Displaced Intra-articular Calcaneus Fractures: Extensile Lateral and Less Invasive Approaches.

Treatment of displaced intra-articular calcaneal fractures is controversial and must be individualized by patient and fracture type. With an extensile lateral approach, all components of the deformity in displaced intra-articular calcaneal fractures can be addressed. The extensile lateral approach is indicated in more complex fracture patterns and when delay of surgery is necessary because of severe soft-tissue injury beyond 2 to 3 weeks. Careful patient selection, proper surgical timing, incision placement, and soft-tissue handling minimize the high rate of wound healing complications associated with the extensile lateral approach. The goals of surgical treatment of displaced intra-articular calcaneal fractures may also be achieved using less invasive approaches, such as the sinus tarsi approach and closed reduction with percutaneous fixation, decreasing the risk of wound complications. Multiple factors influence determination of the specific approach.

Physiologic Motion in the Intact and Unstable Syndesmosis During Plantigrade Weightbearing in Controlled Ankle Motion Boots.

Consensus has not been reached for the optimal postoperative care after high ankle sprain and syndesmotic fixation. A potential drawback of earlier return to activity is greater instability of the ankle and fixation failure. The controlled ankle motion (CAM) boot has been an effective implementation to stabilize the leg and may aid in safe early weightbearing status. However, there is insufficient study of its effect on motion in the syndesmosis following injury. Hence, the aim of this cadaveric study was to determine the stability of the ankle with a CAM boot at 3 levels of injury: syndesmosis ligaments intact (no injury), syndesmosis ligaments cut, and syndesmosis and fibula cut. Six cadaveric legs were subjected to each level of injury and axially loaded at 1 Hz between 100 N-1.5 times body weight for 50 seconds, and axial force, axial displacement, and optical tracking data were recorded. It was found that the ankle, when protected by the CAM boot, maintained syndesmosis motion with no difference (p > .05) from the uninjured state, regardless of syndesmotic ligament and fibular injury. This finding was consistent across anterior-posterior, medial-lateral, and superior-inferior axes. Overall, our study may suggest that early weightbearing with a CAM boot maintains a physiologically range of motion in the syndesmosis.

Understanding the patellofemoral joint in total knee arthroplasty

Total knee arthroplasty (TKA) is one of the most successful procedures in orthopedic surgery. Nevertheless, postoperative patellofemoral complications remain a challenging problem, affecting a substantial proportion of patients. Complications involving the patellofemoral joint (PFJ) can occur in both resurfaced and nonresurfaced patellae. Types of PFJ complications include anterior knee pain, maltracking, fracture, avascular necrosis and patellar clunk. The causes of patellofemoral complications can be categorized into patient-, surgeon- and implant-related factors. Patient characteristics such as female sex, young age, depression and increased body mass index have been linked with increased complications. Important technical considerations to avoid complications include achieving appropriate rotational alignment of the femoral and tibial components, maintaining joint line height, medializing the patellar button and avoiding "overstuffing" the PFJ. Component design features such as conformity, shape and depth of the femoral trochlea have also been shown to be important. Although the cause of patellofemoral complications after TKA may sometimes be unknown, it remains important to minimize errors that can lead to these complications.

La prothèse totale du genou (PTG) est l'une des interventions qui réussit le mieux en chirurgie orthopédique. Les complications fémoro-patellaires postopératoires n'en restent pas moins un problème complexe qui affecte une proportion substantielle de patients. Les complications affectant l'articulation fémoro-patellaire (AFP) peuvent survenir en présence de rotules resurfacées ou non. Les types de complications de l'AFP incluent, douleur au devant du genou, défaut d'alignement, fracture, nécrose avasculaire et accrochage rotulien. Les causes des complications fémoro-patellaires peuvent appartenir à diverses catégories selon qu'elles sont liées au patient, au chirurgien ou à la prothèse elle-même. Des caractéristiques liées aux patients, comme le fait d'être de sexe féminin, le jeune âge, la dépression et un indice de masse corporelle élevé, sont associées à une hausse des complications. Les enjeux techniques importants pour éviter les complications incluent : obtenir un alignement rotationnel approprié des éléments fémoraux et tibiaux, maintenir la hauteur de la ligne articulaire, médialiser le bouton patellaire et éviter d'encombrer l'AFP. Les caractéristiques de la modélisation des éléments, comme la conformité, la forme et la profondeur de la trochlée fémorale se sont aussi révélées importantes. Même si la cause des complications fémoro-patellaires post-PTG est parfois inconnue, il est important de prévenir les erreurs susceptibles de mener à de telles complications.

Differences in Trochlear Surface Damage and Wear Between Three Different Total Knee Arthroplasty Designs.

INTRODUCTION: Trochlear design plays a role in patellofemoral kinematics. Little is known regarding differences in the contact properties between modern designs. The purpose of the present study was to analyze patellofemoral joint contact by identifying areas of joint surface damage and wear in retrieved femoral components of 3 modern designs. MATERIALS: Eighteen retrieved femoral components featuring 3 different modern designs (Triathlon, SIGMA, and GENESIS II) were matched based on time-in-vivo, age, gender, and body mass index. Trochlear wear and surface damage were assessed using visual inspection, light microscopy, and light profilometry. RESULTS: Visual inspection of the femoral components showed evidence of surface damage in all implant types. No significant differences between the groups were found with respect to surface damage and wear on visual inspection. Light profilometry of retrieved components showed that retrieved Triathlon (P = .002) and SIGMA (P = .009) components were significantly rougher than the corresponding reference components. The GENESIS II retrieved components were not substantially rougher than the reference components (P = .48). Light profilometry analysis showed significantly increased roughness of retrieved SIGMA components compared with Triathlon or GENESIS II components, particularly in the proximal trochlear groove and the medial trochlea. CONCLUSION: As the volume and patient demands for total knee arthroplasty increase, a greater understanding of the patellofemoral joint is warranted. Patellofemoral kinematics can have an effect on the surface characteristics of total knee arthroplasty components. Retrieved SIGMA components appeared to have increased roughness compared with Triathlon or GENESIS II components. The etiology and long-term effects of increased trochlear roughness require further investigation.

Do Changes in Patellofemoral Joint Offset Lead to Adverse Outcomes in Total Knee Arthroplasty With Patellar Resurfacing? A Radiographic Review.

BACKGROUND: Patellofemoral joint biomechanics contribute to anterior knee pain, instability, and dysfunction following total knee arthroplasty (TKA). Information about specific factors leading to anterior knee pain and dysfunction is currently limited. Changes in patellofemoral joint offset (PFO) refers to a mismatch between the preoperative and postoperative anteroposterior geometry of the patellofemoral joint. It remains unclear whether these changes lead to adverse outcomes in TKA. METHODS: A retrospective radiographic review of 970 knees pre-TKA and post-TKA was completed to correlate the radiographic and clinical outcomes of changing the PFO using a posterior-stabilized single knee design with patellar resurfacing. RESULTS: A total of 970 patients were reviewed. Postoperatively, the anterior femoral offset, anteroposterior femoral size, and anterior patellar offset were changed in 40%, 60%, and 71% of knees, respectively, compared to preoperative values. The Western Ontario and McMasters Osteoarthritis Index total score as well as subscale scores for pain and function were not significantly affected by an increase or decrease in PFO. Similarly, Knee Society Scores and range of motion were not significantly affected. Increased anterior patellar offset was, however, associated with increased postoperative patellar tilt. Postoperative patellar tilt was not correlated with adverse patient satisfaction scores or loss of range of motion. CONCLUSION: Changes in PFO (decreased, maintained, or increased) are common post-TKA and are not associated with a difference in clinical outcomes. Increases in anterior patellar offset led to increased patellar tilt, which was not associated with adverse patient satisfaction scores.

Balancing Benefits and Risks of Immortal Data: Participants' Views of Open Consent in the Personal Genome Project.

An individual's health, genetic, or environmental-exposure data, placed in an online repository, creates a valuable shared resource that can accelerate biomedical research and even open opportunities for crowd-sourcing discoveries by members of the public. But these data become "immortalized" in ways that may create lasting risk as well as benefit. Once shared on the Internet, the data are difficult or impossible to redact, and identities may be revealed by a process called data linkage, in which online data sets are matched to each other. Reidentification (re-ID), the process of associating an individual's name with data that were considered deidentified, poses risks such as insurance or employment discrimination, social stigma, and breach of the promises often made in informed-consent documents. At the same time, re-ID poses risks to researchers and indeed to the future of science, should re-ID end up undermining the trust and participation of potential research participants. The ethical challenges of online data sharing are heightened as so-called big data becomes an increasingly important research tool and driver of new research structures. Big data is shifting research to include large numbers of researchers and institutions as well as large numbers of participants providing diverse types of data, so the participants' consent relationship is no longer with a person or even a research institution. In addition, consent is further transformed because big data analysis often begins with descriptive inquiry and generation of a hypothesis, and the research questions cannot be clearly defined at the outset and may be unforeseeable over the long term. In this article, we consider how expanded data sharing poses new challenges, illustrated by genomics and the transition to new models of consent. We draw on the experiences of participants in an open data platform-the Personal Genome Project-to allow study participants to contribute their voices to inform ethical consent practices and protocol reviews for big-data research.

Live liver donors' risk thresholds: risking a life to save a life.

BACKGROUND: There is still some controversy regarding the ethical issues involved in live donor liver transplantation (LDLT) and there is uncertainty on the range of perioperative morbidity and mortality risks that donors will consider acceptable. METHODS: This study analysed donors' inclinations towards LDLT using decision analysis techniques based on the probability trade-off (PTO) method. Adult individuals with an emotional or biological relationship with a patient affected by end-stage liver disease were enrolled. Of 122 potential candidates, 100 were included in this study. RESULTS: The vast majority of participants (93%) supported LDLT. The most important factor influencing participants' decisions was their wish to improve the recipient's chance of living a longer life. Participants chose to become donors if the recipient was required to wait longer than a mean ± standard deviation (SD) of 6 ± 5 months for a cadaveric graft, if the mean ± SD probability of survival was at least 46 ± 30% at 1 month and at least 36 ± 29% at 1 year, and if the recipient's life could be prolonged for a mean ± SD of at least 11 ± 22 months. CONCLUSIONS: Potential donors were risk takers and were willing to donate when given the opportunity. They accepted significant risks, especially if they had a close emotional relationship with the recipient.

Modified Dresden Technique With a Distal Locking Suture for Achilles Tendon Repair: Technique Tip.

[Formula: see text].

Rapid structural alterations of the active zone lead to sustained changes in neurotransmitter release.

The likelihood with which an action potential elicits neurotransmitter release, the release probability (p(r)), is an important component of synaptic strength. Regulatory mechanisms controlling several steps of synaptic vesicle (SV) exocytosis may affect p(r), yet their relative importance in determining p(r) and eliciting temporal changes in neurotransmitter release at individual synapses is largely unknown. We have investigated whether the size of the active zone cytomatrix is a major determinant of p(r) and whether changes in its size lead to corresponding alterations in neurotransmitter release. We have used a fluorescent sensor of SV exocytosis, synaptophysin-pHluorin, to measure p(r) at individual synapses with high accuracy and employed a fluorescently labeled cytomatrix protein, Bassoon, to quantify the amount of active zone cytomatrix present at these synapses. We find that, for synapses made by a visually identified presynaptic neuron, p(r) is indeed strongly correlated with the amount of active zone cytomatrix present at the presynaptic specialization. Intriguingly, active zone cytomatrices are frequently subject to synapse-specific changes in size on a time scale of minutes. These spontaneous alterations in active zone size are associated with corresponding changes in neurotransmitter release. Our results suggest that the size of the active zone cytomatrix has a large influence on the reliability of synaptic transmission. Furthermore, they implicate mechanisms leading to rapid structural alterations at active zones in synapse-specific forms of plasticity.

A dual-sensor ultrasound based method for detecting elevated muscle compartment pressures: A prospective clinical pilot study.

BACKGROUND: Acute compartment syndrome (ACS) is a limb-threatening condition associated with elevated muscle compartment pressures (MCPs). The only existing treatment of ACS is to reduce MCP by fasciotomy; however, a reliable clinical method for detecting elevated MCPs is lacking. A dual-sensor (ultrasound and pressure) technology to detect elevated MCPs was previously tested on cadavers. Our goal was to examine the use of this technology in the clinical setting. METHODS: Patients with tibia fractures were prospectively enrolled. Observers used a dual-sensor probe to measure the amount of pressure required to flatten the anterior compartment fascia (CFFP). Direct-MCP measurements and 4-compartment fasciotomy were done for suspected ACS. RESULTS: Fifty-two patients were enrolled into the study. Nine patients underwent fasciotomy for a clinical diagnosis of ACS. Both CFFP (p-value = 8.395e-08) and delta-CFFP (p-value = 4.114e-05) were significantly larger in the fasciotomy group compared to the non-fasciotomy group. CFFP measurements showed very strong correlations to the direct MCP measurements (p-value = 0.006746, rho = 0.9285714), and delta-CFFP showed strong correlation (p-value = 0.06627, rho = 0.75). CFFP measurements had good inter-observer variability, with an interclass correlation (ICC) of 0.814 (95%-Confidence Interval: 0.631-0.907) and excellent intra-observer variability with an ICC of 0.942 (95%-Confidence Interval: 0.921-0.958). CONCLUSION: The results of this pilot study suggest that the proposed ultrasound-based method is useful in detecting elevated MCPs and may be helpful in the diagnosing ACS or ruling out the need for urgent fasciotomy. Large-scale clinical trials are needed to validate these claims.

Use of Osteobiologics for Fracture Management: The When, What, and How.

Osteobiologics are defined as a group of natural and synthetic materials used to augment bone healing. The selection of the most appropriate osteobiologic from the growing list of available options can be a challenging task. In selecting a material, surgeons should weigh a variety of considerations, including the indication for their use (the when), the most suitable substance (the what), and the correct mode of application (the how). This summary reviews these considerations and seeks to provide the surgeon with a basis for informed clinical evidence-based decision-making in their choice of a successful option.

The Iliopectineal Fascia: A Cadaveric Anatomical Study.

OBJECTIVES: The iliopectineal fascia (IPF) serves as an important anatomical compass during the ilioinguinal and anterior intrapelvic approaches. The purpose of this investigation is to qualitatively and quantitatively describe the IPF by cadaveric dissection. METHODS: Dissections were performed on 7 paired fresh-frozen cadaveric pelvic specimens. Measurements were made with surgical rulers to determine attachments of the IPF relative to surrounding anatomy. RESULTS: The IPF is the thickened anterior portion of the iliopsoas fascia, attached superolaterally at the iliac crest for a mean insertion distance of 2.5 cm (range, 2.0-3.0 cm), immediately posterior to the origin of the inguinal ligament. Inferomedially, the IPF attaches to a bony ridge along the apex of the iliopectineal eminence, between the pelvic brim posteriorly and the anterior wall of the acetabulum anteriorly (mean distance, 4.3 cm; range, 3.1-5.6 cm). The attachment at the iliopectineal eminence is 7.8 cm (range, 6.0-10.0 cm) from the pubic symphysis, measured curvilinearly along the brim. The mean length of the IPF between its superolateral and inferomedial attachments is 9.2 cm (range, 8.0-11.8 cm). Anterolaterally, the IPF is the site of attachment of the internal oblique and transversus abdominis. Posteriorly, the IPF continues as the iliopsoas fascia. CONCLUSIONS: The authors have sought clarity and reconciliation of the myriad terms and descriptions of the IPF and its surrounding anatomy. We recommend a thorough understanding of this anatomy to enable safe and effective surgery via the ilioinguinal and anterior intrapelvic approaches to the acetabulum.

Management of Pelvic Ring Injury Patients With Hemodynamic Instability.

Pelvic ring injuries (PRI) are among the most difficult injuries to deal with in orthopedic trauma. When these injuries are accompanied by hemodynamic instability their management becomes significantly more complex. A methodical assessment and expeditious triage are required for these patients followed by adequate resuscitation. A major triage decision is whether these patients should undergo arterial embolization in the angiography suit or prompt packing and pelvic stabilization in the operating room. Patient characteristics, fracture type and injury characteristics are taken into consideration in the decision-making process. In this review we discuss the acute evaluation, triage and management of PRIs associated with hemodynamic instability. An evidence based and protocol driven approach is necessary in order to achieve optimal outcomes in these patients.

Does Posterior Condylar Offset Affect Clinical Results following Total Knee Arthroplasty?

Total knee arthroplasty (TKA) is an effective, durable treatment for knee osteoarthritis. However, a subset of patients experiences incomplete pain relief and ongoing dysfunction. Posterior condylar offset (PCO) has previously been shown to be associated with postoperative range of motion (ROM) following TKA; however, an association with patient-reported outcome measures (PROMs) has not been established. The purpose of this study was to evaluate the association between PCO and postoperative ROM and PROMs. A retrospective review of 970 posterior-stabilized single design TKAs was performed. Preoperative and postoperative radiographs were analyzed to measure the change in PCO and anteroposterior (AP) femoral dimension. Clinical outcome measures, including Short Form-12 physical and mental component summaries, Western Ontario and McMaster Universities Arthritis Index, and Knee Society Score were reviewed to determine if these were influenced by changes in PCO and AP dimension. PCO was increased by more than 3 mm in 15.1%, maintained (within 3 mm) in 59.6%, and decreased by more than 3 mm in 25.3% of patients. Comparing between these groups, there were no significant differences in postoperative ROM or PROM. AP dimension increased in 24.4%, maintained in 47.8%, and decreased in 27.8%. Similarly, there were no significant differences in ROM or PROM between these groups. Spearman's correlation analyses failed to identify an association between PCO and ROM or PROMs. In conclusion, increasing or decreasing PCO or AP femoral dimension with this PS TKA design did not significantly affect postoperative ROM or PROM. Similarly, maintenance of PCO within one implant size with this system compared with optimal sizing had no deleterious effect on TKA outcomes.

Social Science-Environmental Health Collaborations: An Exciting New Direction.

The Social Science-Environmental Health Collaborations Conference in May 2016 was a unique gathering of scholars from the social sciences and environmental health sciences, government agency professionals, community organizers and activists, and students. Conference participants described the research and practice of environmental public health as done through a transdisciplinary lens and with a community-based participatory research/community-engaged research model. NIEHS' role in supporting such work has helped create a growing number of social and environmental health scientists who cross boundaries as they work with each other and with community-based organizations.

Preoperative Pelvic Tilt Analysis Reduces Fluoroscopy Time in Direct Anterior Total Hip Arthroplasty.

The direct anterior approach for total hip arthroplasty (THA) requires the use of intraoperative imaging, exposing the patient and surgical team to radiation. The authors hypothesized that calculation of the preoperative pelvic tilt angle and communication of this value with the fluoroscopy technician may result in a decrease in intraoperative fluoroscopy use. The study also examined total radiation exposure during the procedure to ensure that it was within safe limits. The pelvic tilt was calculated preoperatively for 100 consecutive patients undergoing THA by the direct anterior approach. The fluoroscopy technician was blinded to the value of pelvic tilt for the first 50 cases (control group), with the angle being communicated for the following 50 cases (test group). The total duration of fluoroscopy use for each case was recorded. The values were compared for the 2 experienced technicians involved in the study. The surgeon was blinded to the duration of fluoroscopy use in all cases. Mean fluoroscopy time was 28.65 seconds in the control group and 23.61 seconds in the test group (P=.033). No significant difference in duration of fluoroscopy use was found between the 2 fluoroscopy technicians. The control group and the test group were within safe limits of radiation exposure to both the patient and the surgical team. Preoperative pelvic tilt calculation significantly decreases the amount of imaging used during THA by the direct anterior approach. Although it was a statistically significant reduction, both groups were within safe limits for both the surgical team and the patients, and thus the clinical significance is unknown. [Orthopedics.2016; 39(5):e962-e966.].

Reliability of Proximal Junctional Kyphosis Measurements for Young Children With Scoliosis.

DESIGN: Retrospective comparison. OBJECTIVES: To determine whether the choice of proximal junctional kyphosis (PJK) definition affects reported rates and reliability of measurement of PJK for the same group of children treated with growth-friendly surgery. BACKGROUND: Distraction-based surgery has been associated with the development of PJK, which may lead to premature implant failure and may affect the upper instrumented level. Proximal junctional kyphosis has not been clearly defined in the literature and recent studies have used various definitions, resulting in widely varying rates of PJK. As a first step toward defining risk factors that may lead to clinically significant PJK, an evaluation of definitions of PJK should be performed. METHODS: The researchers analyzed radiographs of 36 children who were treated with growth-friendly surgery. The rates of PJK were determined using 3 recently described definitions. Five observers each measured the radiographs 2 weeks apart. Reliability was measured using the kappa statistic and intraclass correlation. RESULTS: At 2-year follow-up, rates of PJK varied between 6% and 42% depending on the definition used. Interobserver agreement for PJK at time 1 yielded fair agreement for definition 1 (κ = 0.31), moderate for definition 2 (κ = 0.40), and fair for definition 3 (κ = 0.38). Interobserver agreement for junctional angle at time 1 was fair (intraclass correlation coefficient [ICC], 0.48) for definition 1, good (ICC, 0.71) for definition 2, and fair (ICC, 0.55) for definition 3. Intra-observer agreement between times 1 and 2 for junctional angle was good (ICC, 0.61) for definition 1, excellent (ICC, 0.82) for Definition 2, and good (ICC, 0.69) for definition 3. CONCLUSIONS: When assessed with the same group of children, rates of PJK varied depending on the definition used. Interobserver reliability was fair to moderate; however, better interobserver and intra-observer agreement were noted with definition 2.

Use of a SILS port in transanal endoscopic microsurgery in the setting of a community hospital.

Transanal endoscopic microsurgery (TEM) is a well-known technique for the removal of rectal lesions. This operation poses several advantages over traditional anal excision, which include better visibility of the rectum, more precise border excision, and a lower recurrence rate of benign and stage T1 malignant neoplasms. Introducing a SILS™ port (Covidien) into the anal canal (originally developed for single-incision laparoscopic surgery), instead of the TEM proctoscope, may further enhance the technique. We performed excisions of rectal lesions in 3 patients using a SILS port in TEM. In all cases, it was easy to maintain the rectum insufflated, and the visibility was excellent. The rectal lesions were successfully resected without significant intraoperative complications. Postoperative recovery was uneventful in both cases. TEM with a SILS port is a promising technique that may provide several advantages over the traditional TEM, including cost-effectiveness, and can be easily implemented in the setting of a community hospital.