag availability to both CD4 and CD8 T cells during an active infection. During the primary immune response, the magnitude of the CD4 and CD8 T cell response was dependent on the duration of Ag availability. Both CD4 and CD8 T cells required sustained antigenic stimulation for maximal expansion. Memory cell differentiation was also dependent on the duration of Ag exposure, albeit to a lesser extent. However, memory development did not correlate with the magnitude of the primary response, suggesting that the requirements for continued expansion of T cells and memory differentiation are distinct. Finally, a shortened period of Ag exposure was sufficient to achieve optimal expansion of both CD4 and CD8 T cells during a recall response. It was also revealed that limiting exposure to Ag late during the response may enhance the CD4 T cell memory pool. Collectively, these data indicated that Ag remains a critical component of the T cell response after the initial APC-T cell interaction.
The process of lymphopoiesis begins in the bone marrow (BM) and requires multiple cellular intermediates. For T cell production, lymphoid progenitors exit the BM and home to the thymus where ...maturation and selection ensue. These processes are dependent on a number of factors, including chemokines and adhesion molecules. Although the β2 integrin CD11a plays an important role in the migration of lymphocytes to lymph nodes, the role of CD11a in T cell development is largely undefined. Our studies now show that, in CD11a(-/-) mice, thymic cellularity was decreased and early T cell development was partially impaired. Remarkably, CD11a was critical for generation of common lymphoid progenitors (CLPs) and lymphoid-primed multipotent progenitors. However, in intact CD11a(-/-) mice, peripheral B and T cell subsets were only modestly altered, suggesting that compensatory mechanisms were operating. In contrast, competitive BM-reconstitution assays revealed an essential role for CD11a in the generation of thymocytes and mature T and B cells. This defect was linked to the requirement for CD11a in the development of CLPs. Furthermore, our results identified CLPs, and not lymphoid-primed multipotent progenitors, as the requisite CD11a-dependent precursor for lymphocyte development. Thus, these findings established a key role for CD11a in lymphopoiesis.
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