Background: Seven patients at a hospital in Houston, TX, were diagnosed during a two-week period in 2009 with joint space infection of pansusceptible P. aeruginosa following arthroscopic procedures of the knee or shou...Background: Seven patients at a hospital in Houston, TX, were diagnosed during a two-week period in 2009 with joint space infection of pansusceptible P. aeruginosa following arthroscopic procedures of the knee or shoulder. Tosh et al. (2011), who investigated and published the principal report discussing this bacterial outbreak, conclude that its most likely cause was the improper reprocessing of certain reusable, physically-complex, heat-stable arthroscopic instruments used during these arthroscopic procedures. These reusable instruments reportedly remained contaminated with remnant tissue, despite diligent efforts by the hospital to clean their internal structures. This retained bioburden presumably shielded the outbreak’s strain of embedded P. aeruginosa from contact with the pressurized steam, reportedly resulting in ineffective sterilization of these arthroscopic instruments and bacterial transmission. Objectives: First, to clarify which specific sterilization methods, in addition to steam sterilization, Methodist Hospital employed to process its reusable arthroscopic instrumentation at the time of its outbreak, in 2009;second, to evaluate Tosh et al.’s (2011) conclusion that ineffective steam sterilization due to inadequate cleaning was the most likely cause of this hospital’s outbreak;third, to consider whether any other hitherto unrecognized factors could have plausibly contributed to this outbreak;and, fourth, to assess whether any additional recommendations might be warranted to prevent disease transmission following arthroscopic procedures. Methods: The medical literature was reviewed;some of the principles of quality assurance, engineering and a root-cause analysis were employed;and Tosh et al.’s (2011) findings and conclusions were reviewed and compared with those of other published reports that evaluated the risk of disease transmission associated with the steam sterilization of physically-complex, heat-stable, soiled surgical instruments. Results and Conclusion: Reports documenting outbreaks of P. aeruginosa or another vegetative bacterium associated with the steam sterilization of inadequately cleaned surgical or arthroscopic instruments are scant. This finding—coupled with a number of published studies demonstrating the effective steam sterilization of complex instruments contaminated with vegetative bacteria mixed with organic debris, or, in one published series of tests, with resistant bacterial endospores coated with hydraulic fluid—raises for discussion whether Methodist Hospital’s outbreak might have been due to one or more factors other than, or in addition to, that which Tosh et al. (2011) conclude was its most likely cause. An example of such a factor not ruled out by Tosh et al. (2011) findings would be the re-contamination of the implicated arthroscopic instruments after sterilization. The specific methods that Methodist Hospital employed at the time of its outbreak to sterilize some of its arthroscopic instrumentation remain unclear. A number of additional recommendations are provided to prevent disease transmission following arthroscopic procedures.展开更多
The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than onethird of the adult meniscus, healing potential in the settin...The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than onethird of the adult meniscus, healing potential in the setting of chronic degeneration remains low. Continued hoop and shear stresses upon the degenerative meniscus results in gross failure, often in the form of complex tears in the posterior horn and midbody. Patient history and physical examination are critical to determine the true source of pain, particularly with the significant incidence of simultaneous articular pathology. Joint line tenderness, a positive Mc Murray test, and mechanical catching or locking can be highly suggestive of a meniscal source of knee pain and dysfunction. Radiographs and magnetic resonance imaging are frequently utilized to examine for osteoarthritis and to verify the presence of meniscal tears, in addition to ruling out other sources of pain. Non-operative therapy focused on nonsteroidal anti-inflammatory drugs and physical therapy may be able to provide pain relief as well as improve mechanical function of the knee joint. For patients re-fractory to conservative therapy, arthroscopic partial meniscectomy can provide short-term gains regarding pain relief, especially when combined with an effective, regular physiotherapy program. Patients with clear mechanical symptoms and meniscal pathology may benefit from arthroscopic partial meniscectomy, but surgery is not a guaranteed success, especially with concomitant articular pathology. Ultimately, the long-term outcomes of either treatment arm provide similar results for most patients. Further study is needed regarding the short and long-term outcomes regarding conservative and surgical therapy, with a particular focus on the economic impact of treatment as well.展开更多
目的:探讨富血小板血浆(platelet-rich plasma,PRP)关节腔注射在关节镜下微骨折术治疗距骨骨软骨损伤(osteochondrallesion of the talus,OLT)中的应用价值。方法:回顾性分析36例OLT患者的病例资料,其中采用关节镜下微骨折术联合PRP...目的:探讨富血小板血浆(platelet-rich plasma,PRP)关节腔注射在关节镜下微骨折术治疗距骨骨软骨损伤(osteochondrallesion of the talus,OLT)中的应用价值。方法:回顾性分析36例OLT患者的病例资料,其中采用关节镜下微骨折术联合PRP关节腔注射治疗19例(联合治疗组),单纯采用关节镜下微骨折术治疗17例(手术治疗组)。比较2组患者治疗前、治疗后6个月、治疗后12个月踝关节疼痛视觉模拟量表(visualanalogue scale,VAS)评分、足与踝关节结局评分(foot and ankleout comescore,FAOS)、美国足与踝关节协会(American Orthopaedic Footand Ankle Society,AOFAS)踝与后足评分及软骨下骨骨髓水肿体积。结果:①踝关节疼痛VAS评分。时间因素和分组因素存在交互效应(F=12.291,P=0.003);2组患者踝关节疼痛VAS评分总体比较,组间差异无统计学意义,即不存在分组效应(F=2.617,P=0.137);治疗前后不同时间点踝关节疼痛VAS评分的差异有统计学意义,即存在时间效应(F=354.262,P=0.000);2组患者踝关节疼痛VAS评分随时间变化均呈下降趋势,但2组的下降趋势不完全一致[联合治疗组:(5.74±1.27)分,(1.94±0.64)分,(0.76±0.25)分,F=532.326,P=0.000;手术治疗组:(5.47±1.05)分,(3.21±0.74)分,(1.64±0.23)分,F=70.097,P=0.000];治疗前,2组患者踝关节疼痛VAS评分比较,差异无统计学意义(t=0.833,P=0.424);治疗后6个月、12个月,联合治疗组踝关节疼痛VAS评分均低于手术治疗组(t=3.634,P=0.005;t=3.627,P=0.005)。②FAOS。时间因素和分组因素存在交互效应(F=7.269,P=0.004);2组患者FAOS总体比较,组间差异有统计学意义,即存在分组效应(F=3.473,P=0.006);治疗前后不同时间点FAOS的差异有统计学意义,即存在时间效应(F=856.830,P=0.000);2组患者FAOS随时间变化均呈上升趋势,但2组的上升趋势不完全一致[联合治疗组:(61.27±3.68)分,(87.81±5.19)分,(97.64±2.43)分,F=630.157,P=0.000;手术治疗组:(60.42±4.82)分,(79.70±7.14)分,(91.12±3.70)分,F=240.758,P=0.000];治疗前,2组患者FAOS比较,差异无统计学意义(t=0.421,P=0.683);治疗后6个月、12个月,联合治疗组FAOS均高于手术治疗组(t=5.846,P=0.000;t=5.420,P=0.000)。③AOFAS踝与后足评分。时间因素和分组因素不存在交互效应(F=0.666,P=0.461);2组患者AOFAS踝与后足评分总体比较,组间差异无统计学意义,即不存在分组效应(F=1.377,P=0.286);治疗前后不同时间点AOFAS踝与后足评分的差异有统计学意义,即存在时间效应(F=1033.580,P=0.000);2组患者AOFAS踝与后足评分随时间变化均呈上升趋势,但2组的上升趋势不完全一致[联合治疗组:(66.93±5.99)分,(88.19±7.87)分,(98.43±6.67)分,F=498.276,P=0.000;手术治疗组:(65.44±4.82)分,(86.47±8.44)分,(94.12±5.09)分,F=413.547,P=0.000];治疗前、治疗后6个月,2组患者AOFAS踝与后足评分比较,组间差异均无统计学意义(t=0.460,P=0.655;t=0.640,P=0.536);治疗后12个月,联合治疗组AOFAS踝与后足评分高于手术治疗组(t=2.400,P=0.037)。④软骨下骨骨髓水肿体积。时间因素和分组因素存在交互效应(F=13.723,P=0.002);2组患者软骨下骨骨髓水肿体积总体比较,组间差异无统计学意义,即不存在分组效应(F=2.256,P=0.164);治疗前后不同时间点软骨下骨骨髓水肿体积的差异有统计学意义,即存在时间效应(F=383.914,P=0.000);2组患者软骨下骨骨髓水肿体积随时间变化均呈下降趋势,但2组的下降趋势不完全一致[联合治疗组:(1.01±0.43)cm3,(0.30±0.17)cm3,(0.12±0.09)cm3,F=204.682,P=0.000;手术治疗组:(0.93±0.37)cm3,(0.52±0.29)cm3,(0.38±0.11)cm3,F=137.510,P=0.000];治疗前,2组患者软骨下骨骨髓水肿体积比较,差异无统计学意义(t=0.760,P=0.465);治疗后6个月、12个月,联合治疗组软骨下骨骨髓水肿体积均小于手术治疗组(t=2.825,P=0.018;t=4.012,P=0.002)。结论:在关节镜下微骨折术治疗OLT中应用PRP关节腔注射,有利于减轻软骨下骨骨髓水肿、缓解踝关节疼痛、改善踝关节功能。展开更多
目的探讨踝关节大骨节病患者采用关节镜清理治疗对缓解其疼痛和改善行走功能及生活质量的影响。方法回顾性分析我院2012年3月-2014年2月40例踝关节大骨节病患者临床病历资料及治疗情况,所有患者均采用关节镜清理治疗,采用视觉模拟评分法...目的探讨踝关节大骨节病患者采用关节镜清理治疗对缓解其疼痛和改善行走功能及生活质量的影响。方法回顾性分析我院2012年3月-2014年2月40例踝关节大骨节病患者临床病历资料及治疗情况,所有患者均采用关节镜清理治疗,采用视觉模拟评分法（visual analogue scale,VAS）评价其治疗前、后疼痛情况,采用美国足踝外科协会（American College of Foot and Ankle Surgeons,AOFAS）踝-后足评分系统及踝关节背伸活动度（range of motion,ROM）评价其行走功能;通过问卷调查来调查患者治疗前、后生活质量情况。结果患者治疗后2月及4月的VAS评分分别为（2.7±1.0）分、（1.5±0.3）分,较治疗前（6.3±1.1）分明显降低,P〈0.05;治疗后2月及4月的AOFAS评分分别为（85.7±5.2）分、（89.7±6.3）分,较治疗前（54.1±6.9）分明显升高,P〈0.05;治疗后2月及4月的踝背伸ROM评分分别为37.9°±5.1°、42.6°±6.8°,较治疗前16.7°±4.2°明显升高,P〈0.05。治疗后2月和治疗后4月患者生活质量评分（76.9±6.7）分、（89.7±10.1）分,较治疗前（51.3±4.1）分明显升高,t=20.61,18.62,P=0.00、0.00。结论应用关节镜清理治疗踝关节大骨节病可有效缓解其关节疼痛,延缓其疾病发展,改善其行走功能,提高患者生活质量。展开更多
文摘Background: Seven patients at a hospital in Houston, TX, were diagnosed during a two-week period in 2009 with joint space infection of pansusceptible P. aeruginosa following arthroscopic procedures of the knee or shoulder. Tosh et al. (2011), who investigated and published the principal report discussing this bacterial outbreak, conclude that its most likely cause was the improper reprocessing of certain reusable, physically-complex, heat-stable arthroscopic instruments used during these arthroscopic procedures. These reusable instruments reportedly remained contaminated with remnant tissue, despite diligent efforts by the hospital to clean their internal structures. This retained bioburden presumably shielded the outbreak’s strain of embedded P. aeruginosa from contact with the pressurized steam, reportedly resulting in ineffective sterilization of these arthroscopic instruments and bacterial transmission. Objectives: First, to clarify which specific sterilization methods, in addition to steam sterilization, Methodist Hospital employed to process its reusable arthroscopic instrumentation at the time of its outbreak, in 2009;second, to evaluate Tosh et al.’s (2011) conclusion that ineffective steam sterilization due to inadequate cleaning was the most likely cause of this hospital’s outbreak;third, to consider whether any other hitherto unrecognized factors could have plausibly contributed to this outbreak;and, fourth, to assess whether any additional recommendations might be warranted to prevent disease transmission following arthroscopic procedures. Methods: The medical literature was reviewed;some of the principles of quality assurance, engineering and a root-cause analysis were employed;and Tosh et al.’s (2011) findings and conclusions were reviewed and compared with those of other published reports that evaluated the risk of disease transmission associated with the steam sterilization of physically-complex, heat-stable, soiled surgical instruments. Results and Conclusion: Reports documenting outbreaks of P. aeruginosa or another vegetative bacterium associated with the steam sterilization of inadequately cleaned surgical or arthroscopic instruments are scant. This finding—coupled with a number of published studies demonstrating the effective steam sterilization of complex instruments contaminated with vegetative bacteria mixed with organic debris, or, in one published series of tests, with resistant bacterial endospores coated with hydraulic fluid—raises for discussion whether Methodist Hospital’s outbreak might have been due to one or more factors other than, or in addition to, that which Tosh et al. (2011) conclude was its most likely cause. An example of such a factor not ruled out by Tosh et al. (2011) findings would be the re-contamination of the implicated arthroscopic instruments after sterilization. The specific methods that Methodist Hospital employed at the time of its outbreak to sterilize some of its arthroscopic instrumentation remain unclear. A number of additional recommendations are provided to prevent disease transmission following arthroscopic procedures.
文摘The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than onethird of the adult meniscus, healing potential in the setting of chronic degeneration remains low. Continued hoop and shear stresses upon the degenerative meniscus results in gross failure, often in the form of complex tears in the posterior horn and midbody. Patient history and physical examination are critical to determine the true source of pain, particularly with the significant incidence of simultaneous articular pathology. Joint line tenderness, a positive Mc Murray test, and mechanical catching or locking can be highly suggestive of a meniscal source of knee pain and dysfunction. Radiographs and magnetic resonance imaging are frequently utilized to examine for osteoarthritis and to verify the presence of meniscal tears, in addition to ruling out other sources of pain. Non-operative therapy focused on nonsteroidal anti-inflammatory drugs and physical therapy may be able to provide pain relief as well as improve mechanical function of the knee joint. For patients re-fractory to conservative therapy, arthroscopic partial meniscectomy can provide short-term gains regarding pain relief, especially when combined with an effective, regular physiotherapy program. Patients with clear mechanical symptoms and meniscal pathology may benefit from arthroscopic partial meniscectomy, but surgery is not a guaranteed success, especially with concomitant articular pathology. Ultimately, the long-term outcomes of either treatment arm provide similar results for most patients. Further study is needed regarding the short and long-term outcomes regarding conservative and surgical therapy, with a particular focus on the economic impact of treatment as well.
文摘目的:探讨富血小板血浆(platelet-rich plasma,PRP)关节腔注射在关节镜下微骨折术治疗距骨骨软骨损伤(osteochondrallesion of the talus,OLT)中的应用价值。方法:回顾性分析36例OLT患者的病例资料,其中采用关节镜下微骨折术联合PRP关节腔注射治疗19例(联合治疗组),单纯采用关节镜下微骨折术治疗17例(手术治疗组)。比较2组患者治疗前、治疗后6个月、治疗后12个月踝关节疼痛视觉模拟量表(visualanalogue scale,VAS)评分、足与踝关节结局评分(foot and ankleout comescore,FAOS)、美国足与踝关节协会(American Orthopaedic Footand Ankle Society,AOFAS)踝与后足评分及软骨下骨骨髓水肿体积。结果:①踝关节疼痛VAS评分。时间因素和分组因素存在交互效应(F=12.291,P=0.003);2组患者踝关节疼痛VAS评分总体比较,组间差异无统计学意义,即不存在分组效应(F=2.617,P=0.137);治疗前后不同时间点踝关节疼痛VAS评分的差异有统计学意义,即存在时间效应(F=354.262,P=0.000);2组患者踝关节疼痛VAS评分随时间变化均呈下降趋势,但2组的下降趋势不完全一致[联合治疗组:(5.74±1.27)分,(1.94±0.64)分,(0.76±0.25)分,F=532.326,P=0.000;手术治疗组:(5.47±1.05)分,(3.21±0.74)分,(1.64±0.23)分,F=70.097,P=0.000];治疗前,2组患者踝关节疼痛VAS评分比较,差异无统计学意义(t=0.833,P=0.424);治疗后6个月、12个月,联合治疗组踝关节疼痛VAS评分均低于手术治疗组(t=3.634,P=0.005;t=3.627,P=0.005)。②FAOS。时间因素和分组因素存在交互效应(F=7.269,P=0.004);2组患者FAOS总体比较,组间差异有统计学意义,即存在分组效应(F=3.473,P=0.006);治疗前后不同时间点FAOS的差异有统计学意义,即存在时间效应(F=856.830,P=0.000);2组患者FAOS随时间变化均呈上升趋势,但2组的上升趋势不完全一致[联合治疗组:(61.27±3.68)分,(87.81±5.19)分,(97.64±2.43)分,F=630.157,P=0.000;手术治疗组:(60.42±4.82)分,(79.70±7.14)分,(91.12±3.70)分,F=240.758,P=0.000];治疗前,2组患者FAOS比较,差异无统计学意义(t=0.421,P=0.683);治疗后6个月、12个月,联合治疗组FAOS均高于手术治疗组(t=5.846,P=0.000;t=5.420,P=0.000)。③AOFAS踝与后足评分。时间因素和分组因素不存在交互效应(F=0.666,P=0.461);2组患者AOFAS踝与后足评分总体比较,组间差异无统计学意义,即不存在分组效应(F=1.377,P=0.286);治疗前后不同时间点AOFAS踝与后足评分的差异有统计学意义,即存在时间效应(F=1033.580,P=0.000);2组患者AOFAS踝与后足评分随时间变化均呈上升趋势,但2组的上升趋势不完全一致[联合治疗组:(66.93±5.99)分,(88.19±7.87)分,(98.43±6.67)分,F=498.276,P=0.000;手术治疗组:(65.44±4.82)分,(86.47±8.44)分,(94.12±5.09)分,F=413.547,P=0.000];治疗前、治疗后6个月,2组患者AOFAS踝与后足评分比较,组间差异均无统计学意义(t=0.460,P=0.655;t=0.640,P=0.536);治疗后12个月,联合治疗组AOFAS踝与后足评分高于手术治疗组(t=2.400,P=0.037)。④软骨下骨骨髓水肿体积。时间因素和分组因素存在交互效应(F=13.723,P=0.002);2组患者软骨下骨骨髓水肿体积总体比较,组间差异无统计学意义,即不存在分组效应(F=2.256,P=0.164);治疗前后不同时间点软骨下骨骨髓水肿体积的差异有统计学意义,即存在时间效应(F=383.914,P=0.000);2组患者软骨下骨骨髓水肿体积随时间变化均呈下降趋势,但2组的下降趋势不完全一致[联合治疗组:(1.01±0.43)cm3,(0.30±0.17)cm3,(0.12±0.09)cm3,F=204.682,P=0.000;手术治疗组:(0.93±0.37)cm3,(0.52±0.29)cm3,(0.38±0.11)cm3,F=137.510,P=0.000];治疗前,2组患者软骨下骨骨髓水肿体积比较,差异无统计学意义(t=0.760,P=0.465);治疗后6个月、12个月,联合治疗组软骨下骨骨髓水肿体积均小于手术治疗组(t=2.825,P=0.018;t=4.012,P=0.002)。结论:在关节镜下微骨折术治疗OLT中应用PRP关节腔注射,有利于减轻软骨下骨骨髓水肿、缓解踝关节疼痛、改善踝关节功能。
文摘目的探讨踝关节大骨节病患者采用关节镜清理治疗对缓解其疼痛和改善行走功能及生活质量的影响。方法回顾性分析我院2012年3月-2014年2月40例踝关节大骨节病患者临床病历资料及治疗情况,所有患者均采用关节镜清理治疗,采用视觉模拟评分法（visual analogue scale,VAS）评价其治疗前、后疼痛情况,采用美国足踝外科协会（American College of Foot and Ankle Surgeons,AOFAS）踝-后足评分系统及踝关节背伸活动度（range of motion,ROM）评价其行走功能;通过问卷调查来调查患者治疗前、后生活质量情况。结果患者治疗后2月及4月的VAS评分分别为（2.7±1.0）分、（1.5±0.3）分,较治疗前（6.3±1.1）分明显降低,P〈0.05;治疗后2月及4月的AOFAS评分分别为（85.7±5.2）分、（89.7±6.3）分,较治疗前（54.1±6.9）分明显升高,P〈0.05;治疗后2月及4月的踝背伸ROM评分分别为37.9°±5.1°、42.6°±6.8°,较治疗前16.7°±4.2°明显升高,P〈0.05。治疗后2月和治疗后4月患者生活质量评分（76.9±6.7）分、（89.7±10.1）分,较治疗前（51.3±4.1）分明显升高,t=20.61,18.62,P=0.00、0.00。结论应用关节镜清理治疗踝关节大骨节病可有效缓解其关节疼痛,延缓其疾病发展,改善其行走功能,提高患者生活质量。
