1726 nm Lasers for the Treatment of Acne Vulgaris.

The treatment of acne vulgaris traditionally consists of a combination of topical and oral medications. The use of lasers to treat this condition has been an area of increasing research, and several types have previously been used in the treatment of acne. New 1726 nm lasers specifically target the sebaceous gland, which is known to be pivotal in acne pathophysiology. This laser wavelength demonstrates substantial potential as a safe and effective therapeutic option for moderate to severe acne without the risks of systemic therapy. This paper reviews the 1726 nm lasers for acne vulgaris.

Effectiveness of three Vitamin D dosing protocols on raising and maintaining blood serum levels of 25-hydroxyvitamin D over a three-month period: a randomized, prospective study.

INTRODUCTION: Vitamin D has gained attention in the medical community due to its critical role in calcium homeostasis and overall bone health. No standard vitamin D dosing protocol in fracture care has been established for patients deficient in 25-hydroxyvitamin D. This prospective and randomized study aimed to find a dosing regimen that would safely achieve and maintain a therapeutic level of 25-hydroxyvitamin D in deficient patients over three months. MATERIALS AND METHODS: Between June 2016 and May 2017, 48 patients with baseline total 25-hydroxyvitamin D less than 30.0 ng/mL were randomly assigned to either group one (one dose of 100,000 international units (IU) of Vitamin D2) or group 2 (100,000 IU of Vitamin D2 once weekly for twelve weeks) or group 3 (50,000 IU of Vitamin D2 daily for ten days followed by 2,000 IU of Vitamin D3 daily for 74 days). Baseline serum levels were drawn followed by interval levels at week 2, 6 and 12. The primary outcome was to determine which protocol could achieve and maintain therapeutic levels of total 25-hydroxyvitamin D over the course of three months. Our secondary outcome was to monitor for negative side effects. RESULTS: Group 1 did not show any statistically significant increase in serum levels and had no reported side effects. There was a statistically significant increase in serum total 25-hydroxyvitamin D in group 2 between all-time points except between weeks 6 and 12. Two (12.5%) participants in group 2 reported side effects. Group 3 had the greatest change in serum levels from weeks 0 to 2 but had a significant decrease between weeks 2 and 6. No change was seen between weeks 6 and 12. Three (17.5%) participants in group 3 reported side effects. CONCLUSIONS: Group 2 sustained and maintained a satisfactory level of total 25-hydroxyvitamin D over three months without any severe side effects.

An NTRK-1-associated soft tissue tumor showing distinctive nodules with peripheral accentuation of cellularity.

Lipofibromatosis-like neural tumor is a recently described entity defined by a low-cellularity spindle cell infiltrate in the subcutaneous fat with admixed inflammatory cells. This tumor is histopathologically similar to lipofibromatosis, but unlike lipofibromatosis shows reactivity for S100 and has an NTRK-1 kinase fusion. These lesions are locally aggressive but appear to have a negligible metastatic potential. Subsequently, a more cellular variant has been described with generally low mitotic rate. This variant also displays S100 reactivity and kinase fusions (typically involving NTRK-1), but it has a low risk of metastasis. In this report, we describe a case that aligns with the more cellular variant of NTRK-1 kinase fusion tumors on histopathologic, immunohistochemical, and molecular grounds, but in addition has distinctive nodules with peripheral accentuation of cellularity, reminiscent of those present in epithelioid malignant peripheral nerve sheath tumors. This latter feature is previously undescribed in NTRK kinase fusion soft tissue tumors and offers further support for the presumed neural differentiation of this neoplasm.

Real-World Evidence Shows Clinicians Appropriately Use the Prognostic 40-Gene Expression Profile (40-GEP) Test for High-Risk Cutaneous Squamous Cell Carcinoma (cSCC) Patients.

Treatment decisions for patients with cutaneous squamous cell carcinoma (cSCC) are traditionally based upon clinicopathologic risk factors and staging systems. Due to the accuracy limitations of these resources in predicting poor outcomes, there is a clinically significant need for more accurate methods of risk assessment. The 40-gene expression profile (40-GEP) test was developed to augment metastatic risk prediction of high-risk cSCC patients and has been validated in two independent, multi-center studies involving over 1,000 patients. This study substantiates that the 40-GEP is appropriately utilized by clinicians and that the personalized risk-stratification results are impactful in guiding risk-aligned patient management.

Hydrocolloid dressing versus conventional wound care after dermatologic surgery.

BACKGROUND: Hydrocolloid dressings (HCD) are helpful in chronic wound care, but research is limited in acute postoperative wounds. HCD can potentially be incorporated into a simplified wound care regimen after excisional surgeries. OBJECTIVE: To examine whether a one-time HCD application after dermatologic surgery results in greater patient satisfaction and improved postoperative outcomes compared with conventional daily dressings (CDD). METHODS: We examined patients who underwent Mohs or standard surgical excision with linear closure followed by HCD. The patients additionally had a history of excisional surgery with CDD in the past 5 years. A modified version of the validated Bluebelle Wound Healing Questionnaire was administered. RESULTS: The survey response rate was 74.4% (64/86). Compared with CDD, HCD rated higher in comfort, convenience, scar appearance, and simplicity of wound care instructions (P < .0001). Nearly all patients (96.8%) preferred HCD over CDD. LIMITATIONS: Variability in time from prior dermatologic surgery may introduce recall bias. Prior surgeries involving CDD were sometimes performed by a different surgeon, which could introduce other confounding factors. CONCLUSIONS: A simplified wound care regimen involving HCD can potentially lead to increased comfort, convenience, simplicity, and a subjective improvement in scar appearance, though additional studies are needed.

Clinical Utility of the 40-Gene Expression Profile (40-GEP) Test for Improved Patient Management Decisions and Disease-Related Outcomes when Combined with Current Clinicopathological Risk Factors for Cutaneous Squamous Cell Carcinoma (cSCC): Case Series.

INTRODUCTION: While improvements have been made to risk assessment of cutaneous squamous cell carcinoma (cSCC) patients, there is a critical need for a uniform and more precise stratification system of their care. To address this unmet clinical need, a prognostic 40-gene expression profile (40-GEP) test has recently been developed and independently validated to show improved stratification of metastatic risk in high-risk cSCC patients compared with current staging systems. METHODS: Two cSCC cases, both male with similar patient profiles and the same staging status across two different staging systems, yet with opposing outcomes, were chosen for retrospective review of their primary biopsy using the 40-GEP test. RESULTS: Case 1 declined further treatment, even when presented with evidence of a small focus of cSCC found in the last layer of nonmarginal tissue obtained from Mohs micrographic surgery (MMS). Case 1 remained recurrence free, and retrospective analysis of the initial biopsy with the 40-GEP test provided a Class 1 result (low likelihood of metastasis). Case 2, even with subsequent clearing of the primary cSCC with MMS, noted another metastatic cSCC 3 months later. Case 2, after multimodal adjuvant treatments, died due to disease progression. Retrospective analysis of the initial biopsy with the 40-GEP test provided a Class 2B result (high likelihood of metastasis). CONCLUSIONS: The cases discussed highlight the utility in 40-GEP to provide additional information to guide treatment decisions and improve outcomes. Integrating novel molecular prognostication with traditional clinicopathological risk factors can improve stratification of high-risk cSCC patients and may inform selection of risk-appropriate treatment and surveillance strategies.

Patient-Reported Outcomes After a Modified Albee Procedure.

BACKGROUND: Trochlear dysplasia (TD) is a recognized condition that can become a risk factor for patellofemoral instability. A modified Albee osteotomy procedure using a trapezoidal-shaped wedge to elevate the lateral wall of the trochlea can be used with the goal of preventing further dislocation. However, outcomes studies are lacking, and scores on patient-reported outcome measures (PROMs) are largely unknown. PURPOSE/HYPOTHESIS: The purpose of this study was to identify PROM scores for the Kujala Anterior Knee Pain Scale (AKPS), International Knee Documentation Committee (IKDC), Activity Rating System (ARS), and 100-point pain visual analog scale (VAS) for patients having undergone the modified Albee osteotomy. The hypothesis was that patients will have acceptable pain and function at mid- to long-term follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: From 1999 to 2017, a total of 46 consecutive patients (49 knees) underwent a modified Albee procedure by a single surgeon at a single health care system. These 46 patients were contacted and asked to complete the AKPS, IKDC, ARS, and pain VAS. Additional demographic information was obtained via chart review. Frequencies and rates for categorical variables and means and standard deviations for continuous variables of the demographics and PROM scores were calculated. RESULTS: PROM scores were obtained in 28 (30 knees; 61%) of the 46 patients. At minimum follow-up of 82 months, the mean scores were 78.5 ± 18.2 for AKPS, 61.2 ± 11.4 for IKDC, 5.2 ± 5.3 for ARS, and 24.4 ± 28.7 for VAS pain. Notably, only 1 of the 28 patients reported a patellofemoral dislocation since surgery, and this was an isolated incident without further instability. CONCLUSION: A modified Albee trochlear osteotomy can be a successful adjunctive procedure to prevent recurrent patellar dislocations in patients with mild TD. However, owing to the loss of one-third of patient follow-up scores and the absence of baseline function scores in this study, the procedure deserves further investigation as a way to address a particularly difficult dilemma for a select subset of patients with patellofemoral instability.

Keratoacanthoma centrifugum marginatum.

Keratoacanthoma centrifugum marginatum (KCM) is an uncommon variant of keratoacanthoma. Keratoacanthoma centrifugum marginatums are most commonly seen on sun-exposed surfaces and present with progressive peripheral expansion and raised, hyperkeratotic borders. Central clearing with atrophy and lack of spontaneous clearance are other key clinical characteristics. The majority of cases are benign with a low risk of metastasis. The size of such growths is variable with reported cases ranging from 5.0cm×5.0cm to as large as 20.0cm×14.0cm. Treatment options include surgical excision, oral retinoids, and intralesional chemotherapeutics such as methotrexate or bleomycin. We herein present a case of KCM manifesting as an exophytic, crateriform plaque in a 61-year-old man.

Establishing Safe Extra-articular Parameters for Cortical Button Distal Fixation During Ulnar Collateral Ligament Reconstruction.

BACKGROUND: A variety of methods exist for fixation during ulnar collateral ligament (UCL) reconstruction on the ulna for the overhead throwing athlete. Current biomechanical evidence suggests that cortical button fixation may fail at a higher load and under more cycles than interference screw fixation alone, while also minimizing the risk of fracture. A safe angle for placement of this cortical button has not yet been determined. PURPOSE: To define a safe angle for cortical button deployment during UCL reconstruction to avoid violation of the proximal radioulnar joint (PRUJ). STUDY DESIGN: Descriptive laboratory study. METHODS: Measurements on 100 cadaveric ulna bones, 50 women and 50 men, were obtained referencing the entry point for ulnar fixation, which is 1 cm distal to the ulnar humeral joint line along the medial UCL ridge. Ulnar width at the entry point and distance to the PRUJ were obtained to calculate safe distal angulation, while distance from the entry point to the posterior ulnar crest ulnarly and distance from the PRUJ to the posterior ulnar crest radially were obtained to calculate safe posterior angulation. Ten bony measurements on the same group of specimens were performed by 3 authors to establish an interobserver reliability. Means, quartiles, and outliers were obtained for the calculated angles. Finally, recommended angles of entry were determined to be approximately 1 interquartile range above the upper limit. RESULTS: The mean distal angle of entry that was obtained was 11.32° (SD, ±4.80°; 95% CI, 10.37°-12.27°; P < .001). Three upper limit outliers were discovered: 24.20°, 23.4°, and 21.1°. The mean posterior angle of entry was 40.44° (SD, ±6.18°; 95% CI, 39.22°-41.67°; P < .001). There were no outliers for the posterior angle of entry. Interobserver reliabilities were strong for the 4 measurements. CONCLUSION: To be safely outside of the PRUJ utilizing a cortical button construct, we recommend 30° distal angulation and 60° posterior angulation for ulnar fixation during UCL reconstruction. Both parameters are 1 quartile above the highest calculated angle of entry. CLINICAL RELEVANCE: These data define safe parameters for distal fixation during UCL reconstruction and highlight a clear entry point for reference.

A Posterior Approach to Open Reduction and Internal Fixation of Displaced Posterior Cruciate Ligament Tibial Osseous Avulsions.

BACKGROUND: The true prevalence of displaced tibial-sided avulsion injuries of the posterior cruciate ligament (PCL; Video 1) is unknown, and the majority of data regarding management has been published in areas other than the Western world, such as China and India (perhaps due to the higher prevalence of two-wheeler motorcycle accidents in these areas). Despite the rarity of data, a better understanding of the approach, fixation techniques, and outcomes is necessary to provide quality patient care. These injuries generally require surgical intervention as nonoperative management leads to complications-specifically, knee arthrofibrosis1,2. There is no consensus regarding the optimal surgical approach for these injuries. A recent systematic review demonstrated that both open and arthroscopic surgical treatment provide satisfactory complication rates and outcomes in the majority of cases3. However, the arthroscopic approach can be performed by only a highly skilled arthroscopist; thus, in this article we focus on the open approach to reach a broader audience of capable surgeons. DESCRIPTION: The principal steps for open reduction and internal fixation of the tibial avulsion fracture include the following:Place the patient in a prone position and utilize a curvilinear L-shaped incision with the longitudinal portion over the medial head of the gastrocnemius muscle and the transverse portion starting distal to the joint line and extending laterally past the midline.Develop the interval between the semimembranosus and medial gastrocnemius muscles, as originally described by Burks and Schaffer4. Lateral retraction of the gastrocnemius muscle exposes the posterior aspect of the capsule, allowing for a vertical capsular incision to adequately visualize the avulsed osseous fragment.Prepare the osseous bed and remove hematoma and/or debris.Reduce the avulsed fragment and obtain provisional fixation with Kirschner wires.Confirm reduction under fluoroscopy with emphasis on sagittal plane alignment.Obtain definitive fixation with the method dictated by the fracture orientation. Options include screw(s) with or without a washer, sutures, Kirschner wires, staples, and toothed plates2,5-7. ALTERNATIVES: An arthroscopic approach can be performed, with results that are similar to those of an open procedure, but considerable expertise is required to perform this procedure arthroscopically. Nonsurgical management is not recommended as it frequently leads to loss of knee motion. RATIONALE: The exact operative indications for PCL injuries remain in question, but we believe that displaced tibial avulsion injuries at the PCL attachment always require operative treatment.

Management of Posterior Cruciate Ligament Tibial Avulsion Injuries: A Systematic Review.

BACKGROUND: Tibial-sided avulsion injuries of the posterior cruciate ligament (PCL) generally require surgical intervention. No consensus exists concerning the optimal surgical treatment approach for these injuries. PURPOSE: To perform a systematic review investigating the open and arthroscopic surgical treatment modalities, outcomes, and complications of PCL tibial-sided bony avulsions. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The authors performed a systematic review of the literature utilizing PubMed and EMBASE from 1975 to present outlining open versus arthroscopic surgical repair of PCL bony avulsion injuries and comparing subjective and objective postoperative patient-reported outcomes, including Tegner, IKDC (International Knee Documentation Committee), and Lysholm scoring systems, as well as rates of patient complications. The quest was performed in June 2016, and searched terms included posterior cruciate ligament, PCL, bony, avulsion(s), tibial-sided, open, and arthroscopic. Inclusion criteria included English-language studies involving surgical fixation strategies for PCL tibial-sided bony avulsions. Exclusion criteria included non-English language, case studies/case series, and subject matter not pertaining to PCL bony avulsions. RESULTS: Twenty-eight articles comprising 637 patients met the criteria and were included in the final review. PCL injuries with a tibial-sided avulsion were the result of motor vehicle accidents in 68.4% of patients, with 59.0% of these injuries resulting from motorcycle accidents. The arthroscopic group had better IKDC grade A scores (78.9%), indicating a normal knee postoperatively, as compared with the open group (65.9%). The postoperative Lysholm scores were similar between the groups, with a mean of 95.0 in the arthroscopic group and 92.8 in the open group. The arthroscopic group also reported 100% return to preinjury level of activity, compared with 86.2% in the open group. The most common complication in both groups was arthrofibrosis, which was reported more often in the arthroscopic group (0%-35%) versus the open treatment group (0%-25%). CONCLUSION: In patients with displaced tibial-sided PCL avulsion fractures treated operatively, surgical approaches render similar outcomes and risks. While the arthroscopic group had somewhat higher subjective and objective knee outcome scores, it demonstrated a slightly higher rate of arthrofibrosis. The clear advantage of the arthroscopic approach is that concomitant intra-articular injuries seen on preoperative magnetic resonance imaging, such as meniscal tears or osteochondral loose fragments, can be addressed at the time of the index operation.

Adolescent Femoroacetabular Impingement: Gender Differences in Hip Morphology.

PURPOSE: To compare the hip morphology of adolescent male patients and female patients who underwent hip arthroscopy for femoroacetabular impingement (FAI) and determine if gender differences exist. METHODS: We retrospectively reviewed the records of 177 adolescents, aged 13 to 18 years, who were treated for FAI with hip arthroscopy. We examined and analyzed preoperative magnetic resonance imaging (MRI) scans and plain radiographs, measuring the lateral center-edge angle, Tönnis angle, and alpha angle. The intraclass correlation coefficient between readers was calculated. We created multiple linear regression models incorporating age, gender, and body mass index (BMI) with the radiographic measurements. Intraoperative findings using the Outerbridge grading system, as well as procedure performed, were documented. We compared these findings with our preoperative imaging measurements using the χ2 test and the Wilcoxon rank sum test. RESULTS: The intraclass correlation coefficient showed moderate to strong agreement between the 3 image readers. The BMI- and age-adjusted mean alpha angle was higher in male patients than female patients on both plain radiographs (55.9° vs 45.2°, P < .0001) and axial oblique MRI scans (54.1° vs 42.5°, P < .0001). An alpha angle greater than 55° was found in 38.9% of male patients compared with only 1% of female patients (P < .0001). The lateral center-edge angle and Tönnis angle on MRI scans and plain radiographs displayed no statistically significant differences between genders after we controlled for BMI and age. Male patients were more likely to have chondral damage intraoperatively than female patients (56.3% vs 32.5%, P = .0041). CONCLUSIONS: Distinct differences between genders were seen both on preoperative imaging and at the time of hip arthroscopy. We found that male patients with FAI displayed a larger mean alpha angle, and therefore a more severe cam-type deformity, than female patients. Our study also found that male patients were more likely to show evidence of chondral damage than female patients at the time of surgery. LEVEL OF EVIDENCE: Level IV.