Gene-environment transactions between peer cigarette use, parental supervision, and Chinese adolescent cigarette smoking initiation.

INTRODUCTION: The initiation and continued use of tobacco products constitute an ongoing source of preventable disease that continues to pose a significant risk to global adolescent health. Scarce research has sought to explore the influences of two well-known environmental risk factors, parental supervision and peer cigarette use, on genetic and environmental contributions to adolescent cigarette use, especially in non-Western populations. METHODS: Following 602 Chinese twin pairs (52% female, N = 1204) from early to middle adolescence at two-time points (Mage = 12 and 15) from 2006 to 2009 and using multivariate biometric modeling, this study examined gene-environment interplay (i.e., gene-environment correlation and interaction) between perceived parental supervision, peer cigarette use, and adolescent cigarette smoking initiation. RESULTS: From early to middle adolescence, genetic influences on cigarette smoking initiation became more pronounced, whereas shared environmental influences that promote similarity between family members diminished. Genetic factors primarily explained the links between parental supervision and cigarette smoking initiation in mid-adolescence. Peer cigarette use displayed stronger associations with and moderating potential in adolescent cigarette smoking initiation than parental supervision. High levels of peer cigarette use amplified genetic risk for cigarette smoking initiation in mid-adolescence. CONCLUSIONS: Chinese adolescent cigarette smoking initiation involves dynamic gene-environment transactions primarily with peer processes over development. Mid-adolescence constitutes a developmental period wherein underlying genetic risk for cigarette smoking initiation is particularly sensitive to peer influences. Targeted interventions aimed at reducing Chinese adolescent cigarette smoking initiation should focus on peer processes during this developmental period.

Interference screw versus suture button fixation for tibialis anterior tendon transfer: a biomechanical analysis.

Tibialis anterior tendon (TAT) transfer to the lateral cuneiform is commonly utilized to treat dynamic supination for relapsed clubfoot deformity. Traditional suture button fixation (SBF) may lead to skin necrosis at the button/skin interface. While interference screw fixation (ISF) would mitigate this concern, this fixation method has not been investigated in clubfoot patients. This study aims to investigate the performance of ISF versus SBF for TAT transfer in a cadaveric model. Ten matched pairs of cadaveric feet were obtained. One of each matched specimen underwent TAT transfer to the lateral cuneiform using ISF and the other underwent TAT transfer using SBF. For each ISF specimen, the tension of the transferred TAT required to bring the ankle to neutral was measured. This tension was then applied to both matched specimens using an MTS machine. Tension dissipation was measured after a 20-minute interval. In specimens with SBF, a load cell was positioned between the plantar skin and suture button to determine plantar skin pressure at the time of initial tension application. Average tension necessary to achieve neutral dorsiflexion was 49.4 N. Average tension dissipation after 20 min was significantly less in the IFS group (20 N versus 23.6 N, P = 0.02). No fixation failures occurred in either group. Average plantar foot skin pressure was 196.5 mmHg at initial tension application, exceeding thresholds for tissue ischemia. ISF allows for tendon tensioning at forces beyond those expected to result in skin necrosis with SBF with less dissipation of tension over time.

Patient-reported outcomes of adolescents with tibia shaft fractures: comparison of closed reduction and casting vs. elastic stable intramedullary nailing.

Tibial shaft fractures are the third most common pediatric long bone fractures. Closed reduction and casting (CRC) is considered initial treatment in this population, however, surgical management using elastic stable intramedullary nailing (ESIN) is also used in adolescents. This study compared patient-reported outcomes in a cohort of adolescents with tibia fractures treated with ESIN or CRC. This single-center retrospective study gathered adolescent patients 10-18 years of age with closed tibia shaft fractures between the years 2015 and 2021 treated by either CRC or ESIN. Measured outcomes include patient demographics, overall casting time, time to full weight bearing, time to full healing, radiographic healing, complications (loss of reduction, malunion >5° and >10°) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores. A total of 141 patients (68% male) were included, with 31 receiving ESIN and 110 having CRC. Patient demographics were similar across groups. At follow-up, CRC had a significant shorter time to healing (11 vs. 15 weeks), but an increased casting duration (7 vs. 4 weeks). Finally, the ESIN group had significantly greater pre-intervention angulation, displacement, and shortening. In both interventions, mobility and pain interference scores showed significant improvements from baseline (2 weeks post-op) at 12, 16, and 24 weeks. No statistically significant differences were noted between CRC and ESIN groups across PROMIS domains of pain interference and mobility. CRC and ESIN are effective in improving pain and mobility in adolescent diaphyseal tibia fractures, but neither intervention is superior based on PROMIS scores at 12, 16 and 24+ weeks. From a patient standpoint, we demonstrate that neither treatment is superior in achieving better-perceived mobility or decreasing pain sooner. Level of Evidence: Level III.

Is There a Benefit to Rigid Fixation in Calcaneal Lengthening Osteotomy in Painful Pediatric Idiopathic Flatfoot Deformity? Comparing Results of Kirschner Wire Versus Plate Fixation.

INTRODUCTION: Flexible flatfoot (FF) is a common pediatric condition that is mostly asymptomatic, and surgical intervention is only considered when painful FF is refractory to conservative treatment. Calcaneal lengthening osteotomy (CLO) is one of the most commonly used procedures to address painful FF. Traditionally, Kirschner wires (K-wires) were used for fixation, but there has been a recent increase in the use of plates. We compared the clinical and radiographic outcomes of these 2 fixation methods. METHODS: This single-center retrospective study included children aged 8 to 18 years with symptomatic FF that received CLO using K-wire or plate fixation. Primary outcomes include weight-bearing radiographic measurements and complications after surgery. Secondary outcomes included patient-reported outcomes. Statistical significance was held at 0.05. RESULTS: Among 102 feet (65 patients), 42 feet (41.2%) underwent K-wire and 60 feet (58.8%) underwent plate fixation. No differences in casting duration ( P =0.525) and time-to-radiographic healing ( P =0.17) were noted. Total complications were higher in the plate cohort (12 vs. 2, P =0.04) due to a higher rate of reoperations (16.7%) for hardware-related pain [10 vs. 0; odds ratio 17.74, 95% CI (1.01, 310.54), P <0.05], and infection rates were similar. Both interventions significantly improved ( P ≤ 0.001) aneteroposterior (AP) Talo-first metatarsal and calcaneal pitch angles. Irrespective of intervention, CLO significantly improved pain at 6 months and mobility scores at 12 months. Neither modality demonstrated superior pain or mobility scores at final follow-up. CONCLUSION: Both K-wire and plate fixations lead to similar radiographic and functional outcomes after CLO in painful, pediatric flatfeet. Compared with K-wire fixation, plates cause a 17.7-fold increased risk of reoperations for painful hardware, with 16.7% of plated cases requiring reoperation. Noting this, along with the higher costs associated with using plates, our study advocates for K-wire fixation for children undergoing CLO. LEVEL OF EVIDENCE: Level III.

Gene-environment interplay linking perceived parental supervision and peer drunkenness with Chinese adolescent alcohol initiation.

Following 602 Chinese twin pairs (48% male, all Han ethnicity) from primarily lower-than-average socioeconomic status families from early to mid-adolescence (Ms  = 12 and 15 in 2006 and 2009), this study investigated gene-environment interplay between perceived parental supervision, peer drunkenness, and adolescent alcohol initiation. For alcohol initiation, shared environmental influences were initially negligible but became substantial. Genetic factors largely explained the links between both correlates with alcohol initiation. Parental supervision amplified genetic risks for alcohol initiation in early adolescence but suppressed it in mid-adolescence. Peer drunkenness augmented genetic and environmental influences at both times. Peer drunkenness showed stronger links and moderating potential than parental supervision. Chinese adolescents show dynamic gene-environment interplay patterns involving parent-child and peer processes in alcohol initiation.

Case report: Asymptomatic bronchopulmonary sequestration in an adult with dual celiac and aortic supply.

A rare congenital malformation of the respiratory tract, bronchopulmonary sequestration generally presents in childhood and adolescence with recurrent pneumonia or in adulthood as an incidental finding on thoracic imaging. Manifesting as intrapulmonary or extrapulmonary types, bronchopulmonary sequestration characteristically receives blood supply from the systemic rather than pulmonary circulation. We present a 45-year-old male patient who received a provisional diagnosis of bronchopulmonary sequestration following an incidental finding on routine imaging. This case describes the way in which a provisional diagnosis may be made based upon imaging as well as underscoring the importance of alleviating the burden of additional imaging studies.

Maternal Parenting Behaviors Amplify Environmental Influences on Developmental Trajectories of Alcohol Use During Adolescence.

Compared to peer alcohol use, less is known on how parenting practices may modify genetic and environmental contributions to alcohol use longitudinally across adolescence. This study examined whether two maternal parenting behaviors, supervision and harsh parenting, may suppress or amplify genetic and environmental influences on three distinct developmental trajectories of adolescent alcohol use: normative increasing, early-onset, and low trajectories. Participants were drawn from a longitudinal study of a population-based twin sample (N = 842, 84% European descent, 52.7% female). Adolescents self-reported their past year alcohol use at ages 13, 14, 15, and 17 years, and their mothers reported their supervision and harsh parenting when twins were 13, 15, and 17 years old. Maternal supervision amplified non-shared environmental influence on the normative increasing and early-onset trajectories, whereas maternal harsh parenting amplified shared environmental influence on the early-onset trajectory and non-shared environmental influence on the low trajectory, respectively. The findings suggest maternal parenting practices as a potent developmental context that modulates the environmental influences of other proximal processes on adolescent alcohol use, and suggest that family-based parenting-focused intervention could be especially beneficial for adolescents following the early-onset trajectory.

Use of Telemedicine in Pediatric Orthopaedics Prior to the Pandemic: A Survey of POSNA Members.

BACKGROUND: Telemedicine, or telehealth, is broadly defined as the use of technology to deliver health care or health education at distance. Synchronous communication telemedicine, which involves the use of real time audio and video between patient and provider, is a developing field and its use in the pediatric orthopaedic population is not well defined. To better understand the existing use of and challenges posed by telemedicine for pediatric orthopaedic providers, the Pediatric Orthopaedic Society of North America (POSNA) practice management committee conducted a survey of current POSNA members. METHODS: A 33-question survey was created by the POSNA Practice Management Committee, piloted among committee members and approved by the POSNA Evidence Based Practice Committee. A total of 167 responses were complete (75% complete response rate). Telemedicine use questions referred to the use of synchronous communication telemedicine. RESULTS: A total of 50% reported being "moderately" or "not really" familiar with telemedicine. Sixty percent of study participants reported their hospital systems utilize telemedicine; however, only 40% reported utilizing telemedicine in their own practice. Sixty-seven percent indicated interest in telemedicine training. Telemedicine was utilized for a variety of patient pathology and visit types 57% of study participants did not bill for telemedicine services. Sixty-three percent were unaware of their states' billing rules regarding telemedicine. CONCLUSION: The survey is an attempt to understand the current landscape of telemedicine use within pediatric orthopaedics. Currently, a minority of survey participants utilize synchronous communication telemedicine. There is a desire for telemedicine training and best billing practices education. Further study to evaluate the limitations and efficacy of telemedicine in the pediatric orthopaedic population will be necessary as its use increases.

Association of Immune-Related Adverse Events and Efficacy Outcomes With Consolidation Pembrolizumab After Chemoradiation in Patients With Inoperable Stage III Non-Small-Cell Lung Cancer.

BACKGROUND: Many patients with non-small-cell lung cancer (NSCLC) treated with immunotherapy experience immune-related adverse events (irAEs). Patients with metastatic NSCLC who receive checkpoint inhibitors (CPI) and experience irAEs generally receive fewer cycles of CPI without decreased efficacy. However, the association between irAEs and efficacy outcomes in patients with locally advanced NSCLC treated with curative intent with CPI after chemoradiation has never been reported. Here we report a retrospective analysis of the association between irAEs and efficacy outcomes from the Hoosier Cancer Research Network (HCRN) LUN 14-179 single-arm phase 2 trial of consolidation pembrolizumab after chemoradiation in patients with stage III NSCLC. PATIENTS AND METHODS: A total of 92 eligible patients were enrolled from March 2015 to November 2016. Demographics, disease characteristics, and number of pembrolizumab cycles received were reported in patients with and without irAEs. Chi-square test was used for comparisons for categorical variables and Wilcoxon test for continuous variables. The Kaplan-Meier method was used to analyze time to metastatic disease or death (TMDD), progression-free survival (PFS), and overall survival (OS). A log-rank test was used to compare groups. RESULTS: Any grade irAEs occurred in 55.4% of patients. There was no significant difference in number of pembrolizumab cycles received, TMDD, OS, or PFS in patients with and without irAEs. Patients who discontinued pembrolizumab early because of irAEs received significantly fewer cycles of pembrolizumab (5 vs 15, P = .0016) without a significant difference in TMDD, PFS, or OS. Similarly, patients who received immunosuppressive therapy received fewer numbers of cycles of pembrolizumab (4 vs 16, P < .001) without significantly reduced TMDD, PFS, or OS. CONCLUSION: irAEs due to pembrolizumab, regardless of grade or number of irAEs, were not associated with decreased efficacy outcomes. Furthermore, early discontinuation of pembrolizumab because of irAEs and/or treatment of irAEs with immunosuppressive therapy was not associated with a decrease in treatment efficacy.

Clavicles continue to grow beyond skeletal maturity: radiographic analysis of clavicle length in adolescents and young adults.

There has been minimal research regarding the clavicle's growth and its clinical implications in the late adolescent and early adult population. Previous studies have evaluated postnatal clavicle growth to age 18 without analysing growth through the age of secondary ossification center closure. The purpose of this study was (1) to determine clavicle length and age-related growth in males and females from age 12 to 25 years and (2) to specifically analyse clavicle growth in late adolescence. This was a retrospective analysis of chest radiographs in patients aged 12-25 years. The ruler tool was used to measure clavicle length. Mean values were tabulated for each year of age in males (n = 697) and females (n = 672). Mean right clavicle growth significantly increased from age 12 to 25 in both males and females (P < 0.0001). In males, the increase from age 16 to 25 was 17.5 mm, representing 10.6% of total clavicle length (P < 0.0001). In females, the increase from age 14 to 25 was 7.7 mm, representing 5.2% of total clavicle length (P < 0.0001). We found that from skeletal maturity to the closure of the secondary ossification center, growth was 17.5 mm (10.6% of total clavicle length) in males and 7.7 mm (5.2% of total clavicle length) in females. During their growth spurts, the adolescent male and female clavicle have growth potentials very similar to previous studies of radius growth. Understanding these clavicular growth potentials can influence operative vs. nonoperative management decisions by orthopaedic surgeons. Level of evidence: Level III.

Pediatric Ankle Fractures: When to Operate and When to Leave Alone?

Ankle fractures are a common pediatric orthopaedic injury and are the second most common site of physeal injury after the distal radius. Concerns regarding these injuries include the risk of premature physeal closure and intra-articular incongruence with subsequent degenerative changes. Salter-Harris type I and II injuries have high rates of premature physeal closure especially in those with a physeal gap greater than 3 mm and pronation-abduction injuries. The authors of this chapter recommend surgical management if acceptable alignment cannot be obtained with closed reduction. A residual physeal gap is not an appropriate sole indicator for surgical management. Salter-Harris type III and IV injuries also have high rates of premature physeal closure and can result in articular incongruence given their intra-articular nature. The authors of this chapter recommend surgical management of these fractures when intra-articular displacement is greater than 2 mm. Transitional fractures (ie, Tillaux and triplane) occur in older patients during distal tibial physeal closure. Fracture lines travel through the relatively weaker lateral tibial physis, which is the last to close in the transitional period. These intra-articular fractures with displacement greater than 2 mm should be managed surgically to anatomically reduce the articular surface and prevent early degenerative changes.

Tibial Shaft Fractures in Children: What to Do When Casting Fails?

Tibial shaft fractures in children can often be successfully managed with a well-molded cast that controls length, alignment, and rotation of the fracture. Acceptable alignment of tibial shaft fractures in children is less than 10° of coronal and sagittal angulation, 50% translation, and 10 mm of shortening. Fractures of the tibial shaft without an associated fibular shaft fracture may fall into varus malalignment despite initial adequate reduction and should be followed closely during the first 3 weeks after injury. Surgical treatment should be considered in adolescent patients and those with open fractures, comminuted fractures, and fractures that cannot be adequately reduced and stabilized with a cast. The predominant modes of surgical stabilization of tibial shaft fractures in children are external fixation or internal fixation with flexible intramedullary nails or via minimally invasive plate osteosynthesis; both methods have reliable results.

Opioid Use Following Operatively Treated Pediatric Elbow and Femur Fractures.

BACKGROUND: Opioids are a commonly utilized component of pain management following pediatric extremity fractures, yet an increasing number of adolescents and children are falling victim to their negative effects. The purpose of this study was to examine opioid use in the pediatric fracture population by determining and comparing the average hospital opioid dosage utilized in the operative pediatric elbow and femur fractures and determining and comparing the average dose prescribed following operative treatment of elbow and femur fractures. METHODS: All elbow and femur fractures treated operatively between January and December 2016 were identified. Patients aged 0 to 17 years with closed injuries who presented to the emergency department (ED) within 24 hours of injury and underwent operative treatment were included. Demographic information, opioid and nonopioid analgesic medication doses administered in the ED and while inpatient, and postdischarge prescription information were recorded. Opioid doses were converted to oral morphine equivalents. RESULTS: In total, 91.9% and 78.1% of patients received opioids during the ED and inpatient periods, respectively. Only 30% of patients in either cohort received a nonopioid analgesic in the ED and only 44% received ibuprofen while inpatient. Average total opioid dose per hour of hospital stay was not significantly different between elbow fracture and femur fracture cohorts, which was unexpected. There was no significant difference between the average opioid dose or number of doses prescribed for postdischarge use between cohorts. CONCLUSIONS: This study provides data on average hospital opioid and nonopioid use following pediatric elbow and femur fractures. The results reveal inconsistent nonopioid analgesic use and similar hospital opioid use in elbow and femur fracture patients. This study provides baseline analgesic use data for future investigations. LEVEL OF EVIDENCE: Level IV.

No impact of under-correction and joint line obliquity on clinical outcomes of total knee arthroplasty for the varus knee.

PURPOSE: It has been hypothesized that under-correction of a preoperative varus deformity may be more natural and improve outcomes after total knee arthroplasty (TKA). This study's purpose was to assess the impact of hip-knee-ankle (HKA) alignment and joint line obliquity on TKA outcomes for the varus knee. METHODS: All patients with a preoperative varus deformity received both preoperative and postoperative standing, full-length radiographs from which two independent observers performed radiographic measurements including the HKA axis and mechanical medial proximal tibial angle (mMPTA). Patients were categorized based on their HKA into neutral (0° ± 3°), mild varus (-6° to -3°), severe varus (≤ -6°), and valgus (>3°) cohorts, and separately categorized based on their mMPTA into neutral (90° ± 2°), mild varus (86°-88°), severe varus (<86°), and valgus (>92°) cohorts. RESULTS: Two hundred and fifty-six patients (mean age 63.8 ± 9.0 years, BMI 33.0 ± 6.2 kg/m2, follow-up 1.3 ± 0.6 years) were included. There was no difference in the postoperative SF-12 physical component, mental component, Oxford knee, Forgotten Joint Score, or incremental improvement in scores based on the postoperative alignment category for either the HKA or mMPTA. There was no correlation between the magnitude of change in HKA (r = 0.03-0.1) and mMPTA (r = 0.02-0.1) from preoperatively to postoperatively with clinical outcomes. CONCLUSIONS: In patients undergoing TKA for a preoperative varus deformity, a specific postoperative HKA or mMPTA alignment category was not associated with improved outcomes. Therefore, categorization of optimal postoperative alignment after TKA may not be possible as static, coronal alignment is just one of many variables that can impact clinical outcomes. Future investigations focusing on the combination of static images with dynamic examinations and ligamentous balancing may shed further insight into the controversy and importance of coronal alignment following TKA. LEVEL OF EVIDENCE: III.

Age and Early Revision After Primary Total Hip Arthroplasty for Osteoarthritis.

Prior reports have noted an increased risk of early revision among younger patients undergoing total hip arthroplasty (THA) but have been confounded by the inclusion of various diagnoses. The purpose of this study was to assess the revision rate and the time to revision for patients undergoing THA for osteoarthritis based on age. Patients with a diagnosis of osteoarthritis who underwent both primary and revision THA at the same institution were identified. The time between primary and revision surgery and the indication for revision were collected. Patients were stratified into 2 groups based on age at the time of primary THA: 64 years or younger (group 1) or 65 years or older (group 2). Between 1996 and 2016, a total of 4662 patients (5543 hips) underwent primary THA for a diagnosis of osteoarthritis. Of these, 100 patients (104 hips) received a revision THA (62 in group 1 and 42 in group 2). Mean age was 52.7±8.4 years in group 1 vs 73.4±6.3 years in group 2 (P<.001). There was no significant difference in mean body mass index (29.7±7.3 kg/m2 vs 28.4±4.6 kg/m2, P=.30). Rate of revision was not significantly different between the groups (1.8% vs 2.0%, P=.7). Average time from primary to revision surgery was 3.0±3.2 years for group 1 and 1.1±2.1 years for group 2 (P=.001). Among patients undergoing primary THA for a diagnosis of osteoarthritis, younger age is not associated with an increased rate of early failure or revision. [Orthopedics. 2017; 40(6):e1069-e1073.].

The Central Slip Fracture: Results of Operative Treatment of Volar Fracture Subluxations/Dislocations of the Proximal Interphalangeal Joint.

PURPOSE: Fractures of the base of the middle phalanx are particularly challenging. Dorsal fracture-subluxations/dislocations of the proximal interphalangeal (PIP) joint are relatively common, but the volar fracture-subluxation/dislocation, the so-called "central slip fracture," is quite rare. The current study presents our experience with surgically treated patients with central slip fracture subluxation/dislocation with a minimum of 1 year follow-up. We hypothesized that the majority of patients with a central slip fracture-subluxation/dislocation have poor outcomes. METHODS: Thirteen patients with central slip fracture-subluxations/dislocation were identified from departmental billing records between 2003 and 2013. Nine patients completed the study follow-up examination and 8 were included in the final analysis. Clinical data assessed included age at injury, sex, mechanism of injury, injured digit, type of treatment, additional intervention(s), complications, length of follow-up, and range of motion follow-up. Fluoroscopic images and Quick Disabilities of the Arm, Shoulder, and Hand surveys were obtained at study follow-up. RESULTS: All patients underwent at least 1 surgery and 7 of 8 underwent open reduction. The average age at the time of injury was 41 years (range, 25-60 years). All injuries were closed. The average follow-up was 43 months (range, 17-67 months). Average passive and active range of motion of the PIP joint at follow-up were 62° and 54°, respectively. Six of 8 patients developed radiographic evidence of arthritic change and 4 experienced an outcome that required additional interventions. CONCLUSIONS: Patients should be counseled about the outcomes following surgical treatment of this uncommon, difficult injury. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Perioperative and Early Postoperative Comparison of a Modern Cemented and Cementless Total Knee Arthroplasty of the Same Design.

BACKGROUND: Cementless total knee arthroplasty (TKA) designs that incorporate a highly porous, titanium surface have the potential to achieve biologic fixation and improve component survivorship. This study's purpose was to compare perioperative and early postoperative outcomes of a cemented vs cementless TKA of the same design. METHODS: This was a retrospective review of a consecutive series of TKAs performed at a single institution using a cemented or cementless TKA of the same design (Triathlon, Stryker Inc, Mahwah, NJ). All patients with a minimum of 1-year clinical and radiographic follow-up were reviewed, with 1:1 matching performed for age, gender, body mass index, and preoperative Oxford Knee Score. Chi-square or independent student t tests were used for statistical analyses. RESULTS: Overall, 62 cemented and 66 cementless TKAs were reviewed, with secondary analyses performed after 1:1 matching of 38 patients in each cohort. In both overall and secondary 1:1 matching analyses, there was no difference in baseline demographics (P = .6-.9). Total operative times were decreased in the cementless cohort (P = .03), but there was no difference in the estimated blood loss or change in hemoglobin levels (P = .2-.7). At a mean of 1.4 ± .5 years postoperatively, patients in both cohorts demonstrated similar improvements in Oxford Knee Scores and satisfaction scores (P = .2-.8), with no patients requiring a revision surgical procedure. CONCLUSION: A recently introduced cementless TKA design demonstrates excellent perioperative and early postoperative results without failures. Continued surveillance is necessary to elucidate the survivorship and potential long-term benefits of this cementless design.

Is the Direct Superior, Iliotibial Band-Sparing Approach Associated With Decreased Pain After Total Hip Arthroplasty?

BACKGROUND: Recently, the direct superior approach (DSA) has been introduced in total hip arthroplasty (THA) with the goal of limiting soft tissue dissection. This study's purpose was to use a visual pain diagram questionnaire to determine the location and severity of pain in patients undergoing THA via a DSA vs miniposterior approach (MPA). METHODS: This was a prospective, Institutional Review Board (IRB)-approved investigation from 3 centers. Patients aged 18-70 years with a diagnosis of osteoarthritis were included. Two centers used the MPA, while 1 center the DSA. The DSA uses a 9- to 12-cm incision with its distal extent at the posterosuperior greater trochanter. Dissection into the iliotibial band is avoided, and the capsule at the inferior femoral neck is preserved. All THAs in both cohorts received a cementless, titanium, proximally coated femoral stem and a hemispherical acetabular component. RESULTS: A total of 42 DSA and 196 MPA THA patients were included. Overall, 43% of patients reported pain in at least 1 of the 8 anatomic areas assessed. There was no difference in the incidence of moderate to severe pain in any anatomic area of interest between the MPA and DSA cohorts (P = .1-.9). Specifically, the incidence of moderate to severe trochanter (17% MPA vs 17% DSA, P = .9), anterior thigh (15% MPA vs 17% DSA, P = .9), and lateral thigh pain (12% MPA vs 12% DSA, P = .9) was nearly identical in both cohorts. CONCLUSION: This study was unable to demonstrate a difference in the incidence of residual pain after use of a DSA or an MPA approach after THA.

Knee Extensor Mechanism Repairs: Standard Suture Repair and Novel Augmentation Technique.

Patellar and quadriceps tendon ruptures are relatively common injuries. Rupture of the knee extensor mechanism may occur because of a forceful eccentric contraction of the quadriceps against a resisted flexed knee, though atraumatic cases have also been described. Patients at higher than normal risk for knee extensor mechanism rupture include those with systemic co-morbidities, fluoroquinolone use, and chronic tendinopathy. Early operative treatment and mobilization of acute extensor mechanism ruptures has proven effective, and numerous techniques have been described. A 46-year-old male on anastrozole therapy simultaneously ruptured his left patellar and right quadriceps tendons during a deadlift attempt. Diagnosis was by history and physical examination. Repair of both injuries was performed 5 days after injury. Described within and shown in the accompanying video is a standard technique for primary repair using Krackow stitches through the ruptured tendon that are passed through patellar bone tunnels and tied over a bone bridge. The finer points of this technique are emphasized. Also included is a technique to augment the standard repair with a figure-of-8 stitch passed through additional oblique patellar bone tunnels. The mechanical advantage of the adjuvant figure-of-8 stitch provides additional compression, which nicely reapproximates the tendon edges.

IraL is an RssB anti-adaptor that stabilizes RpoS during logarithmic phase growth in Escherichia coli and Shigella.

UNLABELLED: RpoS (σ(S)), the general stress response sigma factor, directs the expression of genes under a variety of stressful conditions. Control of the cellular σ(S) concentration is critical for appropriately scaled σ(S)-dependent gene expression. One way to maintain appropriate levels of σ(S) is to regulate its stability. Indeed, σ(S) degradation is catalyzed by the ClpXP protease and the recognition of σ(S) by ClpXP depends on the adaptor protein RssB. Three anti-adaptors (IraD, IraM, and IraP) exist in Escherichia coli K-12; each interacts with RssB and inhibits RssB activity under different stress conditions, thereby stabilizing σ(S). Unlike K-12, some E. coli isolates, including uropathogenic E. coli strain CFT073, show comparable cellular levels of σ(S) during the logarithmic and stationary growth phases, suggesting that there are differences in the regulation of σ(S) levels among E. coli strains. Here, we describe IraL, an RssB anti-adaptor that stabilizes σ(S) during logarithmic phase growth in CFT073 and other E. coli and Shigella strains. By immunoblot analyses, we show that IraL affects the levels and stability of σ(S) during logarithmic phase growth. By computational and PCR-based analyses, we reveal that iraL is found in many E. coli pathotypes but not in laboratory-adapted strains. Finally, by bacterial two-hybrid and copurification analyses, we demonstrate that IraL interacts with RssB by a mechanism distinct from that used by other characterized anti-adaptors. We introduce a fourth RssB anti-adaptor found in E. coli species and suggest that differences in the regulation of σ(S) levels may contribute to host and niche specificity in pathogenic and nonpathogenic E. coli strains. IMPORTANCE: Bacteria must cope with a variety of environmental conditions in order to survive. RpoS (σ(S)), the general stress response sigma factor, directs the expression of many genes under stressful conditions in both pathogenic and nonpathogenic Escherichia coli strains. The regulation of σ(S) levels and activity allows appropriately scaled σ(S)-dependent gene expression. Here, we describe IraL, an RssB anti-adaptor that, unlike previously described anti-adaptors, stabilizes σ(S) during the logarithmic growth phase in the absence of additional stress. We also demonstrate that iraL is found in a large number of E. coli and Shigella isolates. These data suggest that strains containing iraL are able to initiate σ(S)-dependent gene expression under conditions under which strains without iraL cannot. Therefore, IraL-mediated σ(S) stabilization may contribute to host and niche specificity in E. coli.