Novel Allograft in the Load-Bearing Portion of the Femoral Head.

Background: An osteochondral defect in the hip can be a painful and limiting pathologic process. The damaged joint may progress into premature osteoarthritis, further limiting a patient's functionality. Case Report: A 24-year-old male presented to the clinic with left hip pain. The patient had been involved in a motor vehicle accident 3 years prior to presentation to our clinic. His injury from the high-speed accident required intramedullary rod fixation for a right-sided (contralateral) subtrochanteric femur fracture. The patient complained of left groin pain when in a sitting position, with activities of daily living, and with exercise. He failed conservative management consisting of nonsteroidal anti-inflammatory drugs and physical therapy. Imaging on presentation demonstrated an osteochondral defect in the weight-bearing portion of the left femoral head consistent with an International Cartilage Repair Society grade 4b lesion, a cam lesion was noted on assessment of bone morphology, and magnetic resonance imaging revealed degenerative labral pathology. The patient was treated with surgical hip dislocation through a modified Hardinge approach, femoral head osteochondral allograft transplantation using a Missouri Osteochondral Preservation System (MOPS) graft, acetabuloplasty, femoral neck osteoplasty, and open labral repair. Conclusion: Femoral head osteochondral MOPS allograft transplantation is a viable technique for joint preservation in young patients with posttraumatic osteochondral defects of the femoral head.

Comparative, Controlled, Retrospective Study of Patient-Reported Outcomes After Meniscectomy With Adjunctive Use of Platelet-Rich Plasma or Amniotic Umbilical Cord Tissue.

Background: Meniscal tears are one of the most frequent injuries to the knee, with an estimated incidence of 222 per 100,000 individuals aged 18 to 55 years based on magnetic resonance imaging. Poor outcomes following meniscal surgical interventions are common and have led many surgeons to use biologic augmentation strategies to enhance the healing. Methods: We conducted a single-center, retrospective, observational study of patients who underwent arthroscopic meniscectomy with and without adjunctive platelet-rich plasma (PRP) or the particulate form of amniotic umbilical cord (AMUC) tissue. We evaluated patient-reported outcomes on the visual analog scale for pain, International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Lysholm Knee Scoring Scale, 12-Item Short Form Survey, and Knee Injury and Osteoarthritis Outcome Score (KOOS) during a 1-year postoperative period. Complications and follow-up procedures were also evaluated. Results: We evaluated 113 patients who underwent meniscectomies from November 2010 to March 2017. Pain severity was significantly decreased only in the AMUC group at 6 months (P=0.0143). Patients in the AMUC group demonstrated significant improvement in functional recovery based on the IKDC and the KOOS subscales of pain, symptoms, activities of daily living, and sport and recreation function at 6 months. Patients in the PRP group had a significant benefit in the KOOS subscales of pain, symptoms, sport and recreation function, and knee-related quality of life at 3 months. Improvement in the control group was less substantial. Patients in the PRP group had more complications and follow-up procedures (30.0%) than patients in the AMUC group (8.3%). Conclusion: In our study population, arthroscopic meniscectomy with adjunctive use of AMUC tissue improved patient-reported outcomes and reduced the reoperation rate compared to conventional technique or adjunctive use of PRP.

Viable cartilage allograft outperforms existing treatments for focal knee cartilage defects.

PURPOSE: Viable cartilage allograft (VCA) is a cartilage tissue matrix that contains cryopreserved viable allogeneic cartilage fibres. This study aimed to assess safety and benefits in treating focal knee cartilage defects with VCA. We hypothesized that VCA is a safe single-stage procedure in isolated chondral defects. METHOD: In vitro analysis, in vivo studies and a prospective case series were performed. VCA was evaluated in a goat cartilage repair model. Symptomatic International Cartilage Repair Society grade 3/4A lesions of the femoral condyle or patella were implanted with VCA. International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome (KOOS) subscales, Lysholm, Short Form-12, Visual Analog Scale and pain frequency levels were assessed. Radiographic and magnetic resonance imaging (MRI) was performed at regular intervals postoperatively. Data were analysed by statisticians to determine the power and significance of the results. RESULTS: The goat study confirmed that VCA is effective for cartilage repair. Twenty patients were implanted; the mean age was 28.1 (16-56), the mean body mass index (BMI) was 27.9 ± 5.6 and the mean follow-up was 24.1 months (range = 12.0-36.0 months). Lesions were in either the femoral condyle (7) or patella (13). Lesion sizes ranged from 1.5 to 6.0 cm2 (mean = 4.58 cm2 ). Outcome scores improved from preoperative baseline (POB): IKDC (78.2), Lysholm (89.0), KOOS: Pain (95.8), Symptoms (86.3), ADL (87.8), Sports (85.0) and QOL (75.0). MRI imaging demonstrated excellent osteochondral allograft assimilation. Second-look arthroscopy (two patients) demonstrated complete fill and incorporation (Brittberg scores 11/12). Functional scores were maintained at 24 (M): IKDC (86.24 ± 17.2), Lysholm (87.23 ± 15.0), KOOS: Pain (91.72 ± 17.3), Symptoms (84.92 ± 16.1), ADLs (93.80 ± 16.1), Sports (84.45 ± 27.7), QOL (81.30 ± 20.8). CONCLUSION: VCA is an off-the-shelf, single-stage, conformable allogeneic graft that treats chondral defects with no additional fixation. Preclinical and short-term prospective clinical studies show that VCA can safely treat chondral defects with potential advantages to existing options. LEVEL OF EVIDENCE: Level IV study.

Mild traumatic brain injury impairs the coordination of intrinsic and motor-related neural dynamics.

Mild traumatic brain injury (mTBI) poses a considerable burden on healthcare systems. Whilst most patients recover quickly, a significant number suffer from sequelae that are not accompanied by measurable structural damage. Understanding the neural underpinnings of these debilitating effects and developing a means to detect injury, would address an important unmet clinical need. It could inform interventions and help predict prognosis. Magnetoencephalography (MEG) affords excellent sensitivity in probing neural function and presents significant promise for assessing mTBI, with abnormal neural oscillations being a potential specific biomarker. However, growing evidence suggests that neural dynamics are (at least in part) driven by transient, pan-spectral bursting and in this paper, we employ this model to investigate mTBI. We applied a Hidden Markov Model to MEG data recorded during resting state and a motor task and show that previous findings of diminished intrinsic beta amplitude in individuals with mTBI are largely due to the reduced beta band spectral content of bursts, and that diminished beta connectivity results from a loss in the temporal coincidence of burst states. In a motor task, mTBI results in diminished burst amplitude, altered modulation of burst probability during movement, and a loss in connectivity in motor networks. These results suggest that, mechanistically, mTBI disrupts the structural framework underlying neural synchrony, which impairs network function. Whilst the damage may be too subtle for structural imaging to see, the functional consequences are detectable and persist after injury. Our work shows that mTBI impairs the dynamic coordination of neural network activity and proposes a potent new method for understanding mTBI.

Dysregulated oscillatory connectivity in the visual system in autism spectrum disorder.

Autism spectrum disorder is increasingly associated with atypical perceptual and sensory symptoms. Here we explore the hypothesis that aberrant sensory processing in autism spectrum disorder could be linked to atypical intra- (local) and interregional (global) brain connectivity. To elucidate oscillatory dynamics and connectivity in the visual domain we used magnetoencephalography and a simple visual grating paradigm with a group of 18 adolescent autistic participants and 18 typically developing control subjects. Both groups showed similar increases in gamma (40-80 Hz) and decreases in alpha (8-13 Hz) frequency power in occipital cortex. However, systematic group differences emerged when analysing intra- and interregional connectivity in detail. First, directed connectivity was estimated using non-parametric Granger causality between visual areas V1 and V4. Feedforward V1-to-V4 connectivity, mediated by gamma oscillations, was equivalent between autism spectrum disorder and control groups, but importantly, feedback V4-to-V1 connectivity, mediated by alpha (8-13 Hz) oscillations, was significantly reduced in the autism spectrum disorder group. This reduction was positively correlated with autistic quotient scores, consistent with an atypical visual hierarchy in autism, characterized by reduced top-down modulation of visual input via alpha-band oscillations. Second, at the local level in V1, coupling of alpha-phase to gamma amplitude (alpha-gamma phase amplitude coupling) was reduced in the autism spectrum disorder group. This implies dysregulated local visual processing, with gamma oscillations decoupled from patterns of wider alpha-band phase synchrony (i.e. reduced phase amplitude coupling), possibly due to an excitation-inhibition imbalance. More generally, these results are in agreement with predictive coding accounts of neurotypical perception and indicate that visual processes in autism are less modulated by contextual feedback information.

Acute Traumatic Tear of the Gluteus Medius and Gluteus Minimus in a Marathon Runner.

Background: Tears of the gluteus medius and gluteus minimus are common causes of chronic lateral hip pain in the middle-aged population. These tears are postulated to occur after chronic degeneration of the muscle-tendon unit. The majority of these patients have a long history of peritrochanteric pain. Acute traumatic tear of the gluteus medius and gluteus minimus in otherwise asymptomatic patients is rare but can occur. Case Report: We report the case of a 78-year-old male marathon runner with acute traumatic tear of the gluteus medius and gluteus minimus. After conservative management (physical therapy, a nonsteroidal antiinflammatory drug for pain, and cortico-steroid and local anesthetic injection) failed, the patient underwent operative repair. The surgery was successful, and the patient returned to his preinjury lifestyle 6 months postoperatively with no limitations. Conclusion: In most cases, chronic injuries are far more common than acute tears. Because of the nonspecific and slowly progressive symptoms, patients are often misdiagnosed with radiculopathy, osteoarthritis, or trochanteric bursitis. Patients typically present to the clinic with an insidious onset of dull pain over the lateral hip. This pain is often worse when lying on the affected side. Certain gluteal-focused movements, such as climbing stairs, may exacerbate the pain. To our knowledge, our report is only the third case of acute traumatic tear of the gluteus medius and gluteus minimus reported in the literature.

Patellofemoral Arthroplasty.

BACKGROUND: Patellofemoral arthritis is a common cause of anterior knee pain and limits flexion-related activities of daily living and exercise. While frequently present in bicompartmental and tricompartmental osteoarthritis, patellofemoral arthritis can occur in isolation. Patellofemoral arthroplasty as a treatment option is gaining in popularity, especially with new implant designs. We report a case in which new inlay implants were used to resurface the patellofemoral joint in a patient with contralateral compromise secondary to a previous below-knee amputation. CASE REPORT: A 37-year-old female with a contralateral right below-knee amputation and progressive left patellofemoral arthritis had failed multiple conservative treatment modalities. She underwent isolated patellofemoral arthroplasty using an inlay-designed implant. The patient was followed for 2 years postoperatively. She noticed an immediate increase in her knee range of motion and her pain scores improved. Two years postoperatively, she demonstrated drastic improvement in all outcome measures: International Knee Documentation Committee score (16.1 to 88.5), Lysholm Knee Scoring Scale (22 to 100), Knee Injury and Osteoarthritis Outcome Score (KOOS) Symptoms (7.14 to 96.43), KOOS Pain (2.78 to 100), KOOS Activities of Daily Living (0 to 100), KOOS Sports (0 to 100), and KOOS Quality of Life (12.5 to 93.75). CONCLUSION: Inlay patellofemoral arthroplasty is a valid treatment option for isolated patellofemoral arthritis. Successful results can be achieved with this procedure after failure of conservative measures in patients with limited or no evidence of tibiofemoral arthritis.

Drivers of hospital length of stay in 56,000 orthopaedic trauma patients: The impact of postoperative cardiac events.

PURPOSE: To determine whether postoperative cardiac complications following orthopaedic trauma treatment are associated with longer lengths of stay. METHODS: This was a retrospective cohort study. We analyzed orthopaedic trauma patients in the United States for whom data was collected in the ACS-NSQIP database between the years of 2006 and 2013. The patient population included 56,217 orthopaedic trauma patients meeting any 1 of the 89 CPT codes selected in the ACS-NSQIP database. The main outcome measure was hospital length of stay following orthopaedic trauma treatment. RESULT: Of the 56,217 orthopaedic trauma patients, 749 (1.3%) developed postoperative adverse cardiac events. There was a significant difference in total length of stay (p < 0.001): patients with cardiac complications on average stayed 10.6 days compared to 5.2 days for patients who did not experience such cardiac complications. This amounted to a difference of $24,316 in total hospital costs. Through multiple linear regression modeling controlling for multiple patient and surgical factors, the presence of cardiac complications significantly added 1.5 days in total hospital stay (p < 0.05). CONCLUSION: Orthopaedic trauma patients sustaining postoperative cardiac events have significantly longer hospital lengths of stay when compared to those who do not develop cardiac complications. This difference amounts to significantly higher health care costs.

THETA-Rhythm Makes the World Go Round: Dissociative Effects of TMS Theta Versus Alpha Entrainment of Right pTPJ on Embodied Perspective Transformations.

Being able to imagine another person's experience and perspective of the world is a crucial human ability and recent reports suggest that humans "embody" another's viewpoint by mentally rotating their own body representation into the other's orientation. Our recent Magnetoencephalography (MEG) data further confirmed this notion of embodied perspective transformations and pinpointed the right posterior temporo-parietal junction (pTPJ) as the crucial hub in a distributed network oscillating at theta frequency (3-7 Hz). In a subsequent transcranial magnetic stimulation (TMS) experiment we interfered with right pTPJ processing and observed a modulation of the embodied aspects of perspective transformations. While these results corroborated the role of right pTPJ, the notion of theta oscillations being the crucial neural code remained a correlational observation based on our MEG data. In the current study we therefore set out to confirm the importance of theta oscillations directly by means of TMS entrainment. We compared entrainment of right pTPJ at 6 Hz vs. 10 Hz and confirmed that only 6 Hz entrainment facilitated embodied perspective transformations (at 160° angular disparity) while 10 Hz slowed it down. The reverse was true at low angular disparity (60° between egocentric and target perspective) where a perspective transformation was not strictly necessary. Our results further corroborate right pTPJ involvement in embodied perspective transformations and highlight theta oscillations as a crucial neural code.

Rhythm makes the world go round: An MEG-TMS study on the role of right TPJ theta oscillations in embodied perspective taking.

While some aspects of social processing are shared between humans and other species, some aspects are not. The former seems to apply to merely tracking another's visual perspective in the world (i.e., what a conspecific can or cannot perceive), while the latter applies to perspective taking in form of mentally "embodying" another's viewpoint. Our previous behavioural research had indicated that only perspective taking, but not tracking, relies on simulating a body schema rotation into another's viewpoint. In the current study we employed Magnetoencephalography (MEG) and revealed that this mechanism of mental body schema rotation is primarily linked to theta oscillations in a wider brain network of body-schema, somatosensory and motor-related areas, with the right posterior temporo-parietal junction (pTPJ) at its core. The latter was reflected by a convergence of theta oscillatory power in right pTPJ obtained by overlapping the separately localised effects of rotation demands (angular disparity effect), cognitive embodiment (posture congruence effect), and basic body schema involvement (posture relevance effect) during perspective taking in contrast to perspective tracking. In a subsequent experiment we interfered with right pTPJ processing using dual pulse Transcranial Magnetic Stimulation (dpTMS) and observed a significant reduction of embodied processing. We conclude that right TPJ is the crucial network hub for transforming the embodied self into another's viewpoint, body and/or mind, thus, substantiating how conflicting representations between self and other may be resolved and potentially highlighting the embodied origins of high-level social cognition in general.

Spike firing and IPSPs in layer V pyramidal neurons during beta oscillations in rat primary motor cortex (M1) in vitro.

Beta frequency oscillations (10-35 Hz) in motor regions of cerebral cortex play an important role in stabilising and suppressing unwanted movements, and become intensified during the pathological akinesia of Parkinson's Disease. We have used a cortical slice preparation of rat brain, combined with concurrent intracellular and field recordings from the primary motor cortex (M1), to explore the cellular basis of the persistent beta frequency (27-30 Hz) oscillations manifest in local field potentials (LFP) in layers II and V of M1 produced by continuous perfusion of kainic acid (100 nM) and carbachol (5 µM). Spontaneous depolarizing GABA-ergic IPSPs in layer V cells, intracellularly dialyzed with KCl and IEM1460 (to block glutamatergic EPSCs), were recorded at -80 mV. IPSPs showed a highly significant (P< 0.01) beta frequency component, which was highly significantly coherent with both the Layer II and V LFP oscillation (which were in antiphase to each other). Both IPSPs and the LFP beta oscillations were abolished by the GABAA antagonist bicuculline. Layer V cells at rest fired spontaneous action potentials at sub-beta frequencies (mean of 7.1+1.2 Hz; n = 27) which were phase-locked to the layer V LFP beta oscillation, preceding the peak of the LFP beta oscillation by some 20 ms. We propose that M1 beta oscillations, in common with other oscillations in other brain regions, can arise from synchronous hyperpolarization of pyramidal cells driven by synaptic inputs from a GABA-ergic interneuronal network (or networks) entrained by recurrent excitation derived from pyramidal cells. This mechanism plays an important role in both the physiology and pathophysiology of control of voluntary movement generation.

Engineering and characterization of the chimeric antibody that targets the C-terminal telopeptide of the α2 chain of human collagen I: a next step in the quest to reduce localized fibrosis.

Inhibition of the extracellular process of collagen fibril formation represents a new approach to limiting posttraumatic or postsurgical localized fibrosis. It has been demonstrated that employing a monoclonal antibody that targets the C-terminal telopeptide of the α2 chain of collagen I blocks critical collagen I-collagen I interaction, thereby reducing the amount of collagen deposits in vitro and in animal models. Here, we developed a chimeric variant of a prototypic inhibitory antibody of mouse origin. The structure of this novel antibody was analyzed by biochemical and biophysical methods. Moreover, detailed biochemical and biological studies were employed to test its antigen-binding characteristics. The ability of the chimeric variant to block formation of collagen fibrils was tested in vitro and in high-density cultures representing fibrotic processes occurring in the skin, tendon, joint capsule, and gingiva. The potential toxicity of the novel chimeric antibody was analyzed through its impact on the viability and proliferation of various cells and by testing its tissue cross-reactivity in sets of arrays of human and mouse tissues. Results of the presented studies indicate that engineered antibody-based blocker of localized fibrosis is characterized by the following: (1) a correct IgG-like structure, (2) high affinity and high specificity for a defined epitope, (3) a great potential to limit the accumulation of collagen-rich deposits, and (4) a lack of cytotoxicity and nonspecific tissue reactivity. Together, the presented study shows the great potential of the novel chimeric antibody to limit localized fibrosis, thereby setting ground for critical preclinical tests in a relevant animal model.

Femoral artery angiosarcoma presenting with distal embolization: report of a case.

Angiosarcoma of the femoral artery is an extremely rare malignant vascular tumor. The initial diagnosis is difficult to establish and distal metastasis can sometimes be the only presenting symptom. In this paper, we report the case of a 54-year-old man who presented with multiple painful necrotic lesions over the right foot secondary to an intimal angiosarcoma of the right common femoral artery.

The influence of alcohol and tobacco use in orthopaedic inpatients on complications of surgery.

INTRODUCTION AND AIMS: Tobacco use and heavy alcohol consumption are associated with increased morbidity and mortality. There is limited research on the correlation between tobacco and risky levels of alcohol use and the possible complications associated with a hospital admission. The underestimation of problem drinking, in particular, has obvious repercussions for the management of patients in hospital. If alcohol-related problems go undetected or unrecorded, treatment may be inadequate or inappropriate. The aims of the project were to assess the prevalence of high-risk alcohol and tobacco use in orthopaedic in-patients and to examine any relationship between alcohol and tobacco use and the number and type of complications, management and length of stay. DESIGN AND METHOD: One hundred and fifty-three consecutive orthopaedic admissions to the Orthopaedic Ward at Lismore Base Hospital were screened using the Drinkcheck questionnaire, which is based on the Alcohol Use Disorders Identification Test (AUDIT), but which also screens for tobacco use. Nursing staff on the ward completed a Complications Evaluation Questionnaire (CEQ). The risk status of the subjects was compared to the number and type of complications, to assess any effects of alcohol and tobacco on post-surgical complications. RESULTS: Significant correlations were found between tobacco use, hazardous and harmful alcohol use and numerous medical complications and behavioural problems. Behavioural problems associated with risky alcohol use included verbal abuse, agitation and sleep disturbances, particularly in men; problems associated with tobacco use included agitation and non-compliance. DISCUSSION AND CONCLUSIONS: Orthopaedic patients who smoke and/or drink heavily prior to surgery may have more non-medical complications than non-smokers and light or non-drinkers. All surgery patients should thus be screened for alcohol and tobacco use and alcohol withdrawal, which may cause other symptoms such as behavioural problems, non-compliance and verbal abuse post-surgery.

Mycotic common iliac artery aneurysm complicating methicillin-resistant Staphylococcus aureus bacteremia: an unusual cause of ureteric obstruction.

A 60-year-old man presented with ureteric obstruction secondary to a mycotic right common iliac artery aneurysm complicating methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The diagnosis of MRSA was not known at the time of surgery, and in situ replacement of the aneurysm using a rifampicin-bonded prosthesis was performed. The patient made a full recovery, and to date there is no evidence of residual or recurrent infection. To our knowledge, this is the first reported case of mycotic iliac aneurysm infected with MRSA in the literature. We discuss the consequences and the considerable diagnostic and therapeutic problems that arise.