Evaluation of a pathway to address take own leave events for First Nations peoples presenting for emergency care: The Deadly RED project.

OBJECTIVE: The 'Deadly RED' project primarily aimed to improve culturally competent care to reduce the number of First Nations patients presenting to a Queensland ED who 'Take own leave' (TOL). The secondary aim was to evaluate the implementation project. METHODS: A pre/post-test quasi experimental study design using mixed methods was co-designed with adherence to Indigenous research considerations. Quantitative analysis of First Nations presentations before and after Deadly RED implementation was performed using SPSS. Qualitative analysis of transcribed research yarns in NVIVO was coded and themed for analysis. Staff experiences and perspectives were collated using electronically distributed surveys and process audits were performed. RESULTS: A total of 1096 First Nations presentations June to August 2021 and 1167 in the matched 2022 post-implementation period were analysed. Significantly more patients were recorded as TOL post-implementation (13.0% pre vs 21.3% post) and representations rates were unchanged. Forty-six staff surveyed identified improvements in all parameters including cultural appropriateness and quality of care. Qualitative analysis of 85 research yarns revealed themes migrated to increasingly acceptable, accessible, and usable care. Notably, 45% of the First Nation's patients recorded as TOL self-reported that their treatment was complete. The study was feasible as 80% of packs distributed and 73% follow-up screening after TOL. CONCLUSIONS: The Deadly RED evaluation revealed significant discrepancies in the reported data points of TOL and the 'story' of the First Nations persons experience of appropriate and completed care. Staff awareness and cultural capability improved significantly, and yarning allowed knowledge translation and improvements in communication which contributed to a better healthcare experience for First Nations patients attending our ED.

Clinical guideline on the third generation minimally invasive surgery for hallux valgus.

Minimally invasive surgery for hallux valgus correction, has been attracting great interests in the recent decades, due to the potential benefits of less pain, decreased recovery times, smaller scars with better cosmesis, and improved early post-operative range of motion. The most recent developments in minimally invasive surgery have evolved into the third generation with modifications of the chevron-type osteotomy. This evidence-based clinical guideline of the third generation minimally invasive surgery for hallux valgus is initiated and developed collectively by the Foot and Ankle Committee of Orthopedic Branch of Chinese Medical Doctor Association, Foot and Ankle Committee of Sports Medicine Branch of Chinese Medical Doctor Association, and Foot and Ankle Expert Committee of Orthopedic Branch of the Chinese Association of the Integrative Medicine. This clinical guideline provides recommendations for indications, contraindications, operative planning and techniques, post-operative management, management of complications, and prognosis of the third generation minimally invasive surgery for hallux valgus. The Translational Potential of this Article This comprehensive guideline aims to establish standardized recommendations for the indications, contraindications, operative techniques, and post-operative management of the third generation minimally invasive surgery for hallux valgus. By adhering to this guideline, the success rate of the procedure could be maximized. This comprehensive guideline serves as a valuable reference for practitioners interested in or preparing to perform minimally invasive surgery for hallux valgus.

Yarning to reduce take own leave events in First Nations patients presenting to the Emergency Department-presenting the qualitative themes and co-design of the Deadly RED project.

ISSUE ADDRESSED: The Deadly RED redesign and implementation research aimed to improve take own leave (TOL) rates within a Queensland emergency department by providing a culturally competent care pathway. METHODOLOGY: A mixed methods pre/post evaluation of the feasibility, acceptability and usability of the Deadly RED pathway for First Nations patients presenting to ED was performed. This pathway combined early welcome and information sharing, introduction of screening and follow up for patients who TOL and enhanced access to alternative community healthcare. Yarning circles facilitated co-design of research protocols and tools while a purposefully designed research Yarn enhanced understanding of the 'story' of the people. Qualitative analysis of Yarns allowed deductive themes to be extracted. A Participatory Action Research (PAR) approach and Indigenous research methodology involving First Nations people in design, knowledge sharing and joint ownership of results was used. RESULTS: Common themes from the 85 yarns included the negative impact of long waiting times and positive impact from wholistic care. Unique themes identified included interpretation of waiting room placement and paracetamol prescription as a dismissal. Knowledge dissemination from yarning drove improvements in communications and processes to promote treatment completion resulting in elimination of these themes in post implementation yarns. Eighteen patients who had TOL were included in the post implementation yarns, however only eight of these believed that their treatment was incomplete. CONCLUSION: The use of yarning for consumer engagement has allowed deeper understanding of the reasons for TOL in First Nations emergency patients. The reciprocal knowledge sharing has guided targeted improvements in wholistic emergency care and communication resulting in First Nations patients feeling their care is complete even when the 'number' reports otherwise. SO WHAT?: Indigenous Research methodology including yarning with First Nations patients suggests alternative engagement methods to guide enhanced quality of care monitoring for ED presentations.

Influence of the Synthetic Cannabinoid Agonist on Normal and Inflamed Cartilage: An In Vitro Study.

Medical marijuana (versus Marijuana derivatives) has been reported to possess analgesic, immunomodulatory, and anti-inflammatory properties. Recent studies in animal models of arthritis showed that cannabinoids, a group of compounds produced from marijuana, may attenuate joint damage. However, whether marijuana byproducts can suppress osteoarthritis (OA)-associated cartilage degradation has not been previously reported. In this study, human chondrocytes were isolated from healthy articular cartilage, expanded in vitro, and subjected to pellet culture in a chondrogenic medium to form cartilage tissues. We first examined the influence of marijuana byproducts on normal cartilage by treating chondrocyte-derived tissues with a synthetic cannabinoid agonist, Win-55,212-2 (Win), at different concentrations ranging from 0.01 to 10 µM. After treatment, the tissue phenotype was assessed using glycosaminoglycan (GAG) assay and real-time PCR. Next, cartilage tissues were pre-treated with interleukin-1ß (IL-1ß) to generate an inflamed phenotype and then cultured with Win to assess its therapeutic potential. The results showed that at concentrations lower than 1 µM, Win treatment did not significantly impair chondrocyte growth or cartilage formation capacity, but at a high level (>10 µM), it remarkably suppressed cell proliferation. Interestingly, under the condition of IL-1ß pre-treatment, Win was able to partially preserve the cartilage matrix and decrease the production of interleukin-6, although the protective effect was mild. Taken together, our results indicated that the variable effects of Win on chondrocytes occur in a concentration-dependent manner. Whether cannabinoid derivatives can be used to treat cartilage degradation or can alter other structural changes in OA deserve further investigation.

Economic evaluation of applying the Canadian Syncope Risk Score in an Australian emergency department.

OBJECTIVE: To evaluate the Canadian Syncope Risk Score (CSRS) in syncope patients presenting to the ED from an economic perspective, using very-low and low-risk patients (CSRS -3 to 0) as a threshold for avoiding hospital admissions. METHODS: A decision-analytic model, specifically a decision-tree, was developed to evaluate application of the CSRS. A hypothetical cohort of 1000 patients was modelled based on characteristics and outcome of patients enrolled in a clinical validation study performed alongside this evaluation. Several analytic based approaches were used to handle model outputs and uncertainties. RESULTS: For a cohort of 1000 patients, applying the CSRS was associated with 169 less inpatient admissions from the ED, when compared to usual care. There was also a cost-saving of $8255 per admitted patient, when the CSRS was applied, compared to usual care. Adopting the CSRS was the optimal approach in all scenario analyses and was robust to changes in model parameters. More than three-quarters (78.6%) of all model simulations showed that applying the CSRS is a cost-saving approach to managing syncope. There was high confidence in all results, with the approach using the CSRS reducing the costs and number of syncope-related hospital admissions. CONCLUSIONS: Compared to usual care, applying the CSRS appeared as a cost-effective strategy. This new evidence will help decision-makers choose cost-effective approaches for the management of patients presenting to the ED with syncope, as they search for efficient ways to maximise health gain from a finite budget.

Orthognathic Surgery to Enhance the Smile.

An esthetic smile is an integral feature of beauty. Improvement of the smile can be achieved by a combination of orthognathic surgery, orthodontics, and cosmetic dentistry. Preoperative evaluation serves to address a patient's surgical goals; it allows a surgeon to perform a detailed facial analysis and identify patients who are contraindicated for surgery. LeFort I and bilateral sagittal split osteotomy are performed to minimize the risk of complications. Injuries to the inferior alveolar nerve are the most common complication after orthognathic surgery, in which 90% of patients experience transient sensory disturbance of the lower lip in the postoperative period.

Updates on Lisfranc Complex Injuries.

Lisfranc injuries are a disruption of one or more of the tarsometatarsal joints and have an estimated incidence of 1/55 000 people. However, the total number of Lisfranc injuries could be underreported, because almost 20% of these injuries are initially missed. Because of the relative infrequency of these injuries, the current literature is inconsistent in regard to proper treatment. This article provides a review of Lisfranc complex injuries including relevant anatomy, diagnosis, treatment, classifications, operative approaches, and outcomes and complications. Based on existing evidence, it also proposes an algorithm the authors prefer for the evaluation and treatment of Lisfranc complex injuries.

External validation of the Canadian Syncope Risk Score for patients presenting with undifferentiated syncope to the emergency department.

OBJECTIVE: To validate the accuracy and safety of the Canadian Syncope Risk Score (CSRS) for patients presenting with syncope. METHODS: Single centre prospective observational study in Brisbane, Australia. Adults presenting to the ED with syncope within the last 24 h were recruited after applying exclusion criteria. Study was conducted over 1 year, from March 2018 to March 2019. Thirty-day serious adverse events (SAE) were reported based on the original derivation study and standardised outcome reporting for syncope. Individual patient CSRS was calculated and correlated with 30-day SAE and disposition status from ED. RESULTS: Two hundred and eighty-three patients were recruited to the study. Average age was 55.6 years (SD 22.7 years), 37.1% being male with a 39.9% admission rate. Thirty-day SAE occurred in seven patients (2.5%) and no recorded deaths. The CSRS performed with a sensitivity of 71.4% (95% confidence interval [CI] 30.3-94.9%), specificity 72.8% (95% CI 67.1-77.9%) for a threshold score of 1 or higher. CONCLUSION: Syncope patients in our study were predominantly very low to low risk (72%). The prevalence of 30-day SAE was low, majority occurring following hospital discharge. Sensitivity estimates for CSRS was lower than the derivation study but lacked robustness with wide CIs because of a small sample size and number of events observed. However, the CSRS did not miss any clinically relevant outcomes in low risk patients making it potentially useful in aiding their disposition. Larger validation studies in Australia are encouraged to further test the diagnostic accuracy of the CSRS.

Biologic therapies for foot and ankle injuries.

Introduction: The use of orthobiologics as supplemental treatment for foot and ankle pathologies have increased in the past decades. They have been used to improve the healing of bone and soft tissue injuries. There have been several studies that examined the use of biologics for knee and hip pathologies but the foot and ankle construct has unique features that must be considered.Areas covered: The biologics for foot and ankle injuries that are covered in this review are platelet-rich plasma (PRP), stem cells, growth factors, hyaluronic acid, bone grafts, bone substitutes, and scaffolds. These modalities are used in the treatment of pathologies related to tendon and soft tissue as well as cartilage.Expert opinion: The utilization of biological adjuncts for improved repair and regeneration of ankle injuries represents a promising future in our efforts to address difficult clinical problems. The application of concentrated bone marrow and PRP each represents the most widely studied and commonly used injection therapies with early clinical studies demonstrating promising results, research is also being done using other potential therapies such as stem cells and growth factors; further investigation and outcome data are still needed.

Influence of high-heeled shoe parameters on biomechanical performance of young female adults during stair ascent motion.

BACKGROUND: High-heeled shoes are currently preferred by women due to contemporary aesthetics. However, high-heeled shoes may increase the effort required to ascend stairs and, hence, alter biomechanical performance. RESEARCH QUESTION: How do high-heel shoe parameters affect the pelvis position, lower extremities kinematics, and ground reaction force in young women during stair ascent motion? METHODS: Stair ascent experiments were performed with 20 healthy adult women. The participants were instructed to ascend a 3-step staircase, wearing heeled shoes of different heel heights and heel types and one pair of flat shoes as the control group. Changes in lower body biomechanics were analyzed with kinematics and ground reaction force variables collected from the dominant limb. A two-way repeated ANOVA was performed to determine which variables were affected by heel type and which were affected by heel height or a combination of both. RESULTS: As the heel height increased, an increased range of ankle dorsiflexion-plantarflexion, as well as pelvic rotation, was observed(P = 0.039 and P = 0.003, respectively). A thinner heel type displayed a larger pelvic forward tilt movement(P = 0.026)and 1st peak vertical force(P = 0.025), as well as a smaller 2nd peak vertical force (P = 0.002). With high heels, increased external rotation of the knee, inversion and plantar flexion, and flexion values of the knee were observed. We also observed decreased external rotation of the pelvis, ankle eversion, varum, and dorsiflexion. SIGNIFICANCE: To stabilize body posture during stair ascent motion with high-heeled shoes, compensatory response including increasd pelvic range of motion and changing the joint angles of the lower extremities.

Influences of high-heeled shoe parameters on gait cycle, center of pressure trajectory, and plantar pressure in young females during treadmill walking.

PURPOSE: This study aimed to investigate the influences of high-heeled shoe (HHS) parameters on gait cycle, center of pressure (COP) trajectory, and plantar pressure in young females. METHODS: Twenty healthy adult females were recruited to participate in this study. Subjects walked on a treadmill at a fixed speed (1 m/s). Overall, six pairs of HHSs were evaluated, presenting two heel types (thin and thick) and three different heel heights (low: 3 cm, medium: 6 cm, and high: 8.2 cm). Subjects also wore flat shoes (heel height: 0.2 cm) as the control group. RESULTS: The gait cycle, COP parameters, peak pressure (PP), maximum force, contact area (CA), and force-time integral (impulse) were measured. The comparison between these parameters when the volunteers wore thick heel and flat shoes at different walking conditions indicated that thin heels caused a significant increase in the pre-swing parameter, CA, and PP of the first toe and first metatarsus. Increased heel heights yielded smaller gait line lengths, single support lines, and smaller hindfoot areas. By contrast, increased anterior-posterior positions and plantar pressure parameter values were noted for the forefoot. CONCLUSIONS: Data analyses showed significant differences in the plantar pressure distribution associated with heel height and heel type at increased pressure in the first metatarsal and central forefoot region and decreased pressure in the midfoot and heel sections, thus increasing anterior shift. The results presented herein may allow for the design of HHSs with reduced adverse health effects on the wearer.

Evaluating patients presenting to the emergency department after syncope: validation of the Canadian Syncope Risk Score.

BACKGROUND: Syncope is a common problem but can have any of a broad range of underlying causes. Initial evaluation of the patient in the emergency department often does not identify a specific cause, and the cornerstone of management is reliable risk stratification with clinical decision rules. OBJECTIVES: The primary objective is to validate the utility and safety of the Canadian Syncope Risk Score (CSRS) as a clinical decision rule when assessing patients who present with syncope to Australian emergency departments. Our secondary objective is to evaluate the economic benefits of diverting patients with syncope at low risk of serious adverse events from admission to hospital. METHODS AND ANALYSIS: Prospective, observational study. Patients aged 18 years or more who present to the emergency department (ED) after syncope in the preceding 24 hours and have returned to their baseline state will be enrolled. Patients will be contacted by telephone to determine whether they have experienced any adverse events within 30 days of their initial presentation to the ED. The CSRS will be applied retrospectively to determine the relationship between whether patients were admitted to hospital or discharged home and the reporting of serious adverse events for each CSRS risk level. We will also undertake a cost-effectiveness analysis from the health care perspective. ETHICS APPROVAL: Prince Charles Hospital Human Research Ethics Committee (reference, HREC/17/QPCH/48). DISSEMINATION OF RESULTS: Outcomes will be disseminated by Queensland Health and the funding body via social media, presented at local and national emergency medicine conferences, and published in international emergency medicine and health economics journals. CLINICAL TRIALS REGISTRATION: Not applicable.

Endoscopic-Assisted Radial Forearm Free Flap Harvest: A Novel Technique to Reduce Donor Site Morbidity.

BACKGROUND: The radial forearm free flap (RFFF) remains a workhorse flap but can have significant donor site morbidity. The authors developed a novel technique for endoscopic-assisted RFFF (ERFFF) harvest and hypothesized improved donor site morbidity. METHODS: A retrospective cohort study was conducted evaluating patients who underwent ERFFF or RFFF by a single surgeon for head and neck reconstruction between November 2011 and July 2016; outcomes and complications were compared. A telephone survey was conducted to assess patient satisfaction with donor site appearance and function. RESULTS: Twenty-seven ERFFF and 13 RFFF harvests were performed. The cephalic vein was less commonly incorporated in ERFFF patients compared with RFFF patients (3.70 and 38.46%, respectively, p = 0.0095). ERFFF patients had lower rates of wound healing complications (0% vs. 15.38%, p = 0.10) and perfusion-related complications than RFFF patients (3.70% vs. 23.08%, p = 0.092). Fewer ERFFF patients reported a desire for a more normal appearance (42.86% vs. 71.43%, p = 0.361). The ERFFF group had a higher functional score (64.29% vs. 44.44%, p = 0.101), reporting lower rates of associated discomfort (35.71% vs. 85.71%, p = 0.063). None of the differences in rates of complications or patient-reported outcomes between the groups reached statistical significance. CONCLUSION: ERFFF is safe and effective alternative to RFFF, with similar operative time, similar pedicle safety, and elimination of the lengthy forearm incision. Unnecessary cephalic vein dissection can be avoided with endoscopic visualization of the venae comitantes. Further research with a larger sample size and better standardization is needed to assess effects on donor-site morbidity.

Applying the Keystone Design Perforator Island Flap Concept in a Variety of Anatomic Locations: A Review of 60 Consecutive Cases by a Single Surgeon.

BACKGROUND: The keystone design perforator island flap has been gaining popularity for reconstruction of cutaneous defects. Published experience of this technique in North America is limited predominantly to the trunk and extremities; our study aims to demonstrate expanding applications. METHODS: Retrospective chart review was conducted on all patients who underwent keystone flap reconstruction by a single surgeon. Outcomes of interest were wound healing complications (WHC) and surgical site infections (SSI). Mean follow up time was 24.4 months. RESULTS: Sixty consecutive flaps were performed with an overall WHC rate of 26.7% and SSI rate of 11.7%. Reconstructed sites included 25 lower extremity, 20 trunk, 5 upper extremity, and 10 head and neck. Flap size averaged 405.6 cm (range 16-2303). Wound healing complications were associated with coronary artery disease (P = 0.04) and traumatic defects (P = 0.043). Surgical site infections were associated with coronary artery disease (P = 0.02) and flap size of 251 to 500 cm (P = 0.039), although this association was not seen among flaps greater than 500 cm. Although more common in lower extremity reconstructions, no statistically significant associations between flap location and WHC (P = 0.055) or SSI (P = 0.29) were identified. There were no reconstructive failures and no patients required reoperation. CONCLUSIONS: This series demonstrates the versatility of the keystone flap in a wide variety of anatomic locations, with similar complication rates to those previously reported and no reoperations. Flap design was frequently modified based on the anatomical topography and adjacent subunits. To our knowledge, this is the largest and most diverse North American series of keystone flap reconstructions to date.

Novel Technique for Treatment of Calcaneal Tuberosity Fractures.

Calcaneal tuberosity fractures comprise only 1% to 2% of all calcaneal fractures. Treatment of these injuries has traditionally included open reduction and internal fixation with various means including lag screws, suture anchors, and K-wires. This article reports on a series of cases treated with excision of the tuberosity fragment with repair of the Achilles tendon supplemented by a flexor hallucis longus tendon transfer.

Using cement plugs in soft tissue infection and osteomyelitis.

Operative foot and ankle osteomyelitis is challenging for orthopedic surgeons because of the area's unique anatomy, high trauma incidence, local and systemic disease effects, and often limited space. Standard treatment includes aggressive operative debridement with local and systemic antibiotic administration to control infection. Dead space management is critical yet technically demanding. The authors report a modified antibiotic cement bead therapy technique in which antibiotic sticks, minnows, and mushroom-shaped plugs are used to strike a balance between the stability of the load-bearing unit and radical removal of infection to preserve a functional foot. Three cases are presented.

Th2 differentiation is necessary for soft tissue fibrosis and lymphatic dysfunction resulting from lymphedema.

Lymphedema is a dreaded complication of cancer treatment. However, despite the fact that >5 million Americans are affected by this disorder, the development of effective treatments is limited by the fact that the pathology of lymphedema remains unknown. The purpose of these studies was to determine the role of inflammatory responses in lymphedema pathology. Using mouse models of lymphedema, as well as clinical lymphedema specimens, we show that lymphatic stasis results in a CD4 T-cell inflammation and T-helper 2 (Th2) differentiation. Using mice deficient in T cells or CD4 cells, we show that this inflammatory response is necessary for the pathological changes of lymphedema, including fibrosis, adipose deposition, and lymphatic dysfunction. Further, we show that inhibition of Th2 differentiation using interleukin-4 (IL-4) or IL-13 blockade prevents initiation and progression of lymphedema by decreasing tissue fibrosis and significantly improving lymphatic function, independent of lymphangiogenic growth factors. We show that CD4 inflammation is a critical regulator of tissue fibrosis and lymphatic dysfunction in lymphedema and that inhibition of Th2 differentiation markedly improves lymphatic function independent of lymphangiogenic cytokine expression. Notably, preventing and/or reversing the development of pathological tissue changes that occur in lymphedema may be a viable treatment strategy for this disorder.

CD4(+) cells regulate fibrosis and lymphangiogenesis in response to lymphatic fluid stasis.

INTRODUCTION: Lymphedema is a chronic disorder that occurs commonly after lymph node removal for cancer treatment and is characterized by swelling, fibrosis, inflammation, and adipose deposition. Although previous histological studies have investigated inflammatory changes that occur in lymphedema, the precise cellular make up of the inflammatory infiltrate remains unknown. It is also unclear if this inflammatory response plays a causal role in the pathology of lymphedema. The purpose of this study was therefore to characterize the inflammatory response to lymphatic stasis and determine if these responses are necessary for the pathological changes that occur in lymphedema. METHODS: We used mouse-tail lymphedema and axillary lymph node dissection (ANLD) models in order to study tissue inflammatory changes. Single cell suspensions were created and analyzed using multi-color flow cytometry to identify individual cell types. We utilized antibody depletion techniques to analyze the causal role of CD4+, CD8+, and CD25+ cells in the regulation of inflammation, fibrosis, adipose deposition, and lymphangiogenesis. RESULTS: Lymphedema in the mouse-tail resulted in a mixed inflammatory cell response with significant increases in T-helper, T-regulatory, neutrophils, macrophages, and dendritic cell populations. Interestingly, we found that ALND resulted in significant increases in T-helper cells suggesting that these adaptive immune responses precede changes in macrophage and dendritic cell infiltration. In support of this we found that depletion of CD4+, but not CD8 or CD25+ cells, significantly decreased tail lymphedema, inflammation, fibrosis, and adipose deposition. In addition, depletion of CD4+ cells significantly increased lymphangiogenesis both in our tail model and also in an inflammatory lymphangiogenesis model. CONCLUSIONS: Lymphedema and lymphatic stasis result in CD4+ cell inflammation and infiltration of mature T-helper cells. Loss of CD4+ but not CD8+ or CD25+ cell inflammation markedly decreases the pathological changes associated with lymphedema. In addition, CD4+ cells regulate lymphangiogenesis during wound repair and inflammatory lymphangiogenesis.

An analysis of the Orthopaedic In-Training Examination rehabilitation section.

OBJECTIVE: One subject tested by the Orthopaedic In-Training Examination (OITE) is rehabilitation. Our purpose was to analyze the OITE's rehabilitation section to (1) identify the rehabilitation subjects that are tested, (2) evaluate trainee performance on this section, and (3) evaluate the literature cited for this section as an aide to the trainee preparation for future OITE examinations. DESIGN: This study included OITE examinations from 2004 through 2009. The rehabilitation sections of these examinations were analyzed for content, type of questions asked (taxonomy 1: direct recall; taxonomy 2: diagnosis; taxonomy 3: evaluation/decision making and development of a treatment plan), and literature cited. The mean score in the rehabilitation section of the OITE from 2004 to 2009 was also evaluated, and literature citations were tabulated. SETTING: Orthopaedic surgery residency. RESULTS: In the 2004-2009 OITE examinations, a total of 1619 questions were administered, of which 53 (3.3%) related to rehabilitation. The most common rehabilitation questions assessed knowledge of prosthetic/orthotics (20.8%) and neuro-orthopedics (20.8%). Other questions addressed amputation (18.9%), physical therapy treatment and outcomes (18.9%), rehabilitation terminology (9.4%), and spinal cord injury (7.7%). Most frequently, the questions evaluated the trainee's direct recall of the subject (51%), evaluation/decision making and development of a treatment plan (30.1%), and diagnosis (18.9%). The mean score in the rehabilitation section of the OITE from 2004 through 2009 was 54.1% (range, 40% to 77.8%). A total of 53 references was used. The 3 most common references were the Journal of Bone and Joint Surgery-American Volume (10), Orthopaedic Knowledge Update (volumes 7 through 9) (8), and Clinical Orthopaedics and Related Research (7). CONCLUSION: To our knowledge, our study is the first to analyze the rehabilitation section of the OITE. Our results will help the trainee prepare for the examination by focusing on the appropriate content and literature.

Regulation of adipogenesis by lymphatic fluid stasis: part I. Adipogenesis, fibrosis, and inflammation.

BACKGROUND: Although fat deposition is a defining clinical characteristic of lymphedema, the cellular mechanisms that regulate this response remain unknown. The goals of this two-part study were to determine the effect of lymphatic fluid stasis on adipogenesis and inflammation (part I) and how these changes regulate the temporal and spatial expression of fat differentiation genes (part II). METHODS: Adult female mice underwent tail lymphatic ablation and were euthanized 6 weeks after surgery (n = 20). Fat deposition, fibrosis, and inflammation were then analyzed in the regions of the tail exposed to lymphatic fluid stasis as compared with normal lymphatic flow. RESULTS: Lymphatic fluid stasis in the tail resulted in significant subcutaneous fat deposition, with a 2-fold increase in fat thickness (p < 0.01). In addition, lymphatic stasis was associated with subcutaneous fat fibrosis and collagen deposition. Adipogenesis in response to lymphatic fluid stasis was associated with a marked mononuclear cell inflammatory response (5-fold increase in CD45 cells; p < 0.001). In addition, the authors noted a significant increase in the number of monocytes/macrophages as identified by F4/80 immunohistochemistry (p < 0.001). CONCLUSIONS: The mouse-tail model has pathologic findings that are similar to clinical lymphedema, including fat deposition, fibrosis, and inflammation. Adipogenesis in response to lymphatic fluid stasis closely resembles this process in obesity. This model therefore provides an excellent means with which to study the molecular mechanisms that regulate the pathophysiology of lymphedema.