The nonsalvageable tibia: amputation and prosthetics.

Mangled extremities are a challenging problem for the orthopaedic surgeon. The decision for salvage versus amputation is multifactorial. Several work groups have attempted to create scoring systems to guide treatment, but each case must be regarded individually. As surgical technique and prosthetics continue to improve, amputations should be seen as a viable reconstructive option, rather than failure. This article reviews scoring systems for the mangled extremity, outcomes on salvage versus amputation, amputation surgical technique, and prosthetic options.

Damage-control orthopedics or early total care: What you need to know.

ABSTRACT: Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

Development of a Liquid Chromatography-Tandem Mass Spectrometry (LC-MS/MS) Method for Characterizing Linalool Oral Pharmacokinetics in Humans.

Lavender (Lavandula angustifolia Miller or Lavandula officinalis Chaix) is an ethnopharmacological plant commonly known as English lavender. Linalool and linalyl acetate are putative phytoactives in lavender essential oil (LEO) derived from the flower heads. LEO has been used in aroma or massage therapy to reduce sleep disturbance and to mitigate anxiety. Recently, an oral LEO formulation was administered in human clinical trials designed to ascertain its anxiolytic effect. However, human pharmacokinetics and an LC-MS/MS method for the measurement of linalool are lacking. To address this deficiency, a rapid and sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed for the analysis of linalool in human serum. Prior to the analysis, a simple sample preparation protocol including protein precipitation and liquid-liquid extraction of serum samples was created. The prepared samples were analyzed using a C18 reversed-phase column and gradient elution (acetonitrile and water, both containing 0.1% formic acid). A Waters Xevo TQ-S tandem mass spectrometer (positive mode) was used to quantitatively determine linalool and IS according to transitions of m/z 137.1→95.1 (tR 0.79 min) and 205.2→149.1 (tR 1.56 min), respectively. The method was validated for precision, accuracy, selectivity, linearity, sensitivity, matrix effects, and stability, and it was successfully applied to characterize the oral pharmacokinetics of linalool in humans. The newly developed LC-MS/MS-based method and its application in clinical trial serum samples are essential for the characterization of potential pharmacokinetic and pharmacodynamic interactions.

Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum.

SUMMARY: Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Clinical and Radiographic Comparison of Splinting Constructs for Distal Radius Fractures: An Effort to Free the Elbow.

OBJECTIVES: To compare short-term functional outcomes, reduction loss, and rates of surgery for distal radius fractures initially immobilized with a traditional sugar-tong splint versus clamshell splint freeing the elbow. DESIGN: Prospective randomized trial. SETTING: Level 1 trauma center. PATIENTS: Eighty-nine consecutive patients sustaining distal radius fractures were enrolled between 2018 and 2020. Short-term first follow-up (1-2 weeks) radiographic parameters and 6 weeks for functional questionnaires were established to assess initial outcomes. MAIN OUTCOME MEASURES: The main outcome measures were reduction loss based on radiographic criteria, rate of surgery, and short-term patient functional outcome using the Disabilities of the Arm, Shoulder, and Hand (DASH) score. RESULTS: There were no differences noted in DASH scores ( P -value = 0.8) or loss of reduction ( P -value = 0.69), and splint type was not correlated with likelihood to have surgery ( P = 0.22). A binomial regression model demonstrated splint type was not a significant predictor variable of loss of fracture reduction in the regression model. CONCLUSIONS: These results suggest both sugar-tong splint and clamshell splint construct are acceptable options in the acute management of distal radius fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Preoperative and Intraoperative Considerations Using Intramedullary Nails for the Treatment of Tibial Shaft Fractures Below Total Knee Arthroplasty.

SUMMARY: Periprosthetic tibial shaft fractures below total knee arthroplasty (TKA) are relatively rare, with an incidence of approximately 1%. However, as the rates of arthroplasty increase, orthopaedic surgeons are likely to see a corresponding increase in these types of fractures. Native tibial shaft fractures are routinely treated with either nails or plates, and the success of intramedullary nailing of tibial shaft fractures has been well described in the literature. In this article, we seek to describe a case series of tibial shaft fractures in patients with ipsilateral TKA treated with infrapatellar intramedullary nailing. We will focus on preoperative considerations including templating and measurement of the anterior cortical implant distance on the lateral radiograph to ensure space for safe nail passage. We will also discuss intraoperative technical tricks, including Kirschner wire insertion for sounding the start point, utilization of the curved awl, use of hand reamers, and rotation of the nail to bypass the implant. Using meticulous preoperative planning and technical intraoperative tricks, patients with tibial shaft fractures below TKA may be successfully treated with intramedullary nailing.

Antidiabetic Potential of Volatile Cinnamon Oil: A Review and Exploration of Mechanisms Using In Silico Molecular Docking Simulations.

Cinnamon has been used as a flavoring and medicinal agent for centuries. Much research has focused on cinnamon bark powder, which contains antioxidants, flavonoids, carotenoids, vitamins, minerals, fiber, and small amounts of essential oil. However, isolated and concentrated cinnamon essential oil may also have important medicinal qualities, particularly in antidiabetic therapy. Some of the most common essential oil constituents identified in the literature include cinnamaldehyde, eugenol, and beta-caryophyllene. Due to their high concentration in cinnamon essential oil, these constituents are hypothesized to have the most significant physiological activity. Here, we present a brief review of literature on cinnamon oil and its constituents as they relate to glucose metabolism and diabetic pathogenesis. We also present molecular docking simulations of these cinnamon essential oil constituents (cinnamaldehyde, eugenol, beta-caryophyllene) that suggest interaction with several key enzymes in glucometabolic pathways.

Extra-articular Unstable Iliac Fractures: Associated Injuries, Fixation Strategies, and Outcomes.

OBJECTIVE: To characterize the associated injuries, fixation constructs, and outcomes of extra-articular unstable iliac fractures. DESIGN: Retrospective cohort study. SETTING: Level I trauma center. PATIENTS: Thirty-three extra-articular unstable iliac fractures treated over a 20-year period. INTERVENTION: Percutaneous or open fixation of iliac fractures at the pelvic brim AND/OR iliac crest. MAIN OUTCOME MEASURES: Incidence of union, fixation failure, and angiography at the time of injury. RESULTS: Twenty-five patients were treated operatively with appropriate follow-up. Four patients had fixation failure with displacement, all in the group with only brim OR crest fixation (4/8 patients, 50% rate). In patients with both crest AND brim fixation (n = 17), there were no cases of implant failure or late displacement. In displaced fractures (n = 22), 4 patients (18%) required embolization by interventional radiology. In all 4 cases, the superior gluteal artery was embolized. In patients with both crest AND brim fixation, all went on to uneventful union with an average Visual Analog Scale (VAS) pain score of 0.9 (range, 0-5) at final follow-up. CONCLUSIONS: Extra-articular unstable iliac fractures are high-energy injuries that demonstrate a high rate of union when both pelvic brim AND iliac crest fixation is used. Approximately 1 in 5 patients with a displaced iliac fracture presented with a superior gluteal artery disruption requiring embolization. Pelvic brim OR iliac crest fixation used in isolation was associated with a fixation failure rate of 50%, supporting previous biomechanical work. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Medical termination of pregnancy by general practitioners]. / Medicamenteuze zwangerschapsafbreking door huisartsen.

A medical termination of pregnancy can be carried out effectively and safely up to 9 weeks' amenorrhea by general practitioners. In the case of an early pregnancy, reliable anamnesis and absence of risk factors for an EUG, ultrasound diagnostics are not strictly necessary before a medical termination of pregnancy. Anamnesis and/or b-HCG monitoring are a sound alternative. If there is no loss of blood 4 hours after insertion of misoprostol the woman can insert the extra 2 tablets of misoprostol. If there is heavy blood loss (soaking more than two large pads per hour for two consecutive hours) and/or suspicion of an EUG, the general practitioner should consult a gynecologist. In the event of a positive pregnancy test after 3 weeks, the test can be repeated after a week if there are no symptoms. Rhesus prophylaxis is not necessary.

Repair of Humeral Shaft Nonunion With Plate and Screw Fixation and Iliac Crest Bone Graft.

SUMMARY: A 58-year-old woman with a proximal 1/3 humeral shaft nonunion presented 2 years after initial injury. We present a technique for nonunion repair, including nonunion site preparation, direct compression of the fracture site using plate osteosynthesis, and iliac crest bone graft harvest and utilization. The purpose of this video is to review humeral shaft nonunion literature and describe our management technique.

Sternoclavicular Joint Reconstruction for Medial Clavicle Fracture Nonunion.

SUMMARY: Operative management of sternoclavicular fracture-dislocations is recommended in the setting of symptomatic nonunion. Treatment options include open reduction internal fixation, fragment excision, and ligamentous reconstruction. We present a 29-year-old man with a medial clavicle fracture nonunion that previously failed open reduction internal fixation and was treated with sternoclavicular joint reconstruction using tendon allograft.

Distal Humerus Fractures Evolution of Management.

Distal humerus fractures are a challenging problem that has vexed many orthopedic surgeons through the years. This article reviews the historical management of distal humerus fractures from nonoperative treatment to prolonged traction with ice tongs to the advent of AO technique and beyond. Current controversies, including plate orientation, ulnar nerve management, and the role of arthroplasty, are reviewed. Based on the best available evidence, parallel plating has been shown to be biomechanically superior, but no differences have been found in clinical outcomes, and the surgeon should let the fracture pattern dictate plate placement. The evidence surrounding ulnar nerve management is controversial, but a systematic review has shown no benefits to routine transposition. Finally, total elbow arthroplasty is an excellent option in geriatric fractures with osteoporotic bone and should be considered in these cases. Ultimately, distal humerus fractures, especially in the geriatric population, remain a difficult problem, but with meticulous technique and stable restitution of the bony columns and tie arch, good outcomes can be obtained.

Novel Auristatins with High Bystander and Cytotoxic Activities in Drug Efflux-positive Tumor Models.

Auristatins, a class of clinically validated anti-tubulin agents utilized as payloads in antibody-drug conjugates, are generally classified by their membrane permeability and the extent of cytotoxic bystander activity on neighboring cells after targeted delivery. The drugs typically fall within two categories: membrane permeable monomethyl auristatin E-type molecules with high bystander activities and susceptibility to efflux pumps, or charged and less permeable monomethyl auristatin F (MMAF) analogs with low bystander activities and resistance to efflux pumps. Herein, we report the development of novel auristatins that combine the attributes of each class by having both bystander activity and cytotoxicity on multidrug-resistant (MDR+) cell lines. Structure-based design focused on the hydrophobic functionalization of the N-terminal N-methylvaline of the MMAF scaffold to increase cell permeability. The resulting structure-activity relationships of the new auristatins demonstrate that optimization of hydrophobicity and structure can lead to highly active free drugs and antibody-drug conjugates with in vivo bystander activities.

Are Arthroplasty Procedures Really Better in the Treatment of Complex Proximal Humerus Fractures? A Comprehensive Meta-Analysis and Systematic Review.

OBJECTIVE: A meta-analysis and systematic review was performed to compare outcomes of open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (rTSA) for complex proximal humerus fractures. Data sources: MEDLINE, Embase, and Cochrane Library databases were screened. Search terms included reverse total shoulder arthroplasty, open reduction internal fixation, hemiarthroplasty, and proximal humerus fracture. STUDY SELECTION: English-language studies published within the past 15 years evaluating outcomes of ORIF, rTSA, or HA for complex proximal humerus fractures with minimum of 1-year follow-up were included, resulting in 51 studies with 3064 total patients. Review articles, basic science studies, biomechanical studies, and cadaveric studies were excluded. DATA EXTRACTION: The methodological quality of evidence was assessed using the Jadad scale and methodological index for nonrandomized studies. DATA SYNTHESIS: Demographic data were compared using the χ2 test. Mean data were weighted by study size and used to calculate composite mean values and confidence intervals. Continuous data were compared using the Metan module with fixed effects. Count data were compared using the Kruskal-Wallis test. Alpha was set at 0.05 for all tests. CONCLUSIONS: Patients undergoing rTSA had lower risks of complication (relative risk 0.41) and reoperation (relative risk 0.28) than HA patients. rTSA resulted in higher Constant scores (standard mean difference 0.63) and improved active forward flexion when compared with HA (standard mean difference 0.76). Pooled mean data demonstrated better outcome scores and active forward flexion of ORIF versus HA and rTSA, although the patients were younger and had more simple fracture patterns. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Incidence of Osteomyelitis in Sacral Decubitus Ulcers and Recommendations for Management.

Stage-4 pressure ulcers are defined as ulcerations that violate the fascia and expose underlying bone, muscle, and tendon. Exposed bone is always colonized by bacteria, but this does not necessarily lead to osteomyelitis. The rates of osteomyelitis in exposed bone in stage-4 pressure ulcers range from 14% to 86%.There has been no evidence that the presence of osteomyelitis leads to higher complication rates following flap coverage. There has been no evidence that bone biopsy and preoperative treatment of osteomyelitis have any benefit before flap coverage.

Evaluation of ruminal degradability and metabolism of feedlot finishing diets with or without cotton byproducts.

Cotton byproducts can be an economical source of protein, fat, and fiber in cattle finishing diets. The objectives of this study were 1) to assess the effects of including whole cottonseed (WCS) and cotton gin trash (CGT) in finishing diets on in situ ruminal degradability and 2) to determine the effects of including cotton byproducts in a finishing diet on rumen fluid pH, lactate, and volatile fatty acid concentrations. Six ruminally cannulated steers were used in a crossover design. Treatments included a control diet (CON; 7% prairie hay [PH], 15% Sweet Bran, 67.25% rolled corn, and 5% liquid supplement) and a cotton byproduct diet (CTN; 7% CGT, 15% WCS, 72.25% rolled corn, and 5% water). Both diets included 0.75% urea and 5% dry supplement. In situ bags containing individual diet ingredients and whole diet samples were incubated in the rumen for up to 96 h. Rumen fluid samples were collected over a 24-h period. No treatment × substrate interactions were detected for any fraction of dry matter (DM) or organic matter (OM) degradability for individual ingredients or whole diets (P ≥ 0.14). The A, B, and C fractions, disappearance rate (Kd), and effective degradability of DM and OM differed between diet ingredients (P ≤ 0.04) but were not different between CON and CTN substrates (P ≥ 0.25). A treatment × substrate interaction (P = 0.04) was detected for the effective degradability of neutral detergent fiber (NDF) of CGT and PH but there was no interaction for other fractions (P ≥ 0.27). The A fraction of NDF was greater (P < 0.001) for CGT than PH; however, the B fraction of NDF tended to be greater (P = 0.08) for PH than CGT. No differences (P ≥ 0.37) were detected for the % NDF disappearance at 48 h between CON and CTN substrates. A tendency for a treatment × substrate interaction (P = 0.10) was observed for the effective degradability of starch among diets; however, when the CON substrate was incubated in steers consuming the CON diet, effective degradability of starch was not different (P = 0.84) from when the CTN diet was incubated in steers consuming the CTN diet. There was no treatment × time interaction or treatment effect for rumen pH; however, there was a time effect (P = 0.03). Steers consuming the CTN diet had greater molar proportions of acetate and decreased molar proportions of propionate compared with CON steers (P < 0.01). This experiment suggests that there are minimal differences between the digestibility of finishing diets containing cotton byproducts and those comprised of traditional finishing diet ingredients.

High-energy Lateral Compression Type 1 Injuries of the Pelvis: A Spectrum of Injury.

Lateral compression type 1 pelvic fractures comprise a spectrum of injuries of varying stability. The clinician should be cognizant of signs and symptoms of instability including complete sacral fractures, bilateral ramus fractures, displacement greater than 1 cm, high-energy mechanism, and inability to bear weight. Management of these injuries is controversial, but the clinician should consider examination under anesthesia and potentially surgical stabilization.

Lactone Stabilization is Not a Necessary Feature for Antibody Conjugates of Camptothecins.

Camptothecins exist in a pH-dependent equilibrium between the active, closed lactone and the inactive open-carboxylate forms. Several previous reports underscore the need for lactone stabilization in generating improved camptothecins, and indeed, such designs have been incorporated into antibody-drug conjugates containing this drug. Here, we demonstrate that lactone stabilization is not necessary for camptothecin-based ADC efficacy. We synthesized and evaluated camptothecin SN-38 drug linkers that differed with respect to lactone stability and released SN-38 or the hydrolyzed open-lactone form upon cleavage from the antibody carrier. An α-hydroxy lactone-linked SN-38 drug linker preserved the closed-lactone ring structure, while the phenol-linked version allowed conversion between the closed-lactone and open-carboxylate structures. The in vitro cytotoxicity, pharmacokinetic properties, and in vivo efficacy in the L540cy Hodgkin's lymphoma model of the corresponding ADCs were found to be indistinguishable, leading us to conclude that camptothecin-based antibody-drug conjugates possess pronounced activity regardless of the lactone state of the bound drug. This is most likely a result of ADC processing within acidic intracellular vesicles, delivering camptothecin in its active closed-lactone form.

Case Report: Irreducible Ankle Fracture With Posterior Tibialis Tendon and Retinaculum, Deltoid Ligament, and Anteromedial Joint Capsule Entrapment.

Irreducible ankle fractures are a relatively rare phenomenon. We present a case of a pronation abduction-type ankle fracture that was irreducible in the emergency room despite sedation. The patient was taken to the operating room, where the posterior tibialis tendon and retinaculum, deltoid ligament, and anteromedial capsule were found to be trapped within the joint. After removal of the tissue, alignment was restored. The patient did well clinically and was advanced to full weightbearing at 6 weeks. This is, to the best of our knowledge, the first report of entrapment of all 4 anatomic structures, preventing closed reduction.