Is Subcapital Realignment for Slipped Capital Femoral Epiphysis a Reproducible Technique? Midterm Results.

BACKGROUND: The modified Dunn procedure, which is based on the development of an extended retinacular flap containing the blood supply for the femoral head, allows anatomic reestablishment in patients with moderate to severe slipped capital femoral epiphysis (SCFE). Some controversy exists regarding the short-term to midterm risk of avascular necrosis (AVN) and other complications resulting from the surgical technique. QUESTIONS/PURPOSES: (1) What percentage of patients treated with an extended retinacular flap during the modified Dunn procedure for SCFE with a moderate (slip angle from 30° to 60°) or severe slip (slip angle equal or greater than 60°) develop symptomatic AVN, and what percentage underwent further surgery or had other complications? (2) What femoral head-neck alignment and position parameters relative to the greater trochanter are achieved after surgery? (3) Can we identify radiographic signs of osteoarthritis at a minimum of 4 years after surgery? METHODS: Between January 2006 and December 2018, we treated 61 patients for SCFE. During this time, we generally used the modified Dunn procedure when the slip angle was ≥ 30°. Based on this indication, the modified Dunn procedure was performed in 37 patients (41 hips) during that time period, and those patients were potentially eligible for this retrospective study. Because bilateral hips in the same patient are not statistically independent, for our analyses, we analyzed only the hip with the longer follow-up time. Of those who remained, 11% (4) were lost before the minimum study follow-up of 48 months or had incomplete datasets, leaving 89% (33) for analysis here at a median follow-up of 80 months (range 49 to 208 months). Periacetabular osteotomy or subtrochanteric rotational femoral osteotomy was added under the same anaesthesia time in 33% (11 patients). We added periacetabular osteotomy in 24% (8) when intraoperative anterior instability was present in external rotation. A femoral rotational osteotomy was added in 9% (3) when posterior instability was present in flexion and internal rotation. The mean ± standard deviation age at the time of surgery was 13 ± 1 years, and 33% (11 of 33) of patients were female. The mean slip angle was 51° ± 16º, and 15% (5) of hips had unstable slips, defined as an inability to walk with or without crutches. We documented chronic presentations in 82% (27) of patients, acute and chronic in 12% (4), and acute in 6% (2). The rate of symptomatic AVN was determined by reviewing all radiographs obtained at the latest follow-up interval. Further surgery and other complications were assessed through an electronic medical record review. Radiographic morphologic parameters were measured before surgery and at a minimum follow-up of 4 years by two senior orthopaedic surgeons. Radiographs obtained at the latest follow-up visit were also screened for signs of osteoarthritis by the same surgeons. RESULTS: At the latest follow-up, 3% (1 patient) of patients developed symptomatic AVN and underwent further surgery and 3% (1) underwent revision surgery for screw breakage after a high-energy fall. Postoperatively, the alpha angle was restored to 39º ± 6º, the anterior head-neck offset was restored to 8 ± 3 mm, the neck-shaft angle was 136º ± 6º, and the presence of a positive Klein line decreased from 64% (21 hips) to 0% (0 hips). No patients showed radiographic signs of osteoarthritis at the minimum follow-up of 4 years. CONCLUSION: In this series, the modified Dunn procedure in moderate and severe slips was a reproducible procedure, and few patients developed symptomatic AVN or experienced other complications. Hip morphology was restored, but a longer follow-up duration and a detailed analysis of the results from other centers is warranted to assess the possible long-term risk of progression to AVN or osteoarthritis. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Collapse after Carpal Bone Tunneling. An Underreported Complication?

PURPOSE: To report the complication of carpal bone tunnel collapse in scapholunate reconstruction. METHODS: The authors present six cases of carpal collapse or bone necrosis after bone tunneling for ligamentous reconstruction, three in the scaphoid bone and three in the lunate. RESULTS: All six cases were secondary to ligament reconstruction for chronic scapholunate dissociations, none of which had preoperative structural scaphoid or lunate deformities. CONCLUSIONS: Although the incidence of this occurrence is unknown, the consequences could be substantial; therefore, patients should be warned of this possibility when discussing complications of ligament reconstruction for chronic scapholunate instability requiring the creation of a bone tunnel. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Benefits of Tranexamic Acid in Total Knee Arthroplasty: A Classification and Regression Tree Analysis in Function of Instrumentation, BMI, and Gender.

Tranexamic acid (TXA) is an antifibrinolytic drug that reduces blood loss in patients that undergo Total knee arthroplasty (TKA). Few studies compare its effect on conventional instrumentation (CI) versus patient-specific instrumentation (PSI). The main objective of this study was to understand analytically how TXA usage in both instrumentations influenced blood loss in TKA differently and see if the differences seen could be explained by the patient's body mass index (BMI) and gender. This nonrandomized retrospective study sample consisted of 688 TKA procedures performed on patients who had symptomatic arthrosis resistant to conservative treatment. Descriptive analysis was used to evaluate blood loss using hemoglobin (Hb) mean values and mean variation (%). The Classification and Regression Tree (CRT) method was applied to understand how the independent variables affected the dependent variable. Comparing patients submitted to the same instrumentation, where some received TXA and others did not, patients that received TXA had lower blood loss. Comparing patients who underwent TKA with different instrumentations and without the use of TXA, it was found that patients who underwent TKA with PSI had lower blood loss than those who underwent TKA with CI. However, when these same instruments were compared again, but associated with the use of TXA, the opposite was true with patients undergoing TKA with PSI showing greater blood loss than patients undergoing TKA with CI. TXA usage in TKA is significantly beneficial in minimizing blood loss and regardless of instrumentation. When using TXA, the lowest blood loss was obtained in patients with higher BMI and submitted to TKA with CI. This is most likely explained by the synergistic antifibrotic effect of TXA with adipokines, such as plasminogen activator inhibitor-1 (PAI-1), found in the femoral bone marrow which is perforated using CI. If, however, TXA wasn't used, the lowest blood loss was obtained in patients submitted to TKA with PSI.

Engineered pine nut shell derived activated carbons for improved removal of recalcitrant pharmaceuticals in urban wastewater treatment.

Novel powdered activated carbons (PACs) from pine cones and pine nut shells (PNSs) were tested for the competitive adsorption of pharmaceutical compounds (PhCs) in spiked (100 µg/L) secondary effluent and mixed liquor from an urban wastewater treatment plant. Steam activated PNS77, with hierarchical pore structure and 1463 m2/g of BET area, outperformed the commercial benchmark (WP220, mineral origin) for PhCs and dissolved organic matter (DOM) control. PNS77 attained the highest adsorption capacity and rate in synthetic and real wastewaters. Competitive adsorption isotherms revealed the detrimental effect of direct site competing DOM on PhC removal. The PhCs' adsorbability increased with their hydrophobicity, regardless of the water matrix. Kinetic data allowed inferring that indirect competition due to pore constriction/blockage appeared to occur only in mixed liquor. Adsorption isotherm data modelling for ng/L range revealed 80 % removal of carbamazepine and diclofenac would be achieved dosing 8-15 mg/L PNS77 to secondary effluent, while for mixed liquor the dose must be doubled to balance the increased competition. Hydrophilic sulfamethoxazole required a higher dose (34-44 mg/L), lower in the mixed liquor. PNS77 hierarchical pore network and basic surface chemistry minimized DOM direct site competition, requiring lower doses in practical applications for wastewater treatment.

Measuring Acetabular Version after Total Hip Arthroplasty: A Comparison of Two Radiographic Methods.

Objective The objective of the present work was to compare the measurement of acetabular component version on anteroposterior (AP) and on cross-table radiographs after total hip arthroplasty (THA). Methods Radiographs of 60 hips with a primary THA were selected. Version was calculated on the AP radiograph using the Lewinnek method and, on the cross-table, using the Woo and Morrey direct method. Results Mean and standard deviation (SD) were different on both radiographs, being 9.7° ± 5.5° on the AP, whereas in the cross-table the measurements were 20.6° ± 8.4° ( p < 0.001). Minding our aim of 10°, the cross-table measurements were statistically different from it ( p < 0.001), while the AP measurement did not differ ( p = 0.716). Conclusion The present study showed that the best way to correctly evaluate the acetabular component positioning following a THA is by measuring anteversion and abduction on an AP radiograph after confirming, in a cross-table radiograph, that the component is not retroverted.

Measuring Acetabular Version after Total Hip Arthroplasty: A Comparison of Two Radiographic Methods / Medição da versão acetabular após artroplastia total do quadril: Comparação de dois métodos radiográficos

Abstract Objective The objective of the present work was to compare the measurement of acetabular component version on anteroposterior (AP) and on cross-table radiographs after total hip arthroplasty (THA). Methods Radiographs of 60 hips with a primary THA were selected. Version was calculated on the AP radiograph using the Lewinnek method and, on the cross-table, using the Woo and Morrey direct method. Results Mean and standard deviation (SD) were different on both radiographs, being 9.7° ± 5.5° on the AP, whereas in the cross-table the measurements were 20.6° ± 8.4° (p < 0.001). Minding our aim of 10°, the cross-table measurements were statistically different from it (p < 0.001), while the AP measurement did not differ (p = 0.716). Conclusion The present study showed that the best way to correctly evaluate the acetabular component positioning following a THA is by measuring anteversion and abduction on an AP radiograph after confirming, in a cross-table radiograph, that the component is not retroverted.

Resumo Objetivo O objetivo do presente trabalho foi comparar a medição da versão do componente acetabular em radiografias em incidência anteroposterior (AP) e crosstable após artroplastia total do quadril (ATQ). Métodos Foram selecionadas radiografias de 60 quadris com ATQ primário. A versão foi calculada na radiografia AP usando o método de Lewinnek e, na cross-table, usando o método direto do Woo e Morrey. Resultados A média e o desvio padrão (DP) foram diferentes em ambas as radiografias, sendo 9,7° ± 5,5° no AP, enquanto na cross-table foram 20,6° ± 8,4° (p < 0,001). Considerando nosso objetivo de 10°, as medidas da cross-table foram estatisticamente diferentes dele (p < 0,001), enquanto a medição AP não diferiu (p = 0,716). Conclusão O presente estudo mostrou que a melhor maneira de avaliar corretamente o posicionamento do componente acetabular após uma ATQ é medindo a anteversão e a abdução em uma radiografia AP após confirmar, em uma radiografia cross-table, que o componente não é retrovertido.

Hybrid Process of Adsorption/Coagulation/Ceramic MF for Removing Pesticides in Drinking Water Treatment-Inline vs. Contact Tank PAC Dosing.

Two pilot trials of powdered activated carbon (PAC)/(coagulation)/ceramic microfiltration were conducted to compare continuous 10-12 mg/L PAC inline dosing with 8-10 mg/L dosing to a 2 h-contact tank. Two low turbidity/low natural organic matter (NOM, total organic carbon <2 mg C/L) surface waters spiked with 7.2-10.3 µg/L total-pesticides were tested and the dosing options were compared towards operational performance, average removal of pesticides and NOM and costs. Removal differences between the two PAC dosing options depended on pesticides' amenability to adsorption and NOM characteristics (254 nm absorbance, A254). Waters containing low A254-absorbing NOM and only pesticides amenable to adsorption showed very high removals (all pesticides ≥93%) and no significant differences between the two PAC dosing options. Waters containing higher A254-absorbing NOM and high loads of pesticides less amenable to adsorption (dimethoate, bentazone) required higher inline PAC dose. Those or more severe conditions may require PAC doses higher than tested to comply with the Drinking Water Directive limits for pesticides. Cost analysis showed PAC inline dosing is more cost-effective than PAC dosing to the contact tank when identical PAC dose is sufficient or when the doses are low, even if 50% higher for inline dosing, and the plant is small.

Adsorption/Coagulation/Ceramic Microfiltration for Treating Challenging Waters for Drinking Water Production.

Pressurized powdered activated carbon/coagulation/ceramic microfiltration (PAC/Alum/MF) was investigated at pilot scale for treating low turbidity and low natural organic matter (NOM) surface waters spiked with organic microcontaminants. A total of 11 trials with clarified or non-clarified waters spiked with pesticides, pharmaceutical compounds, or microcystins were conducted to assess the removal of microcontaminants, NOM (as 254 nm absorbance, A254, and dissolved organic carbon, DOC), trihalomethane formation potential (THMFP), aerobic endospores as protozoan (oo)cysts indicators, bacteriophages as viruses indicators, and regular drinking water quality parameters. PAC/(Alum)/MF achieved 75% to complete removal of total microcontaminants with 4-18 mg/L of a mesoporous PAC and 2 h contact time, with a reliable particle separation (turbidity < 0.03 NTU) and low aluminium residuals. Microcontaminants showed different amenabilities to PAC adsorption, depending on their charge, hydrophobicity (Log Kow), polar surface area and aromatic rings count. Compounds less amenable to adsorption showed higher vulnerability to NOM competition (higher A254 waters), greatly benefiting from DOC-normalized PAC dose increase. PAC/Alum/MF also attained 29-47% NOM median removal, decreasing THMFP by 26%. PAC complemented NOM removal by coagulation (+15-19%), though with no substantial improvement towards THMFP and membrane fouling. Furthermore, PAC/Alum/MF was a full barrier against aerobic endospores, and PAC dosing was crucial for ≥1.1-log reduction in bacteriophages.

Multifocal joint infection caused by Enterococcus gallinarum.

Musculoskeletal infections caused by Enterococcus gallinarum are rare, but due to its multi-drug resistance has gained more and more attention from the scientific community. We report a case of a 81-year-old immunocompetent Caucasian female with a multifocal joint infection caused by this agent. Shoulder arthrocentesis and two different blood cultures were used to identify this vancomycin-resistant agent in a symptomatic patient. After surgical debridement and 8 weeks of antibiotherapy with ampicillin (1000 mg IV every 6 h), the clinical and laboratory findings were all remarkably improved after treatment. After 2 years follow-up, the patient had no recurrence.

Ulnar Shortening Osteotomy: Our Experience.

Objective The objective of the present study was to evaluate the clinical and radiographic results of our series regarding ulnar shortening osteotomy, as well as to briefly review the pathology, indications and surgical options of ulnocarpal conflict. Methods We performed a retrospective analysis of consecutive patients who were treated with ulnar shortening osteotomy between January 2012 and June 2017 at our hospital. We clinically evaluated pain, articular range of motion, grip strength and functional outcomes using the quick-DASH questionnaire. We radiographically measured the pre- and postoperative ulnar variance and the shortening performed. Results We identified eight operated patients, and it was possible to evaluate seven of them. Pain decreased in this population (visual analogue scale [VAS] score changed from 7 to 2.6, p < 0.05), there was a decrease in quick-DASH (64 to 28, p < 0.05) and we found a decrease in the articular amplitude ∼ 7° for flexion ( p = 0.2), and of 5.5° for supination ( p = 0.3), as well as decreasing grip strength to about 86% on the contralateral side ( p = 0.07). The ulnar variance changed from a mean of + 5.5 mm to - 1.1 mm ( p < 0.05). Two out of 8 patients (25%) presented plaque-related symptoms and one of them underwent a new intervention to extract the material. Conclusions Ulnar shortening osteotomy is an effective surgical procedure both in the treatment of ulnocarpal conflict and in the discharge of the ulna. The results presented agreement with other results published in the literature, with good clinical and radiographic results.

Ulnar Shortening Osteotomy: Our Experience / Osteotomias de encurtamento da ulna: A nossa experiência

Abstract Objective The objective of the present study was to evaluate the clinical and radiographic results of our series regarding ulnar shortening osteotomy, as well as to briefly review the pathology, indications and surgical options of ulnocarpal conflict. Methods We performed a retrospective analysis of consecutive patients who were treated with ulnar shortening osteotomy between January 2012 and June 2017 at our hospital. We clinically evaluated pain, articular range of motion, grip strength and functional outcomes using the quick-DASH questionnaire. We radiographically measured the pre- and postoperative ulnar variance and the shortening performed. Results We identified eight operated patients, and it was possible to evaluate seven of them. Pain decreased in this population (visual analogue scale [VAS] score changed from 7 to 2.6, p< 0.05), there was a decrease in quick-DASH (64 to 28, p< 0.05) and we found a decrease in the articular amplitude ∼ 7° for flexion (p= 0.2), and of 5.5° for supination (p= 0.3), as well as decreasing grip strength to about 86% on the contralateral side (p= 0.07). The ulnar variance changed from a mean of + 5.5 mm to - 1.1 mm (p< 0.05). Two out of 8 patients (25%) presented plaque-related symptoms and one of them underwent a new intervention to extract the material. Conclusions Ulnar shortening osteotomy is an effective surgical procedure both in the treatment of ulnocarpal conflict and in the discharge of the ulna. The results presented agreement with other results published in the literature, with good clinical and radiographic results.

Resumo Objetivo O objetivo do presente estudo foi avaliar os resultados clínicos e radiográficos da nossa casuística relativamente a osteotomias de encurtamento da ulna, bem como rever sumariamente a patologia, as indicações e as opções cirúrgicas do conflito ulnocárpico. Métodos Realizamos uma análise retrospectiva de pacientes consecutivos que foram tratados com osteotomia de encurtamento da ulna entre janeiro de 2012 e junho de 2017 no nosso hospital. Avaliamos clinicamente a dor, amplitude articular, força da garra e resultados funcionais recorrendo ao questionário quick-DASH. Medimos radiograficamente a variância ulnar pré- e pós-operatória e o encurtamento realizado. Resultados Identificamos oito pacientes operados, tendo sido possível avaliar sete destes. Nesta população, obtivemos uma diminuição da dor (escala analógica visual [VAS, na sigla em inglês] de 7 para 2.6, p< 0,05), uma diminuição do quick-DASH (64 para 28, p< 0,05) e constatamos uma diminuição da amplitude articular ∼ 7° para a flexão (p= 0.2), de 5.5° para a supinação (p = 0,3), bem como diminuição da força da garra para cerca de 86% do lado contralateral (p = 0,07). A variância ulnar foi alterada de uma média de + 5.5 mm para −1.1 mm (p < 0,05). Dois em 8 pacientes (25%) apresentaram sintomatologia relacionada com a placa, sendo que um deles foi submetido a nova intervenção para extração do material. Conclusões A osteotomia de encurtamento da ulna é um procedimento cirúrgico eficaz, tanto no tratamento do conflito ulnocárpico, como na descarga da ulna. Os resultados apresentados vão ao encontro aos demais publicados na literatura, tendo-se obtido bons resultados clínicos e radiográficos.

Assessing the applicability of a new carob waste-derived powdered activated carbon to control pharmaceutical compounds in wastewater treatment.

This paper assesses the applicability of a new carob waste-derived powdered activated carbon (PAC) obtained by steam activation for pharmaceutical compounds (PhCs) removal in urban wastewater treatment plants (WWTPs) with activated sludge (AS) secondary treatment. The new carob-derived PAC presents chemical and textural properties similar to a high-performing commercial PAC produced from vegetable source by physical activation. The adsorption isotherms of three target PhCs, carbamazepine, diclofenac and sulfamethoxazole, spiked (at around 100 µg/L) in mixed liquor (ML) and in clarified-ML from the AS-bioreactor of a WWTP show: (i) minor reduction of PAC capacity with real MLs compared to clarified MLs; (ii) the higher the PhC hydrophobicity, the higher the PAC adsorption capacity in both water matrices; (iii) hydrophobic interactions probably overweight electrostatic interactions between the PhCs and the slightly positively charged PAC in these real water matrices with background organics and inorganics. The PhC adsorption results with ML and clarified-ML are used to calibrate the IAST-based tracer model (TRM) and predict the new PAC performance when added to AS-bioreactor vs. in post-secondary treatment, at the PhC naturally-occurring trace concentrations. The modelling projections show (i) one needs higher PAC doses than those reported in the literature, particularly in post-treatment, and (ii) the benefits of PAC dosing to the bioreactor, with only a slightly higher PAC dose being needed when compared to its post-secondary dosing and minimising the capital investment.

Prognostic factors in ankle sprains: a review.

Ankle sprains are one of the most common musculoskeletal injuries, being the most frequent musculoskeletal trauma among athletes.Most of these injuries are successfully treated conservatively; however, up to 70% of patients can develop long-lasting symptoms. Therefore, understanding prognostic factors for an ankle sprain could help clinicians identify patients with poor prognosis and choose the right treatment.A suggested approach will be presented in order to positively identify the factors that should warrant a more aggressive attitude in the initial conservative treatment.There are some prognostic factors linked to a better recovery and outcome; nevertheless, prognostic factors for full recovery after initial ankle sprain are not consistent. Cite this article: EFORT Open Rev 2020;5:334-338. DOI: 10.1302/2058-5241.5.200019.

Modelling and understanding the competitive adsorption of microcystins and tannic acid.

A predictive model integrating adsorption kinetics and competitive isotherm models (Homogeneous Surface Diffusion Model, Freundlich-type and Fritz & Schlünder isotherms) was developed to describe and understand the competing mechanism(s) and the ionic strength (IS) role on microcystins (MC) and tannic acid (TA) competitive adsorption. The developed model showed good agreement with the experimental data obtained from batch adsorption tests and isotherms conducted with MC extracts and TA model solutions (single-solute and multicomponent, IS presence and absence) using a mesoporous powdered activated carbon (PAC). Results confirm that similar size molecules such as MC and TA are strong competitors and tannin-rich waters may severely affect MC residuals in the treated water. Unlike usually considered, both direct site and pore blockage mechanisms seem relevant. Competition effects appear to be more dependent on the competitor/contaminant molar ratio than on the initial concentrations. The IS affects the extent and the mechanisms of MC-TA competitive adsorption, reducing PAC dose for safe control of MC residuals. The developed model, including a Ds analysis, is an important tool to understand the competitive adsorption of similar size adsorbates.

Cardiomiopatia arritmogênica do ventrículo direito / Arrhythmogenic right ventricular cardiomyopathy

Cardiomiopatia arritmogênica do ventrículo direito, também conhecida como displasia arritmogênica do ventrículo direito, é uma doença primária do músculo cardíaco, caracterizada por um substrato anatomopatológico composto por substituição do músculo cardíaco por um tecido fibrolipomatoso e com escasso infiltrado inflamatório, afetando predominantenete o ventrículo direito, em particular sua parede livre e via de saída. É clinicamente caraterizada pela associação com arritmia ventricular e morte súbita em jovens, particularmente em atletas e durante a atividade física. A prevalência dessa doença não é totalmente conhecida e varia em diferentes continentes. Estima-se que exista um caso em cada 5 mil indivíduos. O diagnóstico é difícil pelo pouco acometimento da função ventricular e pela presença de alterações eletrocardiográficas muito sutís, que com frequência não são percebidas. Assim, o diagnóstico geralmente é feito quando o paciente apresenta algum episódio de arritmia ventricular ou mesmo quando recuperado de morte súbita e mais raramente durante avaliação...