Initial Evaluation and Management of Patients Presenting with Acute Chest Pain in the Emergency Department.

PURPOSE OF THE REVIEW: To review the initial evaluation of chest pain in the emergency department (ED), with a focus on coronary artery disease (CAD) and acute coronary syndromes (ACS), using consensus statements from major cardiovascular disease organizations. RECENT FINDINGS: Major cardiovascular organizations have released consensus statements on this topic, notably the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain and the 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department. Also, recent studies have evaluated the use of high sensitivity troponin (hs-cTn) to safely rule out myocardial infarction (MI), with the development of rule-out pathways designed to be utilized in the ED. This review highlights the comprehensive differential diagnoses of chest pain in the ED and urgent management of these etiologies, with a focus on cardiovascular etiologies. There exist a few rule-out pathways recommended by major cardiovascular organizations, notably the high-STEACS and the ESC 0/1 and 0/2 pathways that can safely and quickly discharge patients with low risk of MI.

Safety of routine protamine in the reversal of heparin in percutaneous coronary intervention: A systematic review and meta-analysis.

OBJECTIVES: To determine the safety and efficacy of protamine in the reversal of heparin in percutaneous coronary intervention (PCI). BACKGROUND: Heparin is routinely used for anticoagulation in PCI. Protamine is not used routinely to reverse heparin's effects in PCI, partly due to the perceived risk of stent thrombosis. METHODS: Relevant studies published in English were searched for in PubMed, Embase, and Cochrane databases from inception to April 26th, 2023. Our primary outcome of interest was stent thrombosis in patients receiving PCI for all indications. Secondary outcomes included mortality, major bleeding complications, and hospitalization length. Dichotomous outcomes were analyzed using a Mantel-Haenszel random-effects model and expressed as odds ratios (OR) with their 95% confidence intervals (CI), while continuous outcomes were analyzed using an inverse variance random-effects model expressed as mean differences (MD) with their 95% CI. RESULTS: 11 studies were included in our analysis. Protamine use was not associated with stent thrombosis: OR 0.58, 95% CI: 0.33, 1.01 (p = 0.05) nor with mortality (p = 0.89). Protamine administration was associated with a decreased incidence of major bleeding complications: OR 0.48; 95% CI: 0.25, 0.95 (p = 0.03) and decreased length of hospitalization (p < 0.0001). CONCLUSIONS: In patients pre-treated with dual antiplatelet therapy (DAPT), protamine may be a safe and efficacious option to facilitate earlier sheath removal, reduce major bleeding complications, and reduce length of hospitalization without increased risk of stent thrombosis.

Cardiac arrhythmias in viral infections.

BACKGROUND: The current COVID-19 pandemic has led to many studies examining its arrhythmogenic effects. However, there are many other viruses that are capable of inducing arrhythmias that have not received as much attention. The objective of this study was to review common viruses and identify studies highlighting their arrhythmogenic effects. METHODS AND RESULTS: In this review, we examined 15 viruses and the literature regarding their arrhythmogenic effects. The common mechanisms of action appear to be direct invasion of myocytes leading to immune mediated damage, infection of vascular endothelium, and alteration of cardiac ion channels. CONCLUSIONS: This review highlights the growing evidence that supports the involvement of other viral infections in the development of arrhythmia. Physicians should be aware of these potentially life-threatening effects when caring for patients with these viruses, some of which are very common. Additional studies are required to better understand the complex mechanism and risk factors of cardiac arrhythmias in patients suffered from viral infections to determine whether the processes can be reversed or even prevented.

An observational study evaluating the efficacy of microfragmented adipose tissue in the treatment of osteoarthritis.

Aim: Osteoarthritis (OA) prevalence is increased in ageing and obese populations. This prospective single-arm cohort study aimed to investigate the efficacy of autologous microfragmented adipose tissue treatment of severe knee or shoulder OA. Materials & methods: Participants received an intra-articular microfragmented adipose tissue injection to the affected joint(s). Multiple patient reported outcome measures (PROMS) were recorded from 0 to 52 weeks for 63 consecutive joints. Results: Compared with baseline, there were significant improvements in all PROMS from 2 to 12 weeks and maintained at 52 weeks. Regression analysis revealed an inverse correlation with BMI and change in PROMS for knee joints. Conclusion: Our observed findings suggest this approach represents a safe, effective treatment for moderate-to-severe knee and shoulder OA, although efficacy may be reduced with increasing obesity.

Swelling and pain in the joints is common and found more often in older and overweight people. Osteoarthritis causes swelling and pain in joints because of a loss of tough, flexible tissue called cartilage. This study looks to see if injection of fat tissue into knee or shoulder joints can improve symptoms. The fat tissue used was called microfragmented adipose tissue (MFAT). This uses a technique to break down the fat tissue before injection. These cells were from the patient's own body. All patients had an injection of MFAT into their painful joints. In total, 59 patients took part. Reports were directly collected from the patient of how well they were doing. This was done before and after the injection at weeks 2, 6, 12, 24 and 52. There were three different types of report collected for knee joints and three for shoulder joints. Scores were then compared from these reports to see if there was a difference. An improvement was found in all three of the combined reports for both knees and shoulders. This stayed until 52 weeks. BMI is a measure of body weight in relation to height. Patients with a higher BMI were found to have had a smaller improvement in their scores. This study shows MFAT injections are safe and effective in treating painful joints.

Update on the Role of Actovegin in Musculoskeletal Medicine: A Review of the Past 10 Years.

BACKGROUND: Actovegin is a biological drug with a controversial history of use in the treatment of sports injuries during the past 60 years. Particular concerns have been raised about its ergogenic potential to enhance performance, but some of these have been based on little more than anecdote. OBJECTIVES: In this article, we review the most recent scientific evidence to determine the clinical efficacy, safety profile, and legal status of Actovegin. METHODS: We considered all studies directly commenting on experience with Actovegin use as the primary intervention within the past 10 years. Outcomes included mechanisms of action, clinical efficacy in enhancing muscle repair, any report of safety issues, and any evidence for ergogenic effect. RESULTS: Our database search returned 212 articles, abstracts were screened, and after inclusion/exclusion criteria were applied, 25 articles were considered: Publications included 11 primary research articles (7 in vitro studies and 4 clinical trials), 8 review articles, 5 editorials, and a single case report. CONCLUSIONS: Current literature is still yet to define the active compound(s) of Actovegin, but suggests that it shows antioxidant and antiapoptotic properties, and may also upregulate macrophage responses central to muscle repair. Clinical efficacy was supported by one new original research article, and the use of Actovegin to treat muscle injuries remains safe and supported. Two articles argued the ergogenic effect of Actovegin, but in vitro findings did not to translate to the outcomes of a clinical trial. An adequate and meaningful scientific approach remains difficult in a field where there is immense pressure to deliver cutting-edge therapies.

The midterm results of a cohort study of patellofemoral arthroplasty from a non-designer centre using an asymmetric trochlear prosthesis.

PURPOSE: Patellofemoral arthroplasty (PFA) prosthesis with asymmetric trochlear component was introduced as an improvement from existing designs for surgical treatment of symptomatic isolated patellofemoral arthritis. The purpose of this study was to evaluate midterm results in patients who underwent PFA procedure using such prosthesis. METHODS: Our study involved a continuous retrospective cohort of patients who underwent PFA using Journey PFA prosthesis with an asymmetric trochlear component, performed between June 2007 and July 2016 at a non-designer centre. The Patient Reported Outcome Measures and patient satisfaction questionnaires were collected for final evaluation. RESULTS: A total of 103 PFA performed on 79 patients were evaluated. Median age at the time of surgery was 58years (range 42 to 78years); the mean follow-up period was 6 years (range 2 to 11years). Four knees were revised to Total Knee Arthroplasty for reasons not related to the implant. The cumulative survival estimated by the Kaplan-Meier method was 94.3% (95% confidence interval: 88.4%-100%). There were statistically significant improvements in functional outcome scores. CONCLUSION: This series of patients who underwent PFA with the asymmetric trochlear component has shown promising mid-term results with no implant-related complications.

An Update on Unloading Knee Braces in the Treatment of Unicompartmental Knee Osteoarthritis from the Last 10 Years: A Literature Review.

Background The incidence of osteoarthritis is increasing and it is one of the most common causes of chronic conditions. Total knee replacement is the mainstay of treatment for end-stage knee osteoarthritis; however, with long waiting lists and high levels of dissatisfaction, a treatment like knee braces could potentially delay surgery. Unicompartmental knee osteoarthritis is associated with misalignment of the knee, and unloader bracing has been recommended by various guidelines to correct this misalignment. The aim of this report was to provide an update of evidence from the past 10 years on knee braces. Methods MEDLINE/EMBASE search was performed from the past 10 years. Results We reviewed the evidence from 14 published articles. Almost all articles supported knee brace use and showed it to decrease pain, improve function, and improve the quality of life of patients. One study in 2017 followed patients for long term and found knee bracing to be more cost effective than total knee replacement, and could replace the need for surgery. Several minor complications were reported with bracing, like soft tissue irritation, which could be due to poor fitting. A management strategy for this could be regular follow-up at a nurse-led clinic. Conclusions Unloader braces are an economical and effective treatment for unicompartmental knee osteoarthritis. They can significantly improve a patient's quality of life and potentially delay the need for surgery. Patients should be managed with a multidisciplinary approach with conservative management and knee bracing, before surgery is considered.

Modern synthetic material is a safe and effective alternative for medial patellofemoral ligament reconstruction.

PURPOSE: Medial patellofemoral ligament (MPFL) reconstruction is often performed using gracilis autografts, which may be associated with donor site morbidity and complications. The use of a synthetic material can circumvent a harvest operation and has previously been demonstrated to be effective in other types of reconstructive procedures and may be effective in MPFL reconstruction. This study reports the clinical result with the use of a modern ultra-high molecular weight polyethylene with a braided jacket of polyester tape (FT) in MPFL reconstruction compared to using standard autografts. METHODS: Data were collected prospectively in 50 MPFL reconstructions. The first 27 underwent reconstruction using gracilis tendon (GT) autograft; the following 23 patients were treated with FT. All patients were clinically and radiologically assessed and underwent pre- and post-operative scoring using the Kujala score, Bartlett score, Tegner activity rating scale, SF-12 score and Lysholm score. Statistical significance was tested between groups using ANOVA with repeated measures. RESULTS: There were no significant differences in the pre-operative scores between the FT and GT groups (n.s.). Both groups showed significant improvements across all scoring modalities between pre- and post-operative periods 12, 24 and 48 months of follow-up (p < 0.05). There were no significant differences in knee function scores between the GT and FT groups. CONCLUSION: The use of FiberTape in MPFL reconstruction is safe and effective, and it significantly improves patient's quality of life and related post-operative outcome measures. There were no significant differences in all knee scores compared to GT autografts. Using this technique for MPFL reconstruction, tendon harvesting is unnecessary and hence eliminates donor site morbidity-associated complications. LEVEL OF EVIDENCE: II.

R3 Cup Does Not Have a High Failure Rate in Conventional Bearings: A Minimum of 5-Year Follow-Up.

BACKGROUND: The R3 cementless acetabular system was first marketed in Australia and Europe in 2007. Previous papers have shown high failure rates of the R3 cup with up to 24% with metal-on-metal bearing. There are currently no medium term clinical results on this cup. The aim of the study is to review our results of the R3 acetabular cup with conventional bearings with a minimum of 5-year follow-up. METHODS: Patients who were implanted with the R3 acetabular cup were identified from our center's arthroplasty database. A total of 293 consecutive total hip arthroplasties were performed in 286 patients. The primary outcome was revision. The secondary outcomes were the Oxford Hip Scores (OHS) and radiographic evaluation. RESULTS: The mean age of the patients was 69.4 years. The mean preoperative OHS was 23 (range 10-34) and the mean OHS was 40 (range 33-48) at the final follow-up. Radiological evaluation showed an excellent ARA score in all patients at 5 years. None of the R3 cups showed osteolysis at the final follow-up. There were 3 revisions in our series, of which 2 R3 cups were revised. The risk of revision was 1.11% at 5 years. CONCLUSION: Our experience of using the R3 acetabular system with conventional bearings showed high survivorship and is consistent with the allocated Orthopaedic Data Evaluation Panel rating of 5A* as rated in 2015 in the United Kingdom.

Delayed Profunda Femoris Artery Bleeding After Intramedullary Nailing of an Unstable Intertrochanteric Fracture: A Case Report.

CASE: A 75-year-old man underwent intramedullary nailing for an unstable intertrochanteric fracture of the left hip. After surgery and postoperative recovery, he was transferred to a rehabilitation ward. He was able to mobilize at 2 days postoperatively; at 2 weeks postoperatively, he developed the sudden onset of tachycardia, hypotension, and a large hematoma on the left thigh. Following immediate resuscitation, a computed tomography (CT) angiogram demonstrated a bleed from a branch of the profunda femoris artery. The 3-dimensional CT reconstruction implicated the displaced lesser trochanter osseous fragment as the cause of the hemorrhage. CONCLUSION: Surgeons should be aware of this rare complication and the possible etiology of fracture displacement as the cause of a delayed-onset bleed after intramedullary nailing, and they should also be cognizant of the subsequent optimal management.

A Short Femoral Stem in Revision Total Hip Replacement: An Alternative Solution for Prosthetic Fracture: A Case Report.

CASE: A 65-year-old farmer re-presented 5 years after sustaining a midshaft prosthetic fracture of a previous long-stem revision hip replacement. He was treated with a proximal-loading short femoral stem, and did not require an extended trochanteric osteotomy for removal of the well-fixed distal implant. He was able to fully bear weight immediately postoperatively, and he remained pain-free without functional loss at the 42-month follow-up. CONCLUSION: This use of a modern short-stem prosthesis is a treatment option for a potentially complex prosthetic fracture in highly active patients, and it reduces intraoperative complexity.

A Systematic Review on the Use of Aspirin in the Prevention of Deep Vein Thrombosis in Major Elective Lower Limb Orthopedic Surgery: An Update from the Past 3 Years.

Introduction Currently there are no consensuses in the national guidance on thromboprophylaxis following major elective lower limb surgery. Emerging clinical evidence suggests that aspirin could be just as effective as anticoagulants with a lower cost. The aim of this study was to provide an update based on literature of the past 3 years for the use of aspirin as thromboprophylaxis after knee and hip arthroplasty. Materials and Methods MEDLINE/EMBASE search was performed with appropriate terms for original articles from 2014 to 2017. Results Eight articles were found. Five articles concluded that aspirin was an effective prophylactic. The collation of results on the deep vein thrombosis rate involved 43,012 patients who were prescribed aspirin, of which 283 (0.66%) suffered from symptomatic deep vein thromboses. Aspirin was noted for its good side effect profile and cost effectiveness. It was noted that anticoagulants had a higher rate of complications, including bleeding and wound-oozing. Conclusion Aspirin is an effective and safe prophylactic against deep vein thrombosis following major elective lower limb arthroplasty surgery.

Our early experience of the Corin Minihip prosthesis.

PURPOSE: Although there have been several varieties of short-stem hip prosthesis in the market, there have been no published clinical results of the Corin MiniHip (Corin, Cirencester, UK) to date. The aim of this study is to describe our early results and experience of this stem in a nondesigner, single-surgeon series; calculate 5-year survival with stem revision as an endpoint; evaluate complications and early revisions; and assess radiolucency and stem subsidence at the latest follow-up review. METHODS: Over a 5-year period, 275 MiniHip were implanted in 239 patients. The mean age of the patients was 63 years (range 20-84); mean follow-up was 37 months (range 12-72 months). RESULTS: The mean Harris Hip Score and Oxford Hip Score improved significantly to 87 (range 49-100) and 41 (range 32-48) at the final follow-up (p = 0.038; p = 0.017). There were 9 intraoperative calcar fractures (3%) of which only 1 required cerlage wiring. 10 patients died in our series and none were lost to follow-up. 2 patients had their stem revised for failure of fixation (secondary to possible undersizing) and sink. The risk of revision was 0.73% at 5 years. The Kaplan Meier estimate of survivorship of cumulative failure gave an implant survival rate of 99.3% (95% confidence interval [CI], 27.0-100) at 5 years for revision for any reason as the endpoint. CONCLUSIONS: This novel, short-stem prosthesis has shown good survival in the short term, similar to other short-stem prostheses currently available. We describe the largest series in the literature of this prosthesis.

Early failure of the Polarstem total hip arthroplasty--can the Australian NJR tell us the full story?

The Australian NJR 2012 has reported that the Polarstem/R3 Total hip arthroplasty has a higher than anticipated revision rate with a three year cumulative percentage of 3%. Out of the 733 Polarstem femoral components, 18 had to be revised within 3 years. Our unit has been using this system since 2009. The aim of this prospective study is to report the clinical outcome of the PolarStem in our cohort of 646 stems with 100% follow up, compared to the Australian registry. Of the 646 hips, 5 returned to theater for a further operation for any reason. The cumulative 3 year survival rate was 99.7%, with revision for any reason as the endpoint. Our 3 year cumulative revision rate for all revisions in the Polarstem femoral stem is 0.15%, which is 20 times less as compared to the 3% reported by the Australian registry.