Precision soft tissue balancing: grid-assisted pie-crusting in total knee arthroplasty.

Introduction: The varus and valgus knee deformities result from imbalance in tension between medial and lateral soft tissue compartments. These conditions need to be addressed during total knee arthroplasty (TKA). However, there is no consensus on optimal soft-tissue release techniques for correcting varus and valgus deformities during TKA. We assessed the efficacy of a novel grid-based pie-crusting technique on soft-tissue release. Methods: Cadaver knees were dissected, leaving only the femur and tibia connected by an isolated MCL or the femur and fibula connected by an isolated LCL. Bone cuts were made as performed during primary TKA. Mechanical testing was performed using an MTS machine. A 3D-printed 12-hole grid was placed directly over the MCL and LCL. Using an 18-gauge needle, horizontal in-out perforations were made 3 mm apart. Deformation and stiffness of the ligaments were collected after every 2 perforations. Means were calculated, and regression analyses were performed. Results: A total of 7 MCL and 6 LCL knees were included in our analysis. The mean medial femorotibial (MFT) space increased from 6.018 ± 1.4 mm-7.078 ± 1.414 mm (R2 = 0.937) following 12 perforations. The mean MCL stiffness decreased from 32.15 N/mm-26.57 N/mm (R2 = 0.965). For the LCL group, the mean gap between the femur and fibula increased from 4.287 mm-4.550 mm following 8 perforations. The mean LCL stiffness decreased from 29.955 N/mm-25.851 N/mm. LCL stiffness displayed a strong inverse relationship with the number of holes performed (R2 = 0.988). Discussion: Our results suggest that using this novel grid for pie-crusting of the MCL and LCL allows for gradual lengthening of the ligaments without sacrificing their structural integrity. Our proposed technique may serve as a valuable piece in the soft-tissue release toolkit for orthopaedic surgeons performing TKA in varus and valgus deformed knees.

Relative Acetabular Retroversion and Its Association With Earlier-Onset Symptomatic Osteoarthritis of the Hip.

Background: Hip osteoarthritis is associated with an aging population with the average total hip arthroplasty patient in the U.S. approximately 65 years of age. Although there is an association between femoroacetabular impingement and early arthritis, there is a paucity of data attributed to variation in native acetabular version and early onset osteoarthritis. We investigated that whether patients with relative acetabular retroversion are predisposed to earlier hip osteoarthritis. Methods: Five hundred sixteen charts of patients undergoing THA by a single surgeon between March 2018 and May 2022 were reviewed (221 male and 295 female subjects; mean age 66.7 years [standard deviation (SD) 9.8]). Patients with advanced dysplasia, who are post-traumatic, septic, have inflammatory arthritis, and osteonecrosis were excluded. Operative hip anteversion was measured using three-dimensional computed tomography. A univariate analysis was used to correlate the age of male and female subjects with anteversion angles of ≤15° and >15°. The effect of age and gender on version angle was studied using a multivariate linear regression model. Results: In patients with anteversion ≤15°, both male (P = .006) and female subjects (P = .015) presented at significantly lesser age (male: 98, avg. age: 63.7, SD: 8.7; female: 62, avg. age: 64.8, SD: 9.8) than those with anteversion >15° (male: 123, avg. age: 67.2, SD: 10.2; female: 233, avg. age: 68.2, SD: 9.8). Male subjects had lower anteversion than female subjects with age held constant (P < .001), and older patients had increased anteversion with gender held constant (P < .001). Conclusions: This study suggests that patients with a relatively decreased version angle (≤15°) are more likely to present with earlier-onset symptomatic hip osteoarthritis.

Complex Orthopaedic Trauma Is Shifting Away From Level I to Non-Level I Trauma Centers: An Analysis of the National Trauma Data Bank.

INTRODUCTION: An increasing number of fellowship-trained orthopaedic trauma surgeons are working in non-Level I centers. This study aimed to examine trends of management of complex orthopaedic trauma in Level I centers versus non-Level I centers and its potential effect on patient outcomes. METHODS: Data from the National Trauma Data Bank from 2008 to 2017 were analyzed. Non-Level I to Level I center ratios for complex fractures and complication rates, median hours to procedure for time-sensitive fractures, and uninsured/underinsured rates of Level I and non-Level I centers were recorded. RESULTS: Three hundred one thousand patients were included. A statistically significant downward trend was identified in the percent of all complex orthopaedic trauma at Level I centers and per-hospital likelihood of seeing a complex orthopaedic fracture in a Level I versus non-Level I hospital. Per-hospital complication rates were consistently lower in non-Level I hospitals after controlling for injury severity and payer mix. Time-sensitive fractures were treated earlier in non-Level I centers. DISCUSSION: This study demonstrates a reduction of complex trauma treatment in Level I centers that did not translate to adverse effects on patient outcomes. Policymakers should notice this trend to ensure the continued quality of orthopaedic trauma training and maintenance of expertise in complex fracture management.

What Are Culturally Relevant Activities of Daily Living in the Asian-Indian Population? A Survey of 402 Patients With Knee Pain.

BACKGROUND: Patient-reported outcome measures are essential tools in assessing clinical outcomes. Although several patient-reported outcome measures such as the Oxford Knee Score and Knee Injury and Osteoarthritis Outcome Score have been developed and validated, their applicability in the Asian-Indian population may be limited; key cultural differences including varying functional demands, ethnicity-specific necessities, and social expectations represent a unique collection of needs. Such differences include preferences toward ground-level activities and those favoring the manual completion of tasks. QUESTIONS/PURPOSES: (1) Which activities of daily living (ADLs) do patients in an Asian-Indian population consider the most important? (2) How do the categories of ADLs (personal care, household, work, travel, and recreation) vary among patients of different gender (men and women) and age (< 60 and > 60 years) groups? METHODS: A cross-sectional study was conducted in October 2019 at a hospital in Mumbai, India. We developed a questionnaire with five domains for physical activity (personal care, household, work, travel, and recreation) formulated from a review and modification of existing categories identified by the WHO and the American Heart Association. Forty key ADLs were identified according to input obtained from detailed interviews of healthcare providers involved in the care of patients with orthopaedic illness, based on established domains. Respondents were instructed to identify the ADLs that were the most relevant to their lifestyle and culture. Responses from 402 patients (mean age 60 ± 12 years; 51% [206 of 402] were women) were analyzed to identify the most commonly selected ADLs. Responses were further evaluated to understand the impact of gender and age on these preferences by comparing men and women, as well as younger (age < 60 years) and older (age > 60 years) patients. RESULTS: The three most frequently reported ADLs in each domain, representing the ADLs that were the most important to the Asian-Indian population, were standing without assistance (82% [331 of 402]), getting up with support (81% [324 of 402]), and toilet use (74% [298 of 402]) in the personal activity category; climbing stairs (80% [322 of 402]), sitting cross-legged (80% [320 of 402]), and praying (79% [319 of 402]) in the household activity category; going to the market (72% [291 of 402]), long-distance walking (62% [250 of 402]), and carrying a shopping bag (60% [242 of 402]) in the work activity category; walking on an uneven surface (66% [266 of 402]), using a taxi (61% [247 of 402]), and traveling by train (59% [239 of 402]) in the travel activity category; and yoga (67% [269 of 402]), playing with children (66% [264 of 402]), and indoor games (63% [252 of 402]) in the recreational activity category. The order of importance of ADL domains was identical in the men versus women groups as well as in the younger age versus older age groups; ADL domains with the highest number of selected ADLs in order of decreasing importance were household care, personal care, work, travel, and recreation when analyzed by individual gender and age groups. Women were more likely than men to report the following ADLs as being important: climbing stairs (84% [172 of 206] of women and 77% [150 of 196] of men), getting up without support (83% [171 of 206] of women and 78% [153 of 196] of men), going to the market (74% [152 of 206] of women and 71% [139 of 196] of men), walking on uneven surfaces (67% [139 of 206] of women and 65% [127 of 196] of men), and playing with children (72% [148 of 206] of women and 59% [116 of 196] of men). CONCLUSION: The findings of this study aim to help providers engage in personalized and socioculturally relevant discussions about knee arthritis. Highlighted areas of importance may facilitate a more comprehensive preoperative discussion of total joint arthroplasty expectations in the context of the needs and demands of Asian-Indian patients. The findings of this study could establish the groundwork for the development of ethnicity-specific patient-reported outcome measures by incorporating the identified ADLs in novel metrics with validation of face and content validity.Level of Evidence Level III, prognostic study.

Reporting on quality of reduction and fixation of intertrochanteric fractures-A systematic review.

BACKGROUND: Patient outcomes after intertrochanteric fracture fixation is the subject of a large body of published and ongoing clinical research. Fracture reduction and stable fixation are a pre-requisite for achieving optimal results. However, reporting on the quality of postoperative reduction and fixation, has been inconsistent in the literature on intertrochanteric fractures. The purpose of this study was to examine the quality and consistency of reporting of immediate postoperative reduction and fixation in clinical outcome studies of intertrochanteric fracture fixation. METHODS: Outcome studies of intertrochanteric fractures, published between 2001 and 2019, were identified using a PubMed. Six journals were identified as having a high impact on intertrochanteric fracture research by either having an impact factor greater than 3.0 or more than 30 published studies fulfilling inclusion criteria. Two independent reviewers reviewed each article for its reporting on immediate post-operative radiographic findings and whether an attempt was made to correlate these findings to outcomes. Quality and consistency of reduction reporting were assessed by recording the type and number of uniquely reported reduction metrics in all of the included studies. RESULTS: The reviewers identified 134 papers for the study, of which 110 (82%) reported on immediate postoperative radiographic findings. Of the papers reporting these findings, 84 (76%) reported quantitative measurements. Quantitative reporting changed from 79% in papers published between 2001-2014 to 86% in papers published between 2015-2019. Sixty-one (46%) papers reported Tip-Apex Distance, 56 (42%) reported degree of varus (compared to non-injured side), 42 (31%) reported Neck-Shaft Angle restoration, 31(23%) reported leg-length discrepancy, 18 (13%) reported rotation, 15(11%) reported on the status of the lateral wall, and 6 (4%) reported on calcar (medial buttress) reduction. Sixty-eight (51%) papers that measured reduction found an association between better immediate post-operative reduction and improved outcomes. CONCLUSIONS: Despite its recognized influence on outcomes of intertrochanteric fractures, leading peer-reviewed journals do not uniformly report on the immediate postoperative assessment of the quality of reduction and fixation. However, reporting has improved over the past five years. Standardized quantitative metrics will need to be reported in the future to allow meaningful comparisons between studies and accurate assessment of intertrochanteric fracture outcome.

Permanent Cerebellar Degeneration After Acute Hyperthermia with Non-toxic Lithium Levels: a Case Report and Review of Literature.

This was a study of a 33-year-old man with bipolar disorder treated with lithium who developed cerebellar atrophy after an event of extreme hyperthermia. Unlike previously reported cases of acute cerebellar atrophy after heat stroke, neuroleptic syndrome or lithium toxicity, this case was characterized by a chronic cerebellar atrophy that developed after sepsis-induced hyperthermia in the setting of non-toxic lithium levels. Unique to this case also was the early finding of cerebellar atrophy on MRI 2 weeks after the episode of hyperthermia, long-term neurotoxicity after the novo lithium therapy, and longest follow-up case of chronic cerebellar syndrome after hyperthermia with non-toxic lithium levels.

L-Arginine Modulates Glucose and Lipid Metabolism in Obesity and Diabetes.

Type 2 diabetes has become a global public health problem affecting approximately 380 million people throughout the world. It can cause many complications and lead to greater mortality. At present, there is no available medicine for effectively preventing diabetes. L-arginine, a functional amino acid, the precursor of nitric oxide, plays a crucial role in maintenance, reproduction, growth, anti-aging and immunity for animals. Growing clinical evidence indicates that dietary L-arginine supplementation can reduce obesity, decrease arterial blood pressure, resist oxidation and normalize endothelial dysfunction to bring about remission of type 2 diabetes. The potential molecular mechanism may play a role in modulating glucose homeostasis, promoting lipolysis, maintaining hormone levels, ameliorating insulin resistance, and fetal programing in early stages. The possible signaling pathway of the beneficial effects of L-arginine likely involves L-arginine-nitric oxide pathway through which cell signal protein can be activated. Accumulating studies have indicated that L-arginine may have potential to prevent and/or relieve type 2 diabetes via restoring insulin sensitivity in vivo.

Dietary grape seed proanthocyanidins (GSPs) improve weaned intestinal microbiota and mucosal barrier using a piglet model.

Proanthocyanidins have been suggested as an effective antibiotic alternative, however their mechanisms are still unknown. The present study investigated the effects of grape seed proanthocyanidins on gut microbiota and mucosal barrier using a weaned piglet model in comparison with colistin. Piglets weaned at 28 day were randomly assigned to four groups treated with a control ration, or supplemented with 250 mg/kg proanthocyanidins, kitasamycin/colistin, or 250 mg/kg proanthocyanidins and half-dose antibiotics, respectively. On day 28, the gut chyme and tissue samples were collected to test intestinal microbiota and barrier function, respectively. Proanthocyanidins treated piglets had better growth performance and reduced diarrhea incidence (P < 0.05), accompanied with decreased intestinal permeability and improved mucosal morphology. Gene sequencing analysis of 16S rRNA revealed that dietary proanthocyanidins improved the microbial diversity in ileal and colonic digesta, and the most abundant OTUs belong to Firmicutes and Bacteroidetes spp.. Proanthocyanidins treatment decreased the abundance of Lactobacillaceae, and increased the abundance of Clostridiaceae in both ileal and colonic lumen, which suggests that proanthocyanidins treatment changed the bacterial composition and distribution. Administration of proanthocyanidins increased the concentration of propionic acid and butyric acid in the ileum and colon, which may activate the expression of GPR41. In addition, dietary proanthocyanidins improved the antioxidant indices in serum and intestinal mucosa, accompanied with increasing expression of barrier occludin. Our findings indicated that proanthocyanidins with half-dose colistin was equivalent to the antibiotic treatment and assisted weaned animals in resisting intestinal oxidative stress by increasing diversity and improving balance of gut microbes.

Metabolites of Dietary Protein and Peptides by Intestinal Microbes and their Impacts on Gut.

Dietary protein is a vital nutrient for humans and animals, which is primarily digested into peptides and free amino acids (FAAs) in the upper gastrointestine with the help of proteases. The products are absorbed by the enterocytes and are metabolized in different organs of body. Dietary protein, peptides and FAAs that escape digestion and absorption of the small intestine will enter the large intestine for further fermentation by the vast gut microbiota. Particularly, amino acid (AAs) metabolism by bacteria occurs via either deamination or decarboxylation reactions and generates short chain fatty acids (SCFAs) or amines, respectively. These metabolites elicit a wide range of biological functions via different receptors and mechanisms. This review discusses the interaction between protein metabolites and gastrointestine, illustrates regulation of intestinal motility and immune response by SCFAs and their receptors, and focuses on modulation of intestinal inflammation and signal transduction by biogenic amines (BAs) involving polyamines and monoamine neurotransmitters.

Dermatology residency selection criteria with an emphasis on program characteristics: a national program director survey.

Background. Dermatology residency programs are relatively diverse in their resident selection process. The authors investigated the importance of 25 dermatology residency selection criteria focusing on differences in program directors' (PDs') perception based on specific program demographics. Methods. This cross-sectional nationwide observational survey utilized a 41-item questionnaire that was developed by literature search, brainstorming sessions, and online expert reviews. The data were analyzed utilizing the reliability test, two-step clustering, and K-means methods as well as other methods. The main purpose of this study was to investigate the differences in PDs' perception regarding the importance of the selection criteria based on program demographics. Results. Ninety-five out of 114 PDs (83.3%) responded to the survey. The top five criteria for dermatology residency selection were interview, letters of recommendation, United States Medical Licensing Examination Step I scores, medical school transcripts, and clinical rotations. The following criteria were preferentially ranked based on different program characteristics: "advanced degrees," "interest in academics," "reputation of undergraduate and medical school," "prior unsuccessful attempts to match," and "number of publications." Conclusions. Our survey provides up-to-date factual data on dermatology PDs' perception in this regard. Dermatology residency programs may find the reported data useful in further optimizing their residency selection process.

Monte Carlo calculations of thermal neutron capture in gadolinium: a comparison of GEANT4 and MCNP with measurements.

GEANT4 is a Monte Carlo code originally implemented for high-energy physics applications and is well known for particle transport at high energies. The capacity of GEANT4 to simulate neutron transport in the thermal energy region is not equally well known. The aim of this article is to compare MCNP, a code commonly used in low energy neutron transport calculations and GEANT4 with experimental results and select the suitable code for gadolinium neutron capture applications. To account for the thermal neutron scattering from chemically bound atoms [S(alpha,beta)] in biological materials a comparison of thermal neutron fluence in tissue-like poly(methylmethacrylate) phantom is made with MCNP4B, GEANT4 6.0 patch1, and measurements from the neutron capture therapy (NCT) facility at the Studsvik, Sweden. The fluence measurements agreed with MCNP calculated results considering S(alpha,beta). The location of the thermal neutron peak calculated with MCNP without S(alpha,beta) and GEANT4 is shifted by about 0.5 cm towards a shallower depth and is 25%-30% lower in amplitude. Dose distribution from the gadolinium neutron capture reaction is then simulated by MCNP and compared with measured data. The simulations made by MCNP agree well with experimental results. As long as thermal neutron scattering from chemically bound atoms are not included in GEANT4 it is not suitable for NCT applications.

Gadolinium neutron capture brachytherapy (GdNCB), a new treatment method for intravascular brachytherapy.

Restenosis is a major problem after balloon angioplasty and stent implantation. The aim of this study is to introduce gadolinium neutron capture brachytherapy (GdNCB) as a suitable modality for treatment of stenosis. The utility of GdNCB in intravascular brachytherapy (IVBT) of stent stenosis is investigated by using the GEANT4 and MCNP4B Monte Carlo radiation transport codes. To study capture rate, Kerma, absorbed dose and absorbed dose rate around a Gd-containing stent activated with neutrons, a 30 mm long, 5 mm diameter gadolinium foil is chosen. The input data is a neutron spectrum used for clinical neutron capture therapy in Studsvik, Sweden. Thermal neutron capture in gadolinium yields a spectrum of high-energy gamma photons, which due to the build-up effect gives an almost flat dose delivery pattern to the first 4 mm around the stent. The absorbed dose rate is 1.33 Gy/min, 0.25 mm from the stent surface while the dose to normal tissue is in order of 0.22 Gy/min, i.e., a factor of 6 lower. To spare normal tissue further fractionation of the dose is also possible. The capture rate is relatively high at both ends of the foil. The dose distribution from gamma and charge particle radiation at the edges and inside the stent contributes to a nonuniform dose distribution. This will lead to higher doses to the surrounding tissue and may prevent stent edge and in-stent restenosis. The position of the stent can be verified and corrected by the treatment plan prior to activation. Activation of the stent by an external neutron field can be performed days after catherization when the target cells start to proliferate and can be expected to be more radiation sensitive. Another advantage of the nonradioactive gadolinium stent is the possibility to avoid radiation hazard to personnel.