Tibial Intramedullary Nail From a Suprapatellar Approach in a Semi-Extended Position.

An intramedullary nail is a common and reliable treatment option for diaphyseal tibial fractures. One such approach for this technique is suprapatellar. This video shows the surgical technique of a tibial nail through a suprapatellar approach in a semi-extended position in a 22-year-old man with a distal third tibial shaft fracture.

The Production of Antibiotic Cement Beads.

The use of antibiotic beads in open fracture cases can lead to decreased rates of infection and surgeon production is associated with significant time and cost savings. This video demonstrates production of antibiotic impregnated polymethylmethacrylate beads used in the setting of a grade IIIB open tibial shaft fracture.

Chromosomal instability in untreated primary prostate cancer as an indicator of metastatic potential.

BACKGROUND: Metastatic prostate cancer (PC) is highly lethal. The ability to identify primary tumors capable of dissemination is an unmet need in the quest to understand lethal biology and improve patient outcomes. Previous studies have linked chromosomal instability (CIN), which generates aneuploidy following chromosomal missegregation during mitosis, to PC progression. Evidence of CIN includes broad copy number alterations (CNAs) spanning > 300 base pairs of DNA, which may also be measured via RNA expression signatures associated with CNA frequency. Signatures of CIN in metastatic PC, however, have not been interrogated or well defined. We examined a published 70-gene CIN signature (CIN70) in untreated and castration-resistant prostate cancer (CRPC) cohorts from The Cancer Genome Atlas (TCGA) and previously published reports. We also performed transcriptome and CNA analysis in a unique cohort of untreated primary tumors collected from diagnostic prostate needle biopsies (PNBX) of localized (M0) and metastatic (M1) cases to determine if CIN was linked to clinical stage and outcome. METHODS: PNBX were collected from 99 patients treated in the VA Greater Los Angeles (GLA-VA) Healthcare System between 2000 and 2016. Total RNA was extracted from high-grade cancer areas in PNBX cores, followed by RNA sequencing and/or copy number analysis using OncoScan. Multivariate logistic regression analyses permitted calculation of odds ratios for CIN status (high versus low) in an expanded GLA-VA PNBX cohort (n = 121). RESULTS: The CIN70 signature was significantly enriched in primary tumors and CRPC metastases from M1 PC cases. An intersection of gene signatures comprised of differentially expressed genes (DEGs) generated through comparison of M1 versus M0 PNBX and primary CRPC tumors versus metastases revealed a 157-gene "metastasis" signature that was further distilled to 7-genes (PC-CIN) regulating centrosomes, chromosomal segregation, and mitotic spindle assembly. High PC-CIN scores correlated with CRPC, PC-death and all-cause mortality in the expanded GLA-VA PNBX cohort. Interestingly, approximately 1/3 of M1 PNBX cases exhibited low CIN, illuminating differential pathways of lethal PC progression. CONCLUSIONS: Measuring CIN in PNBX by transcriptome profiling is feasible, and the PC-CIN signature may identify patients with a high risk of lethal progression at the time of diagnosis.

Radial Head Replacement Through a Kocher Approach.

PURPOSE: Radial head fractures are some of the most common elbow fractures. Fractures with 3 or more fracture fragments have been shown to have worse outcomes when treated with open reduction and internal fixation (ORIF). Radial head replacement offers an alternative treatment for those more comminuted radial head fractures. METHODS: Three-part radial head fractures make anatomical reduction more difficult to obtain with ORIF. Radial head fractures requiring replacement have shown good clinical outcomes. As a result, radial head arthroplasty offers a good treatment option for 3-or-more-part radial head fractures. RESULTS: This video presents a case of a radial head arthroplasty for a 3-part radial head fracture in a 23-year-old man. The radial head implant provides a smooth and concentric surface for articulation with the capitellum while providing stability to the elbow. CONCLUSIONS: Radial head replacement provides a good alternative to ORIF, producing similar elbow range of motion and providing good stability compared with the contralateral elbow.

Direct Anterior Approach for Hip Hemiarthroplasty.

PURPOSE: The purpose of this video is to demonstrate a surgical technique for a hemiarthroplasty of the hip joint through a direct anterior approach. We have found this technique to be a viable option for the treatment of displaced femoral neck fractures. METHODS: Multiple approaches to the hip are described for arthroplasty. Direct anterior approach for hemiarthroplasty is a safe, reproducible approach. RESULTS: The video displays our technique for performing a direct anterior approach to the hip joint for a hemiarthroplasty in the setting of a displaced femoral neck fracture. CONCLUSIONS: Hemiarthroplasty after femoral neck fractures in the elderly population is becoming increasingly more common. The direct anterior approach to the hip joint provides a safe approach for this procedure. The following video demonstrates our key principles when performing this technique.

Posterior Approach for a Cemented Hemiarthroplasty.

PURPOSE: Femoral neck fractures are common injuries with over 1 million occurring yearly. This video demonstrates a case of a displaced femoral neck fracture treated with a cemented hemiarthroplasty through a posterior approach. METHODS: Multiple approaches to the hip for arthroplasty have been described, each with advantages and disadvantages. Careful technique is critical to success. RESULTS: This presents a case of a displaced femoral neck fracture treated with a cemented hemiarthroplasty through a posterior approach. CONCLUSIONS: Displaced femoral neck fractures are common fractures. The posterior approach for cemented hemiarthroplasty is a safe, reproducible technique.

Clonal diversity revealed by morphoproteomic and copy number profiles of single prostate cancer cells at diagnosis.

Tumor heterogeneity is prevalent in both treatment-naïve and end-stage metastatic castration-resistant prostate cancer (PCa), and may contribute to the broad range of clinical presentation, treatment response, and disease progression. To characterize molecular heterogeneity associated with de novo metastatic PCa, multiplatform single cell profiling was performed using high definition single cell analysis (HD-SCA). HD-SCA enabled morphoproteomic and morphogenomic profiling of single cells from touch preparations of tissue cores (prostate and bone marrow biopsies) as well as liquid samples (peripheral blood and bone marrow aspirate). Morphology, nuclear features, copy number alterations, and protein expression were analyzed. Tumor cells isolated from prostate tissue touch preparation (PTTP) and bone marrow touch preparation (BMTP) as well as metastatic tumor cells (MTCs) isolated from bone marrow aspirate were characterized by morphology and cytokeratin expression. Although peripheral blood was examined, circulating tumor cells were not definitively observed. Targeted proteomics of PTTP, BMTP, and MTCs revealed cell lineage and luminal prostate epithelial differentiation associated with PCa, including co-expression of EpCAM, PSA, and PSMA. Androgen receptor expression was highest in MTCs. Hallmark PCa copy number alterations, including PTEN and ETV6 deletions and NCOA2 amplification, were observed in cells within the primary tumor and bone marrow biopsy samples. Genomic landscape of MTCs revealed to be a mix of both primary and bone metastatic tissue. This multiplatform analysis of single cells reveals several clonal origins of metastatic PCa in a newly diagnosed, untreated patient with polymetastatic disease. This case demonstrates that real-time molecular profiling of cells collected through prostate and bone marrow biopsies is feasible and has the potential to elucidate the origin and evolution of metastatic tumor cells. Altogether, biological and genomic data obtained through longitudinal biopsies can be used to reveal the properties of PCa and can impact clinical management.

Anatomic and Molecular Imaging in Prostate Cancer.

Prostate cancer is characterized by a complex set of heterogeneous disease states. This review aims to describe how imaging has been studied within each specific state. As physicians transition into an era of precision medicine, multiparametric magnetic resonance imaging (mpMRI) is proving to be a powerful tool leading the way for a paradigm shift in the diagnosis and management of localized prostate cancer. With further research and development, molecular imaging modalities will likely change the way we approach recurrent and metastatic disease. Given the range of possible oncological progression patterns, a thorough understanding of the underlying carcinogenesis, as it relates to imaging, is a requisite if we are to appropriately manage prostate cancer in future decades.

Impact of treatment on progression to castration-resistance, metastases, and death in men with localized high-grade prostate cancer.

Men with high-grade prostate cancer (HGPC) are at greatest risk of disease progression. Clinical risk factors associated with castration-resistant prostate cancer (CRPC), metastases, and prostate cancer-specific mortality (PCSM) were identified in a contemporary HGPC cohort. Clinical data was collected from men diagnosed with Gleason sum (GS) ≥8 at the Greater Los Angeles Veterans Affairs (GLA-VA) Healthcare System between 2000 and 2013. Multivariable competing risks regression analyses assessed progression to CRPC, metastases, and PCSM within three treatment strata. The cumulative incidence of disease progression was calculated at 2, 5, and 10-year time points. Review of 2149 prostate cancer cases yielded 322 with HGPC. Median survival times for cancer-specific and overall mortality were significantly shorter in men treated with primary androgen deprivation therapy (ADT) (P = 0.0002 and P < 0.0001). Multivariable analyses revealed that clinical stage N1, GS 10, and treatment with primary ADT were significantly associated with increased risk of CRPC, metastases, and PCSM. Significant differences in these outcomes were not observed in men treated with radical prostatectomy (RP) when compared to those treated with radiation therapy combined with short-term ADT (XRT-ADT). Ten-year event rates of progression to CRPC, metastases, and PCSM, for men treated with primary ADT, were 45.5%, 25.4%, and 25.1%, respectively. In conclusion, GS 10 and lymph node involvement, as well as primary ADT treatment in men with HGPC was associated with increased risk of CRPC, metastases, and PCSM. Curative-intent treatment with RP or XRT-ADT is associated with reduced progression rates and death in men with HGPC.

Using established predictors of post-traumatic stress to explain variations in recovery outcomes among orthopedic patients.

The present studies examine whether information contained in medical records can be used to predict outcomes following two orthopedic procedures: repair of hip fracture and total knee replacement. Study 1 reports the acute, in-hospital recovery data from the medical records of 119 hip fracture patients. Study 2 is a prospective, longitudinal investigation of 3-month postoperative recovery of 110 total knee replacement patients. Patients characterized by a greater number of post-traumatic stress risk factors experienced poorer outcomes following orthopedic surgery. Our results suggest that patients at risk for negative outcomes can be identified by information readily available to medical personnel.

Outcomes of shipped live donor kidney transplants compared with traditional living donor kidney transplants.

The disparity between kidney transplant candidates and donors necessitates innovations to increase organ availability. Transporting kidneys allows for living donors and recipients to undergo surgery with a familiar transplant team, city, friends, and family. The effect of shipping kidneys and prolonged cold ischemia time (CIT) with living donor transplantation outcomes is not clearly known. This retrospective matched (age, gender, race, and year of procedure) cohort study compared allograft outcomes for shipped live donor kidney transplants and nonshipped living donor kidney transplants. Fifty-seven shipped live donor kidneys were transplanted from 31 institutions in 26 cities. The mean shipping distance was 1634 miles (range 123-2811) with mean CIT of 12.1 ± 2.8 h. The incidence of delayed graft function in the shipped cohort was 1.8% (1/57) compared to 0% (0/57) in the nonshipped cohort. The 1-year allograft survival was 98% in both cohorts. There were no significant differences between the mean serum creatinine values or the rates of serum creatinine decline in the immediate postoperative period even after adjusted for gender and differences in recipient and donor BMI. Despite prolonged CITs, outcomes for shipped live donor kidney transplants were similar when compared to matched nonshipped living donor kidney transplants.

DETERMINATION OF OXALATE ION DOPANT LEVEL IN POLYPYRROLE USING FT-IR.

A pellet method using standard addition and FT-IR was used to estimate oxalate ion doping levels in electrosynthesized polypyrrole. The method is useful for materials where removal of analyte from an insoluble material is problematic. Here, electrosynthesized oxalate doped polypyrrole is dispersed in potassium bromide. Spikes of sodium oxalate are added and the mixtures pressed into pellets. The oxalate carbonyl absorption peak is then used to quantify the amount of oxalate present in the polypyrrole. The mass fraction of oxalate dopant in polypyrrole was determined to be 0.4 ± 0.1 % and coincides with the original synthesis solution composition.

Extended Neviaser portal approach to antegrade humeral nailing.

Certain arthropathies can distort the normal acromiohumeral relationship and make traditional anterolateral access to the proximal humerus for nailing difficult or impossible. This article presents a case of bilateral antegrade humeral nailing in which the Neviaser portal approach was used for humeral shaft fractures in a patient with distorted shoulder anatomy secondary to severe cuff tear arthropathy and rheumatoid arthritis. Based on a literature review, extending the traditional superomedial (Neviaser) portal to the shoulder to perform humeral nailing has never been described clinically. An 85-year-old woman with rheumatoid arthritis and bilateral cuff tear arthropathy presented after a mechanical fall from standing height with bilateral acute humeral shaft fractures. Preoperative fluoroscopy confirmed the inability to access the traditional starting point with an anterolateral approach due to a shield acromion resulting from cuff tear arthropathy and rheumatoid arthritis. Bilateral locked antegrade humeral nails were successfully placed through a 3-cm incision just off the medial border of the acromion and directly posterior to the acromioclavicular joint (the extended Neviaser portal approach). Postoperatively, the patient demonstrated early evidence of clinical and radiographic union. She was able to return to her preinjury function level, with an active range of motion comparable with her baseline. The Neviaser portal approach to antegrade humeral nailing is an effective solution to diaphyseal humeral fractures when access to the traditional anterolateral proximal humeral starting port is not possible due to distorted shoulder anatomy.

"Living independently is good": residence patterns in rural north China reconsidered.

Filialpiety provides an important ideological basis for family-based support in China. Evidence indicates that in recent years the support of the aged within the Chinese extended family has decreased. This article examines filial piety, residence, and support arrangements in three rural Chinese villages. Anthropologists independently conducted research in these villages in the 1990s: Hong Zhang in Zhongshan Village in Hubei Province, Yunxiang Yan in Xiajia Village in Heilongliang Province, and myself in Lijia Village in Shandong Province. This article examines the strategies used by the young and old in negotiating intergenerational support and residential arrangements within the context of local village circumstances and policies. In each village, the aged are increasingly likely to live apart from children, and to express a preference for living independently. Although these facts appear to contradict filialpiety, filialpiety continues to be valued. Filial respect of elders, however, is seen less as an inherent right and more as a reciprocal relationship that can be built, maintained, and lost. Housing policies and the economic status of the aged both appear to play an important role in explaining the common trends in these villages as well as explaining the differences between them. To varying degrees in each village, power has shifted to the younger generation.