Effect of device constraint: a comparative network meta-analysis of ACDF and cervical disc arthroplasty.

BACKGROUND CONTEXT: Clinical trials have demonstrated that cervical disc arthroplasty (CDA) is an effective and safe alternative treatment to anterior cervical discectomy and fusion (ACDF) for cervical degenerative disc disease in the appropriately indicated patient population. Various devices for CDA exist, differing in the level of device constraint. PURPOSE: To investigate outcomes following Anterior Cervical Discectomy and Fusion (ACDF) versus CDA stratified based on the level of device constraint: Constrained, Semiconstrained, and Unconstrained. STUDY DESIGN: Systematic review and network meta-analysis. PATIENT SAMPLE: 2,932 CDA patients (979 Constrained, 1,214 Semiconstrained, 739 Unconstrained) and 2,601 ACDF patients from 41 studies that compared outcomes of patients undergoing CDA or ACDF at a single level at a minimum of 2 years follow-up. OUTCOME MEASURES: Outcomes of interest included the development of adjacent segment degeneration (ASD), index and adjacent segment reoperation rates, range of motion (ROM), high-grade heterotopic ossification (HO, McAfee Grades 3/4), and patient-reported outcomes (NDI/VAS). METHODS: CDA devices were grouped based on the degrees of freedom (DoF) allowed by the device, as either Constrained (3 DoF), Semiconstrained (4 or 5 DoF), or Unconstrained (6 DoF). A random effects network meta-analysis was conducted using standardized mean differences (SMD) and log relative risk (RR) were used to analyze continuous and categorical data, respectively. RESULTS: Semiconstrained (p=.03) and Unconstrained CDA (p=.01) demonstrated a significantly lower risk for ASD than ACDF. All levels of CDA constraint demonstrated a significantly lower risk for subsequent adjacent segment surgery than ACDF (p<.001). Semiconstrained CDA also demonstrated a significantly lower risk for index level reoperation than both ACDF and Constrained CDA (p<.001). Unconstrained devices retained significantly greater ROM than both Constrained and Semiconstrained CDA (p<.001). As expected, all levels of device constraint retained significantly greater ROM than ACDF (p<.001). Constrained and Unconstrained devices both demonstrated significantly lower levels of disability on NDI than ACDF (p=.02). All levels of device constraint demonstrated significantly less neck pain than ACDF (p<.05), while Unconstrained CDA had significantly less arm pain than ACDF (p=.02) at final follow-up greater than 2 years. CONCLUSION: Cervical Disc Arthroplasty, particularly the unconstrained and semiconstrained designs, appears to be more effective than ACDF in reducing the risk of adjacent segment degeneration and the need for further surgeries, while also allowing for greater range of motion and better patient-reported outcomes. Less constrained CDA conferred a lower risk for index level reoperation, while also retaining more range of motion than more constrained devices.

Comparing two spatial variables with the probability of agreement.

Computing the agreement between 2 continuous sequences is of great interest in statistics when comparing 2 instruments or one instrument with a gold standard. The probability of agreement quantifies the similarity between 2 variables of interest, and it is useful for determining what constitutes a practically important difference. In this article, we introduce a generalization of the PA for the treatment of spatial variables. Our proposal makes the PA dependent on the spatial lag. We establish the conditions for which the PA decays as a function of the distance lag for isotropic stationary and nonstationary spatial processes. Estimation is addressed through a first-order approximation that guarantees the asymptotic normality of the sample version of the PA. The sensitivity of the PA with respect to the covariance parameters is studied for finite sample size. The new method is described and illustrated with real data involving autumnal changes in the green chromatic coordinate (Gcc), an index of "greenness" that captures the phenological stage of tree leaves, is associated with carbon flux from ecosystems, and is estimated from repeated images of forest canopies.

Chronic Volar Distal Radial Ulnar Joint Dislocation: A Case Report with Proposed Treatment Algorithm.

CASE: We report the case of a 34-year-old woman with a chronic right volar dislocation of the distal radioulnar joint (DRUJ) and associated ulnar styloid fracture. The patient presented 1 month after a dog bite injury with wrist pain and limited range of motion, and radiographs demonstrated volar DRUJ dislocation. Closed reduction was unsuccessful, and thus, open reduction was performed. CONCLUSION: Isolated volar DRUJ dislocations in the absence of fractures are easy to misdiagnose on plain radiographs. We present our surgical technique and fixation algorithm for open reduction and stabilization for chronic volar DRUJ dislocations.

Return-to-Play Outcomes of Athletes After Operative and Nonoperative Treatment of Lumbar Disc Herniation.

PURPOSE OF REVIEW: Lumbar disc herniation (LDH) is a common injury experienced by athletes and has important clinical considerations for athletes including the timing of return to sport. Lumbar disc herniation may result in loss of individual training and playing time for athletes. Current literature is inconclusive on whether surgical or conservative treatment of LDH is superior in athletes. Our aim was to review the literature to identify return-to-play (RTP) rates and performance outcomes following operative and nonoperative treatment of LDH in the athletic population. RECENT FINDINGS: Athletes have unique measurements of successful treatment for LDH such as time to return to their sport and performance outcomes that are not as applicable as traditional metrics. It is suggested that surgical treatment may provide a quicker return to sport than nonoperative care in athletes. Additionally, conflicting findings have been seen in career length and performance status based on sport, often due to short and tumultuous career patterns. These differences may be seen based on the unique physical demands of each sport, different motivations to prolong sport, or other confounding factors that could not be controlled for or unrelated to LDH. Recent literature on RTP outcomes in athletes treated for LDH show variable results based on sport. Further research is needed to assist physicians and athletes in making the decision to undergo conservative or surgical treatment of LDH in the athletic population.

Acute Myocarditis From the Use of Selective Androgen Receptor Modulator (SARM) RAD-140 (Testolone).

Selective Androgen Receptor Modulators (SARMs) work at the level of the androgen receptor and are potential alternatives to testosterone supplementation in patients with hypogonadism. We report the case of a young male who presented with possible acute myocarditis from self-medication with SARM for bodybuilding.

Chronic Rhomboid Origin Tear with Seroma: An Unusual Cause of Winging Scapula: A Case Report.

CASE: We present a case of a patient who sustained a rhomboid major origin tear with subsequent seroma formation. The rhomboid major origin was reattached using an Achilles tendon allograft to supplement the repair, and the seroma wall was excised. We were able to alleviate the patient's pain and improve his shoulder function. We present our surgical technique. CONCLUSION: Scapular winging is most often attributed to neurogenic causes, but the goal of this case report is to help orthopaedic surgeons realize that scapular winging is not only a nerve issue but can result from an acute muscle tear.

The black carbon dispersion in the Southern Hemisphere and its transport and fate to Antarctica, an Anthropocene evidence for climate change policies.

Black carbon (BC) has been measured in Antarctica's air, and its global warming effect can potentially speed up the ice melting in the most solid water reservoir of the planet. However, the primary responsible sources are not well evidenced in this region. The dispersion of black carbon emissions from the Southern Hemisphere was conducting using atmospheric chemical transport model and we compared the results with satellite registries from March 1st to April 30th in 2014. The emission inventory considered the anthropogenic and biomass burning emissions from global datasets. The largest and most populated cities in Southern Hemisphere showed the higher emission of BC. As a result, the average daily concentrations of atmospheric BC were around 4 ng/m3 in most regions of Antarctica according to its pristine characteristics. We analyzed fifteen relevant sites in coastal zones of Antartica and some peaks registered by the satellite records were not replicated by model outputs and it was mainly associated with the lack of emissions. Finally, we made simulations in the same period without biomass burning emissions and we observed decreased concentrations of BC in the range of 20-50%. As a result, we show that the black carbon transportation from the continental land to the polar region took place in 17-24 days during the Austral summer and the biomass burning emissions were the primary source. Black Carbon deposition in Antarctica is not permanent, but the uncontrolled emissions from Southern Hemisphere can increase its transportation to the white continent and make its accumulation during the period when the weak polar vortex occurs.

Ecophysiological Features Shape the Distribution of Prophages and CRISPR in Sulfate Reducing Prokaryotes.

Sulfate reducing prokaryotes (SRP) are a phylogenetically and physiologically diverse group of microorganisms that use sulfate as an electron acceptor. SRP have long been recognized as key players of the carbon and sulfur cycles, and more recently, they have been identified to play a relevant role as part of syntrophic and symbiotic relations and the human microbiome. Despite their environmental relevance, there is a poor understanding about the prevalence of prophages and CRISPR arrays and how their distribution and dynamic affect the ecological role of SRP. We addressed this question by analyzing the results of a comprehensive survey of prophages and CRISPR in a total of 91 genomes of SRP with several genotypic, phenotypic, and physiological traits, including genome size, cell volume, minimum doubling time, cell wall, and habitat, among others. Our analysis discovered 81 prophages in 51 strains, representing the 56% of the total evaluated strains. Prophages are non-uniformly distributed across the SRP phylogeny, where prophage-rich lineages belonged to Desulfovibrionaceae and Peptococcaceae. Furthermore, our study found 160 CRISPR arrays in 71 SRP, which is more abundant and widely spread than previously expected. Although there is no correlation between presence and abundance of prophages and CRISPR arrays at the strain level, our analysis showed that there is a directly proportional relation between cellular volumes and number of prophages per cell. This result suggests that there is an additional selective pressure for strains with smaller cells to get rid of foreign DNA, such as prophages, but not CRISPR, due to less availability of cellular resources. Analysis of the prophage genes encoding viral structural proteins reported that 44% of SRP prophages are classified as Myoviridae, and comparative analysis showed high level of homology, but not synteny, among prophages belonging to the Family Desulfovibrionaceae. We further recovered viral-like particles and structures that resemble outer membrane vesicles from D. vulgaris str. Hildenborough. The results of this study improved the current understanding of dynamic interactions between prophages and CRISPR with their hosts in both cultured and hitherto-uncultured SRP strains, and how their distribution affects the microbial community dynamics in several sulfidogenic natural and engineered environments.

The Loop 'n' Tack Knot: Biomechanical Analysis of a Novel Suture Technique for Proximal Biceps Tenodesis.

BACKGROUND: Secure tendon grasping is critical to the success of any tenodesis procedure. Several techniques currently used for tendon grasping can result in longitudinal splitting of the tendon, causing construct failure and failure of the tenodesis. PURPOSE: To compare the Loop 'n' Tack knot as a tendon-grasping technique with other common suture techniques. We investigated the biomechanical strength and mode of failure. STUDY DESIGN: Controlled laboratory study. METHODS: Eleven matched pairs of proximal biceps were harvested from fresh-frozen cadaveric shoulders. One tendon from each pair was stitched using 1 of 4 different techniques. The suture techniques evaluated included the Loop 'n' Tack with 2 different types of high-strength nonabsorbable suture, a double half-racking stitch, and a Krakow stitch. Samples were cyclically loaded between 5 and 20 N for 100 cycles, followed by a pull to failure at 33 mm/s. RESULTS: The Loop 'n' Tack techniques were equivalent to the double half-racking and Krakow techniques for load to ultimate failure (P = .817 and P = .984, respectively). The double half-racking technique was the stiffest construct, which was significantly greater than the second-stiffest group, the Loop 'n' Tack method with both FiberLink suture (P = .012) and SutureTape (P = .002), which had greater stiffness than the Krakow group (P < .001). The most common failure mode for the Loop 'n' Tack stitch was suture breakage compared with the Krakow and double half-racking methods, where the most common mode of failure was suture pullout from the tendon (P < .001). CONCLUSION: Biomechanical testing found that the Loop 'n' Tack techniques had similar ultimate load to failure values when compared with the double half-racking and Krakow methods. Mode-of-failure analysis showed that the Loop 'n' Tack construct typically failed by suture breakage, whereas the other techniques failed by suture pullout. CLINICAL RELEVANCE: The Loop 'n' Tack technique allows for secure grasping of tissue without the need for externalization of the tendon. This technique may be beneficial in compromised or poor-quality tissue without reducing overall pullout strength when compared with a standard half-racking or Krakow stitch.

Examining Techniques for Treatment of Medial Meniscal Ramp Lesions During Anterior Cruciate Ligament Reconstruction: A Systematic Review.

PURPOSE: The purpose of this study was to systematically review the clinical outcomes and adverse events among different techniques for treatment of medial meniscal ramp lesions performed in conjunction with anterior cruciate ligament (ACL) reconstruction. METHODS: A systematic review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane Reviews, Web of Science, and Medline databases were searched for studies examining clinical outcomes after surgical treatment of ramp lesions. Studies were selected if they met the following criteria: (1) evaluation of the outcome of surgical repair of meniscal ramp lesions, (2) injuries associated with ACL tears, (3) minimum 6-month follow up, (4) publication in a peer-reviewed journal, and (5) English language or translation readily available. RESULTS: Seven studies met inclusion criteria (485 patients; mean age 27.1 years [range 12 to 59]; mean follow-up 26.9 months [range 8 to 40]). Two all-inside techniques (suture-hook and an all-inside meniscus repair device) in addition to abrasion and trephination alone were analyzed. Each technique demonstrated significant increases in postoperative Lysholm and International Knee Documentation Committee (IKDC) scores, reaching the established minimal clinically important difference (MCID) for each patient reported outcome. Incomplete healing was documented in 12.1% to 12.9% of cases in which the tear was not repaired at the time of ACL reconstruction, 2.3% to 11.7% in cases using the suture-hook for repair, and 10.8% to 15% in the all-inside meniscus repair device group. CONCLUSION: This systematic review demonstrated that several approaches used to treat medial meniscal ramp lesions associated with ACL tears lead to positive clinical outcomes. Small, stable tears <2 cm in size may be managed with debridement alone. For larger, more unstable lesions, an all-inside approach has demonstrated positive clinical outcomes. Prospective trials are needed to determine the best management for meniscal ramp lesions. Additionally, further research is needed to better understand how to minimize the risk of technique-related complications (e.g., improper implant deployment). LEVEL OF EVIDENCE: Level IV, systematic review of level II, III, and IV studies.

Investigating the Bias in Orthopaedic Patient-reported Outcome Measures by Mode of Administration: A Meta-analysis.

BACKGROUND: Patient-reported outcome measures (PROMs) are critical and frequently used to assess clinical outcomes to support medical decision-making. QUESTIONS/PURPOSE: The purpose of this meta-analysis was to compare differences in the modes of administration of PROMs within the field of orthopaedics to determine their impact on clinical outcome assessment. PATIENTS AND METHODS: The PubMed database was used to conduct a review of literature from 1990 to 2018 with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. All articles comparing PROMs for orthopaedic procedures were included and classified by the mode of administration. Each specific survey was standardized to a scale of 0 to 100, and a repeated random effectsmodel meta-analysis was conducted to determine the mean effect of each mode of survey. RESULTS: Eighteen studies were initially included in the study, with 10 ultimately used in the meta-analysis that encompassed 2384 separate patient survey encounters. Six of these studies demonstrated a statistically notable difference in PROM scores by mode of administration. The meta-analysis found that the standardized mean effect size for telephone-based surveys on a 100-point scale was 71.7 (SE 5.0) that was significantly higher (P , 0.0001) than survey scores obtained via online/tech based (65.3 [SE 0.70]) or self-administered/paper surveys (61.2 [SE 0.70]). CONCLUSIONS: Overall, this study demonstrated that a documented difference exists in PROM quality depending on the mode of administration. PROM scores obtained via telephone (71.7) are 8.9% higher than scores obtained online (65.3, P , 0.0001), and 13.8% higher than scores obtained via self-administered on paper (61.8, P , 0.0001). Few studies have quantified statistically notable differences between PROM scores based solely on the mode of acquisition in orthopaedic.

A Destructive Tumor of the Proximal Tibia and Fibula: A Case Report Highlighting Challenging Diagnosis and Treatment of a Locally Advanced, Non-recurrent Chondroblastoma in 16 Years Old Patient.

INTRODUCTION: Chondroblastoma is a rare, cartilaginous primary bone tumor, which presents predominantly in children and young adults. These tumors represent 1% of all primary bone tumors. Patients tend to complain of progressive joint pain which usually aids in early diagnosis. However, early diagnosis has made the understanding of the untreated, progressive course of chondroblastoma quite difficult. This case report highlights a patient who was first encountered with locally advanced chondroblastoma and discusses the challenges of diagnosis and treatment with a focus on the natural progression of this disease. CASE REPORT: We report the case of a 16-year-old male encountered during relief efforts after the 2010 Haiti earthquake, who was found to have a massive, expansile, and destructive mass of the proximal left tibia and fibula. Radiographic appearance was concerning for a malignant bone forming process. However, biopsy revealed features most consistent with chondroblastoma with secondary aneurysmal bone cyst formation. Marginal resection was considered, but the degree of soft tissue and neurovascular invasion made it impossible to salvage the leg and thus an above-the-knee amputation was performed. CONCLUSION: This report reviews the challenging diagnosis of a massive chondroblastoma with locally aggressive features which required ablative surgery. This may provide insight into the untreated, natural course of this pathology.

Cost Determinants in the 90-Day Management of Isolated Ankle Fractures at a Large Urban Academic Hospital.

OBJECTIVES: To determine the independent risk factors associated with increasing costs and unplanned hospital readmissions in the 90-day episode of care (EOC) for isolated operative ankle fractures at our institution. DESIGN: Retrospective cohort study. SETTING: Level I Trauma Center. PATIENTS: Two hundred ninety-nine patients undergoing open reduction internal fixation for the treatment of an acute, isolated ankle fracture between 2010 and 2015. INTERVENTION: None. MAIN OUTCOME MEASURES: Independent risk factors for increasing 90-day EOC costs and unplanned hospital readmission rates. RESULTS: Orthopaedic (64.9%) and podiatry (35.1%) patients were included. The mean index admission cost was $14,048.65 ± $5,797.48. Outpatient cases were significantly cheaper compared to inpatient cases ($10,164.22 ± $3,899.61 vs. $15,942.55 ± $5,630.85, respectively, P < 0.001). Unplanned readmission rates were 5.4% (16/299) and 6.7% (20/299) at 30 and 90 days, respectively, and were often (13/20, 65.0%) due to surgical site infections. Independent risk factors for unplanned hospital readmissions included treatment by the podiatry service (P = 0.024) and an American Society of Anesthesiologists score of ≥3 (P = 0.017). Risk factors for increasing total postdischarge costs included treatment by the podiatry service (P = 0.011) and male gender (P = 0.046). CONCLUSIONS: Isolated operative ankle fractures are a prime target for EOC cost containment strategy protocols. Our institutional cost analysis study suggests that independent financial clinical risk factors in this treatment cohort includes podiatry as the treating surgical service and patients with an American Society of Anesthesiologists score ≥3, with the former also independently increasing total postdischarge costs in the 90-day EOC. Outpatient procedures were associated with about a one-third reduction in total costs compared to the inpatient subgroup.

Differences in gut microbial composition correlate with regional brain volumes in irritable bowel syndrome.

BACKGROUND: Preclinical and clinical evidence supports the concept of bidirectional brain-gut microbiome interactions. We aimed to determine if subgroups of irritable bowel syndrome (IBS) subjects can be identified based on differences in gut microbial composition, and if there are correlations between gut microbial measures and structural brain signatures in IBS. METHODS: Behavioral measures, stool samples, and structural brain images were collected from 29 adult IBS and 23 healthy control subjects (HCs). 16S ribosomal RNA (rRNA) gene sequencing was used to profile stool microbial communities, and various multivariate analysis approaches were used to quantitate microbial composition, abundance, and diversity. The metagenomic content of samples was inferred from 16S rRNA gene sequence data using Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt). T1-weighted brain images were acquired on a Siemens Allegra 3T scanner, and morphological measures were computed for 165 brain regions. RESULTS: Using unweighted Unifrac distances with hierarchical clustering on microbial data, samples were clustered into two IBS subgroups within the IBS population (IBS1 (n = 13) and HC-like IBS (n = 16)) and HCs (n = 23) (AUROC = 0.96, sensitivity 0.95, specificity 0.67). A Random Forest classifier provided further support for the differentiation of IBS1 and HC groups. Microbes belonging to the genera Faecalibacterium, Blautia, and Bacteroides contributed to this subclassification. Clinical features distinguishing the groups included a history of early life trauma and duration of symptoms (greater in IBS1), but not self-reported bowel habits, anxiety, depression, or medication use. Gut microbial composition correlated with structural measures of brain regions including sensory- and salience-related regions, and with a history of early life trauma. CONCLUSIONS: The results confirm previous reports of gut microbiome-based IBS subgroups and identify for the first time brain structural alterations associated with these subgroups. They provide preliminary evidence for the involvement of specific microbes and their predicted metabolites in these correlations.

Early adverse life events are associated with altered brain network architecture in a sex- dependent manner.

INTRODUCTION: Early adverse life events (EALs) increase the risk for chronic medical and psychiatric disorders by altering early neurodevelopment. The aim of this study was to examine associations between EALs and network properties of core brain regions in the emotion regulation and salience networks, and to test the influence of sex on these associations. METHODS: Resting-state functional and diffusion tensor magnetic resonance imaging were obtained in healthy individuals (61 men, 63 women). Functional and anatomical network properties of centrality and segregation were calculated for the core regions of the two networks using graph theory. Moderator analyses were applied to test hypotheses. RESULTS: The type of adversity experienced influences brain wiring differently, as higher general EALs were associated with decreased functional and anatomical centrality in salience and emotion regulation regions, while physical and emotional EALs were associated with increased anatomical centrality and segregation in emotion regulation regions. Sex moderated the associations between EALs and measures of centrality; with decreased centrality of salience and emotion regulation regions with increased general EALs in females, and increased centrality in salience regions with higher physical and emotional EALs in males. Increased segregation of salience regions was associated with increased general EALs in males. Centrality of the amygdala was associated with physical symptoms, and segregation of salience regions was correlated with higher somatization in men only. CONCLUSIONS: Emotion regulation and salience regions are susceptible to topological brain restructuring associated with EALs. The male and female brains appear to be differently affected by specific types of EALs.