MetaZooGene Atlas and Database: Reference Sequences for Marine Ecosystems.

The MetaZooGene Atlas and Database (MZGdb; https://metazoogene.org/mzgdb/ ) is an open-access data and metadata portal synchronized with the NCBI GenBank and BOLD data repositories. The MZGdb includes sequences for genes used for the classification and identification of marine organisms based on DNA barcoding and metabarcoding. The focus of the MZGdb is biodiversity of marine ecosystems, including phytoplankton and microbes, zooplankton and invertebrates, fish, and other marine vertebrates (pinnipeds, cetaceans, and sea turtles). DNA sequences currently included are mitochondrial cytochrome oxidase I (COI), 12S, and 16S rRNA, and nuclear 18S and 28S rRNA. The MZGdb provides data and mapping tools for assembling and downloading compilations of reference sequence data that are specific to selected genes, taxonomic groups, and/or ocean regions. An additional feature of the MZGdb is the Atlas which summarizes data coverage and proportional completeness based on statistics of species with available sequences versus species commonly found in each ocean region.This chapter is a collaborative effort of the Scientific Committee for Ocean Research (SCOR) Working Group WG157: MetaZooGene: Toward a new global view of marine zooplankton biodiversity based on DNA metabarcoding and reference DNA sequence databases ( https://metazoogene.org ).

Cost Savings Associated With Implementing 4 Total Joint Replacement Electronic Clinical Quality Measures Nationally: 2020-2040.

BACKGROUND: Digital transformation using widely available electronic data is a key component to improving health outcomes and customer choice and decreasing cost and measurement burden. Despite these benefits, existing information on the potential cost savings from electronic clinical quality measures (eCQMs) is limited. METHODS: We assessed the costs of implementing 4 eCQMs related to total hip and/or total knee arthroplasty into electronic health record systems across healthcare systems in the United States. We used published literature and technical expert panel consultation to calculate low-, mid-, and high-range hip and knee arthroplasty surgery projections, and used empirical testing, literature, and technical expert panel consultation to develop an economic model to assess projected cost savings of eCQMs when implemented nationally. RESULTS: Low-, mid-, and high-range projected cost savings for year's 2020, 2030, and 2040 were calculated for 4 orthopedic eCQMs. Mid-range projected cost savings for 2020 ranged from $7.9 to $31.9 million per measure per year. A breakeven of between 0.5% and 5.1% of adverse events (measure dependent) must be averted for cost savings to outweigh implementation costs. CONCLUSIONS: All measures demonstrated potential cost savings. These findings suggest that eCQMs have the potential to lower healthcare costs and improve patient outcomes without adding to physician documentation burden. The Centers for Medicare and Medicaid Services' investment in eCQMs is an opportunity to reduce adverse outcomes and excess costs in orthopedics.

Combined Utility of the Semmes-Weinstein Monofilament and the Timed Vibration Test in the Prediction of Diabetic Foot Ulcers.

BACKGROUND: Neurologic screening tests are often used to identify and stratify patients at risk for diabetic foot complications such as infections, ulcers, and amputations. Two of the most commonly cited methods are the 5.07 Semmes-Weinstein monofilament (SWM) for loss of protective sensation and vibratory sensation testing. The aim of this study was to determine whether combined SWM and the timed vibration test (TVT) more effectively predicts diabetic foot ulcer (DFU) development compared with each test alone. METHODS: An electronic medical record database search was performed restricted to podiatric medical clinic patients with diabetes and DFU ICD-10 diagnosis codes. Of 200 patients who met the criteria, 24 developed DFUs. A statistical analysis was performed comparing the SWM and TVT at various cutoff times and the combined SWM/TVT in their ability to predict DFUs. RESULTS: Statistical analysis revealed that the TVT cutoff time of less than 4 sec was superior to the other times for prediction of DFUs. The combined SWM/TVT results at less than 4 sec were superior to each test individually: sensitivity, 87.5%; specificity, 84.7%; positive predictive value, 43.8%; and receiver operating characteristics area under the curve, 0.86. CONCLUSIONS: The SWM combined with TVT was shown to be superior compared with either test alone in discriminating DFU risk. In addition, the TVT cutoff time of less than 4 sec proved to have greater diagnostic yield than other times, including 0 sec. This unexpected finding might impact providers relying on the absence of vibration sensation via tuning fork testing as an optimal marker of DFU risk.

Linking Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form and PROMIS Physical Function.

INTRODUCTION: Linking scores on patient-reported outcome measures can enable data aggregation for research, clinical care, and quality. We aimed to link scores on the Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS) and the Patient-reported Outcomes Measurement Information System Physical Function (PROMIS PF). METHODS: A retrospective study was conducted from 2017 to 2020 evaluating patients with hip osteoarthritis who received routine clinical care from an orthopaedic surgeon. Our sample included 3,382 unique patients with 7,369 pairs of HOOS-PS and PROMIS PF measures completed at a single nonsurgical, preoperative, or postoperative time point. We included one randomly selected time point of scores for each patient in our linking analysis sample. We compared the accuracy of linking using four methods, including equipercentile and item response theory-based approaches. RESULTS: PROMIS PF and HOOS-PS scores were strongly correlated ( r = -0.827 for raw HOOS-PS scores and r = 0.820 for summary HOOS-PS scores). The assumptions were met for equipercentile and item response theory approaches to linking. We selected the item response theory-based Stocking-Lord approach as the optimal crosswalk and estimated item parameters for the HOOS-PS items on the PROMIS metric. A sensitivity analysis demonstrated overall robustness of the crosswalk estimates in nonsurgical, preoperative, and postoperative patients. CONCLUSION: These crosswalks can be used to convert scores between HOOS-PS and PROMIS PF metric at the group level, which can be valuable for data aggregation. Conversion of individual patient-level data is not recommended secondary to increased risk of error.

Linking the KOOS-PS to PROMIS Physical Function in Knee Patients Evaluated for Surgery.

INTRODUCTION: The Knee Injury and Osteoarthritis Outcome Score-Physical Function Short-form and the Patient-Reported Outcomes Measurement Information System Physical Function are widely used patient-reported outcome measures in orthopaedic practice and research. It would be helpful for clinicians and researchers to compare scores obtained on one instrument with those collected on another. To achieve this goal, this study conducted a linking analysis and computed a crosswalk table between these two scales. DATA: The data of this study were collected as part of the clinical care of total knee arthroplasty patients in a large urban and suburban health system. The sample was a mix of responses from nonsurgical (no surgery performed), preoperative (before surgical intervention), and postoperative (after surgical intervention) groups. METHODS: This study applied five linking methods: the item response theory (IRT)-based linking methods including fixed-parameter calibration, separate-parameter calibration with Stocking-Lord constants, and calibrated projection; and the equipercentile methods with log-linear smoothing and nonsmoothing approaches. Before conducting the linking analysis, we checked the linking assumptions including the similar content of the two scales, the unidimensionality of the combined scales, and the population invariance. The results of the five linking methods were evaluated by mean difference, SD, root-mean-squared deviation, intraclass correlation coefficient of the observed T scores and the crosswalk-derived T scores. RESULTS: The linking assumptions were all met. T scores generated from the Stocking-Lord crosswalk had the smallest mean difference (= -0.03) and relatively small SD (= 4.91) and root-mean-squared deviation (= 4.91) among the five linking methods. We validated this crosswalk in a larger sample with the nonsurgical, preoperative, and postoperative groups and in an external sample. DISCUSSION: This study provides clinicians and researchers a practical tool (ie, a crosswalk table) to link scores from two popular physical function measures. Given the diversity of patient-reported outcome measures in use for knee conditions, these crosswalk tables would accelerate clinical and research interpretation of aggregating functional outcomes among the patients evaluated for knee surgery each year.

Morbidly Obese Patients Undergoing Primary Total Joint Arthroplasty May Experience Higher Rates of Venous Thromboembolism When Prescribed Direct Oral Anticoagulants vs Aspirin.

BACKGROUND: Morbidly obese (body mass index [BMI] >40 kg/m2) patients undergoing total joint arthroplasty (TJA) are at high risk for postoperative venous thromboembolism (VTE); however, there is debate surrounding the optimal pharmacologic agent for prevention of VTE after TJA in this patient subset. Current guidelines recommend against direct-acting oral anticoagulants (DOACs) in patients of BMI >40 kg/m2 due to low quality evidence justifying their use. We evaluated whether patients of BMI >40 kg/m2 undergoing primary unilateral TJA would have increased risk of postoperative VTE if prescribed DOACs compared to non-DOAC agents such as aspirin. METHODS: This retrospective study analyzed 897 patients of BMI >40 kg/m2 undergoing primary unilateral TJA. Demographic and comorbidity-related variables were collected. The association between postoperative VTE and prophylactic pharmacologic agent prescribed was evaluated by multivariate logistic regression. RESULTS: After controlling for comorbidities, we found that the sole use of DOACs, specifically apixaban, for VTE prophylaxis was associated with an increased risk of developing VTE compared to prophylaxis with aspirin alone in patients of BMI >40 kg/m2 (odds ratio 2.962, P = .016). Regardless of VTE prophylactic agent, patients with BMI >40 kg/m2 undergoing TKA had at least 4.5-fold increased odds of developing VTE compared to patients undergoing THA (OR 4.830, P = .019). CONCLUSION: In our retrospective study of a large sample size of patients with BMI >40 kg/m2, we found that the use of DOACs, specifically apixaban, for VTE prophylaxis following TJA was associated with increased odds of a VTE complication compared to the use of aspirin alone.

One-Year Readmissions Following Total Joint Arthroplasty May Be Associated With Failure to Achieve the Minimal Clinically Important Difference of Patient-Reported Outcomes Measurement Information System Physical, Mental, and Physical-Short Form-10a.

The primary aims of our study were to determine if hospital readmissions within one year following primary total joint arthroplasty (TJA) and their relative timing influence patients' ability to achieve the two-year Patient-Reported Outcomes Measurement Information System (PROMIS) physical, PROMIS mental, and PROMIS Physical-Function-Short-Form-10a (SF-10a) minimal clinically important difference (MCID). This is a retrospective study conducted using data from a multi-institutional, arthroplasty registry. Only patients with paired patient-reported outcome measure (PROM) assessments (preoperatively and two years postoperatively) were included. Five separate readmission cohorts were formed: (1) any-cause readmission within one year, (2) any-cause readmission within 90 days, (3) non-index-surgery-related readmission within 90 days, (4) index-surgery-related readmission within one year, and (5) index-surgery-related readmission within 90 days. A propensity score match was used to match each of the patients to one of the 972 patients (1:1 basis) in the non-readmission group. The association between failure to achieve each of the three two-year MCIDs and Readmission status was analyzed using logistic regression. We found that all readmissions within one year and index-surgery-related readmissions within one year resulted in an increased risk of failure to achieve the two-year MCID across all three collected PROMs. Index surgery-related readmissions within 90 days (OR 3.24; 95% CI 1.05-11.05; p=0.048) sustained significantly different rates of two-year PROMIS physical MCID achievement compared to matched controls. Postoperative complications requiring readmission, particularly those related to the joint arthroplasty and those within 90 days of index surgery, significantly impact the ability to achieve the two-year MCID of PROMs.

Establishing a recommended duration of blood glucose monitoring in nondiabetic patients following orthopaedic surgery.

Previous studies have demonstrated that blood glucose (BG) levels should be monitored for at least 1 week after orthopaedic surgery in diabetic patients, but no study has determined how long nondiabetic patients should be monitored. As postoperative elevations in BG have deleterious effects, determining a duration for monitoring the BG of nondiabetic patients after major orthopaedic surgery is needed to detect hyperglycemic events, create comprehensive protocols for nondiabetic orthopaedic patients, and reduce adverse outcomes. A retrospective study was conducted including consecutive patients who underwent a major orthopaedic surgery at a community hospital. A BG level of 150 mg/dl was the cutoff used to define hyperglycemia according to our institutional guidelines. A χ2 , analysis of variance, and subgroup analysis were performed separately. Greater than 67% of nondiabetic patients experienced a high BG level (>150 mg/dl) after surgery. We found that nondiabetic patients reached their postoperative maximum BG level at 20 h, which was sooner compared to diabetic patients. We discovered more than 92% of nondiabetic patients reached a maximum BG levels within the first 72 h of hospitalization, while the BG levels after this period were found to be within normal limits in greater than 87% of cases. We propose that BG management be instituted in nondiabetics from the preoperative period to 72 h after surgery, including patients who are same-day discharges. There may not be a need to continue inpatient BG monitoring beyond the first 72 h for nondiabetic hospitalized patients with extended hospitalizations.

Assessing the quality of shared decision making for elective orthopedic surgery across a large healthcare system: cross-sectional survey study.

BACKGROUND: Clinical guidelines recommend engaging patients in shared decision making for common orthopedic procedures; however, limited work has assessed what is occurring in practice. This study assessed the quality of shared decision making for elective hip and knee replacement and spine surgery at four network-affiliated hospitals. METHODS: A cross-sectional sample of 875 adult patients undergoing total hip or knee joint replacement (TJR) for osteoarthritis or spine surgery for lumbar herniated disc or lumbar spinal stenosis was selected. Patients were mailed a survey including measures of Shared Decision Making (SDMP scale) and Informed, Patient-Centered (IPC) decisions. We examined decision-making across sites, surgeons, and conditions, and whether the decision-making measures were associated with better health outcomes. Analyses were adjusted for clustering of patients within surgeons. RESULTS: Six hundred forty-six surveys (74% response rate) were returned with sufficient responses for analysis. Patients who had TJR reported lower SDMP scores than patients who had spine surgery (2.2 vs. 2.8; p < 0.001). Patients who had TJR were more likely to make IPC decisions (OA = 70%, Spine = 41%; p < 0.001). SDMP and IPC scores varied widely across surgeons, but the site was not predictive of SDMP scores or IPC decisions (all p > 0.09). Higher SDMP scores and IPC decisions were associated with larger improvements in global health outcomes for patients who had TJR, but not patients who had spine surgery. CONCLUSIONS: Measures of shared decision making and decision quality varied among patients undergoing common elective orthopedic procedures. Routine measurement of shared decision making provides insight into areas of strength across these different orthopedic conditions as well as areas in need of improvement.

Can the Knee Outcome and Osteoarthritis Score (KOOS) Function Subscale Be Linked to the PROMIS Physical Function to Crosswalk Equivalent Scores?

BACKGROUND: An increased focus on patient-reported outcome measures (PROMs) has led to a proliferation of these measures in orthopaedic surgery. Mandating a single PROM in clinical and research orthopaedics is not feasible given the breadth of data already collected with older measures and the emergence of psychometrically superior measures. Creating crosswalk tables for scores between measures allows providers to maintain control of measure choice. Furthermore, crosswalk tables permit providers to compare scores collected with older outcome measures with newly collected ones. Given the widespread use of the newer Patient-reported Outcome Measure Information System Physical Function (PROMIS PF) and the established Knee Outcome and Osteoarthritis Score (KOOS), it would be clinically useful to link these two measures. QUESTION/PURPOSE: Can the KOOS Function in Activities of Daily Living (ADL) subscale be robustly linked to the PROMIS PF to create a crosswalk table of equivalent scores that accurately reflects a patient's reported physical function level on both scales? METHODS: We sought to establish a common standardized metric for collected responses to the PROMIS PF and the KOOS ADL to develop equations for converting a PROMIS PF score to a score for the KOOS-ADL subscale and vice versa. To do this, we performed a retrospective, observational study at two academic medical centers and two community hospitals in an urban and suburban healthcare system. Patients 18 years and older who underwent TKA were identified. Between January 2017 and July 2020, we treated 8165 patients with a TKA, 93% of whom had a diagnosis of primary osteoarthritis. Of those, we considered patients who had completed a full KOOS and PROMIS PF 10a on the same date as potentially eligible. Twenty-one percent (1708 of 8165) of patients were excluded because no PROMs were collected at any point, and another 67% (5454 of 8165) were excluded because they completed only one of the required PROMs, leaving 12% (1003 of 8165) for analysis here. PROMs were collected each time they visited the health system before and after their TKAs. Physical function was measured by the PROMIS PF version 1.0 SF 10a and KOOS ADL scale. Analyses to accurately create a crosswalk of equivalent scores between the measures were performed using the equipercentile linking method with both unsmoothed and log linear smoothed score distributions. RESULTS: Crosswalks were created, and adequate validation results supported their validity; we also created tables to allow clinicians and clinician scientists to convert individual patients' scores easily. The mean difference between the observed PROMIS PF scores and the scores converted by the crosswalk from the KOOS-ADL scores was -0.08 ± 4.82. A sensitivity analysis was conducted, confirming the effectiveness of these crosswalks to link the scores of two measures from patients both before and after surgery. CONCLUSION: The PROMIS PF 10a can be robustly linked to the KOOS ADL measure. The developed crosswalk table can be used to convert PROMIS PF scores from KOOS ADL and vice versa. CLINICAL RELEVANCE: The creation of a crosswalk table between the KOOS Function in ADL subscale and PROMIS PF allows clinicians and researchers to easily convert scores between the measures, thus permitting greater choice in PROM selection while preserving comparability between patient cohorts and PROM data collected from older outcome measures. Creating a crosswalk, or concordance table, between the two scales will facilitate this comparison, especially when pooling data for meta-analyses.

Impaired dermal microvascular reactivity and implications for diabetic wound formation and healing: an evidence review.

Diabetic foot ulcers (DFUs) are among the most consequential and costly complications faced by patients with diabetes and the global healthcare system. Acknowledged risk factors for DFUs include diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD), microtrauma and foot deformities. Research on additional risk factors for DFUs has recently focused on dysregulated, autonomic vasomotor control in the skin of patients with DPN. In particular, impaired dermal microvascular reactivity (IDMR) with its attendant reduction in nutritive capillary blood flow has been identified as an emerging risk factor. This especially relates to refractory wounds noted in patients without overt PAD signs. In this paper, evidence will be reviewed supporting the evolving understanding of IDMR and its impact on DFU formation and healing. Advances in diagnostic instrumentation driving this research along with the most promising potential therapies aimed at improving microvascular function in the diabetic foot will be discussed in brief.

A database of zooplankton biomass in Australian marine waters.

Zooplankton biomass data have been collected in Australian waters since the 1930s, yet most datasets have been unavailable to the research community. We have searched archives, scanned the primary and grey literature, and contacted researchers, to collate 49187 records of marine zooplankton biomass from waters around Australia (0-60°S, 110-160°E). Many of these datasets are relatively small, but when combined, they provide >85 years of zooplankton biomass data for Australian waters from 1932 to the present. Data have been standardised and all available metadata included. We have lodged this dataset with the Australian Ocean Data Network, allowing full public access. The Australian Zooplankton Biomass Database will be valuable for global change studies, research assessing trophic linkages, and for initialising and assessing biogeochemical and ecosystem models of lower trophic levels.

An initial evaluation of a proof-of-concept 128-Hz electronic tuning fork in the detection of peripheral neuropathy.

BACKGROUND: Diabetic peripheral neuropathy (DPN) is an essential precursor leading to diabetic limb loss. Neurologic screening tests, including the 128-Hz tuning fork (TF), have long been used to identify and track the progression of DPN, thereby guiding the implementation of preventive strategies. Although a sensitive indicator of neuropathy, shortcomings of TF testing include the lack of standardization and quantification of clinical findings. In an attempt to overcome these limitations, a novel 128-Hz electronic TF (ETF) prototype has been developed that is capable of performing accurate timed vibration tests (TVTs). This study was designed to assess the ability of the ETF to detect sensory impairment compared with three established neurologic screening methods: the Semmes-Weinstein monofilament test, the biothesiometer, and the sharp/dull discrimination test. METHODS: Fifty-five test patients were recruited from the primary author's practice and enrolled according to an approved protocol. The 10-g Semmes-Weinstein monofilament test and the sharp/dull discrimination test were administered in standard fashion to the plantar aspects of digits 1 and 5 bilaterally. The ETF and the biothesiometer (25-V setting) were applied to the dorsal aspects of the distal phalanx of the hallux and fifth metatarsal head bilaterally. RESULTS: The sensitivity and specificity of neuropathy detection for the ETF were 0.953 and 0.761, respectively, using conventional tests as reference standards. CONCLUSIONS: Performance of TVTs with the ETF detected sensory impairment compared with three conventional neurologic screening methods. Given these findings, the ETF could facilitate the use of standardized TVTs as an indicator of DPN progression.

Relative sensory sparing in the diabetic foot implied through vibration testing.

BACKGROUND: The dorsal aspect of the hallux is often cited as the anatomic location of choice for vibration testing in the feet of diabetic patients. To validate this preference, vibration tests were performed and compared at the hallux and 5th metatarsal head in diabetic patients with established neuropathy. METHODS: Twenty-eight neuropathic, diabetic patients and 17 non-neuropathic, non-diabetic patients underwent timed vibration testing (TVT) with a novel 128 Hz electronic tuning fork (ETF) at the hallux and 5th metatarsal head. RESULTS: TVT values in the feet of diabetic patients were found to be reduced at both locations compared to controls. Unexpectedly, these values were significantly lower at the hallux (P<0.001) compared to the 5th metatarsal head. CONCLUSION: This study confirms the hallux as the most appropriate location for vibration testing and implies relative sensory sparing at the 5th metatarsal head, a finding not previously reported in diabetic patients.

Biodiversity and ecosystem function in the Gulf of Maine: pattern and role of zooplankton and pelagic nekton.

This paper forms part of a broader overview of biodiversity of marine life in the Gulf of Maine area (GoMA), facilitated by the GoMA Census of Marine Life program. It synthesizes current data on species diversity of zooplankton and pelagic nekton, including compilation of observed species and descriptions of seasonal, regional and cross-shelf diversity patterns. Zooplankton diversity in the GoMA is characterized by spatial differences in community composition among the neritic environment, the coastal shelf, and deep offshore waters. Copepod diversity increased with depth on the Scotian Shelf. On the coastal shelf of the western Gulf of Maine, the number of higher-level taxonomic groups declined with distance from shore, reflecting more nearshore meroplankton. Copepod diversity increased in late summer, and interdecadal diversity shifts were observed, including a period of higher diversity in the 1990s. Changes in species diversity were greatest on interannual scales, intermediate on seasonal scales, and smallest across regions, in contrast to abundance patterns, suggesting that zooplankton diversity may be a more sensitive indicator of ecosystem response to inter annual climate variation than zoo plankton abundance. Local factors such as bathymetry, proximity of the coast, and advection probably drive zooplankton and pelagic nekton diversity patterns in the GoMA, while ocean-basin scale diversity patterns probably contribute to the increase in diversity at the Scotian Shelf break, a zone of mixing between the cold-temperate community of the shelf and the warm-water community offshore. Pressing research needs include establishment of a comprehensive system for observing change in zooplankton and pelagic nekton diversity, enhanced observations of "underknown" but important functional components of the ecosystem, population and metapopulation studies, and development of analytical modeling tools to enhance understanding of diversity patterns and drivers. Ultimately, sustained observations and modeling analysis of biodiversity must be effectively communicated to managers and incorporated into ecosystem approaches for management of GoMA living marine resources.

Induction of an osteoarthritis-like phenotype and degradation of phosphorylated Smad3 by Smurf2 in transgenic mice.

OBJECTIVE: To determine whether Smurf2, an E3 ubiquitin ligase known to inhibit transforming growth factor beta (TGFbeta) signaling, is expressed in human osteoarthritic (OA) cartilage and can initiate OA in mice. METHODS: Human OA cartilage was obtained from patients undergoing knee arthroplasty. Samples were graded histologically using the Mankin scale and were examined immunohistochemically for Smurf2 expression. A transgene driven by the collagen 2alpha1 promoter was used to overexpress Smurf2 in mice. Smurf2 overexpression in mouse sternal chondrocytes was confirmed by reverse transcription-polymerase chain reaction and Western blotting. Changes in articular cartilage area, chondrocyte number, and chondrocyte diameter were assessed histomorphometrically using OsteoMeasure software. Alterations in type X collagen and matrix metalloproteinase 13 (MMP-13) in articular chondrocytes were examined by in situ hybridization and immunohistochemistry, respectively. Joint bone phenotypes were evaluated by microfocal computed tomography. The effects of Smurf2 overexpression on TGFbeta signaling were examined using a luciferase-based reporter and immunoprecipitation/Western blotting. RESULTS: Human OA cartilage strongly expressed Smurf2 as compared with nonarthritic human cartilage. By 8 months of age, Smurf2-transgenic mice exhibited decreased articular cartilage area, fibrillation, clefting, eburnation, subchondral sclerosis, and osteophytes. Increased expression of type X collagen and MMP-13 were also detected in articular cartilage from transgenic mice. Transgenic sternal chondrocytes showed reduced TGFbeta signaling as well as decreased expression and increased ubiquitination of pSmad3. CONCLUSION: Smurf2 is up-regulated during OA in humans, and Smurf2-transgenic mice spontaneously develop an OA-like phenotype that correlates with decreased TGFbeta signaling and increased pSmad3 degradation. Overall, these results suggest a role of Smurf2 in the pathogenesis of OA.

Flexible titanium nailing for the treatment of the unstable pediatric tibial fracture.

Tibia fractures in the skeletally immature patient can usually be treated without surgery. The purpose of this study was to assess the use of flexible titanium nails in the tibia that requires operative stabilization. Over a 5-year period, 16 unstable tibia fractures in 14 patients were treated with flexible titanium intramedullary nails. All charts and radiographs were reviewed. The average age was 10 years 4 months. There were three open fractures. All fractures healed. Closed injuries obtained union by an average of 8 weeks, open fractures by an average of 15 weeks. There were no malunions. The average follow-up was 1 year 5 months. There were no instances of growth arrest, remanipulations, or refracture. In the unstable pediatric tibia fracture, flexible titanium nails are an effective treatment to obtain and maintain alignment and stability.

The crescentic inverted scarf osteotomy.

A hybrid procedure combining the inverted scarf and crescentic osteotomies is presented. This procedure may serve as a viable modification of the inverted scarf bunionectomy for those surgeons desiring true rotational correction of high intermetatarsal angles.

Surgical Considerations in the Treatment of Ankle Instability.

OBJECTIVE: To review the surgical indications, techniques, biomechanical testing, and clinical results reported for the most common surgical techniques used to treat ankle instability. DATA SOURCES: We searched MEDLINE from 1960-2001 using the terms ankle instability, functional ankle instability, mechanical ankle instability, ankle ligament surgery, Broström, Chrisman-Snook, and Evans. DATA SYNTHESIS: Although 80% to 85% of acute ankle sprains are successfully treated with a functional ankle-rehabilitation program, the remaining 15% to 20% have recurrent ankle instability and reinjury, necessitating surgical intervention. The fundamentals of the surgical approach to lateral ankle instability are based on the anatomy of the lateral ankle ligaments, the anterior talofibular ligament, and the calcaneofibular ligament. Ankle-instability surgery has been broadly divided into an anatomic repair consisting of an imbrication of the lateral ligamentous complex and an ankle-ligament reconstruction. An ankle-ligament reconstruction weaves a harvested tendon graft, most commonly the peroneus brevis, to augment the lateral ligaments of the ankle. Goals of surgery are to reestablish ankle stability and function without compromising motion and without complications. Anatomic repair and imbrication of the lateral ligament complex with the Gould modification has an 85% to 95% success rate, and the risk of associated nerve injuries is low. This approach provides increased stability by reinforcing local host tissue, preserving subtalar and talocrural motion, eliminating the comorbidity associated with tendon-graft harvest, and offering a quicker functional recovery. One concern in using the anatomic approach is the resultant strength of the repair, although the literature does not support this concern. Ankle-reconstruction procedures that sacrifice tendons are thought to provide a stronger construct, and hence, more stability. This increased stability results in loss of talocrural and subtalar range of motion, prolonging recovery and decreasing sport performance. Adjacent nerve injury is more common with ankle-ligament reconstruction. CONCLUSIONS/RECOMMENDATIONS: Based on the literature, we believe that a modified Broström lateral-ligament repair should be considered the first choice for persistent ankle instability refractory to a functional ankle-rehabilitation protocol. Ankle reconstruction with tendon augmentation should be reserved for patients with generalized ligamentous laxity or long-standing ligamentous insufficiency or as a salvage procedure in a patient with a failed modified Broström lateral-ligament repair.