Achilles Tendon Rip-Stop SpeedBridge Repair.

Achilles tendon injuries have been on the rise secondary to our increased participation in sports, increase in societal obesity rates, and the growing elderly population. There has been disagreement in recent years about whether to treat injuries such as Achilles tendon ruptures operatively or nonoperatively with aggressive functional rehabilitation. For those opting to surgically manage Achilles tendon ruptures, insertional Achilles tendonitis, or augment the described SpeedBridge Achilles tendon repair, we propose a modified rip-stop technique. The goal of this technique is to provide a biomechanical advantage to our current operative interventions for these injuries, a greater load-to-failure and a speedier, more reliable return to sport in our athletic populations.

Treatment of Severe Ankle and Hindfoot Deformity: Technique Using Femoral Head Allograft for Tibiotalocalcaneal Fusion Using a Cup-and-Cone Reamer.

Limb shortening due to structural bone loss in tibiotalocalcaneal arthrodesis is a concern that can negatively impact the patient's gait and weight-bearing. To aid in preventing the risk of limb shortening, the use of a femoral head allograft and intramedullary nail in tibiotalocalcaneal arthrodesis has been shown to successfully preserve limb length in patients with structural bone deficits. We present our technique using a femoral head allograft with a cup-and-cone reamer for the treatment of severe ankle and hindfoot deformity.

Injury of the suprascapular nerve during arthroscopic repair of superior labral tears: an anatomic study.

HYPOTHESIS: The purpose of this cadaveric anatomic study was to investigate the risk of iatrogenic suprascapular nerve injury during the standard drilling techniques in arthroscopic superior labrum anterior-posterior (SLAP) repairs. MATERIALS AND METHODS: Cadaveric shoulder girdles were isolated and drilled at the glenoid peripheral rim by use of standard arthroscopic equipment reproducing common drill locations and portal orientations for SLAP repairs. Drill hole depth was determined by the manufacturer's drill stop (20 mm), and any subsequent drill perforations through the medial bony surface of the glenoid were directly confirmed by dissection. The suprascapular nerve was then isolated to note the presence of any observable direct nerve injury from the drilling. The bone tunnel depth, subsequent distance to the suprascapular nerve, scapular height and width, and humeral length were also recorded. RESULTS: Eighteen drill perforations through the medial glenoid wall occurred in 8 of 21 cadavers (38%). Twelve perforations occurred through anterosuperior drill holes with only one associated nerve injury. Six perforations occurred through low posterosuperior drill holes with four associated nerve injuries. Five of the six shoulders with low posterosuperior perforation also had an associated anterior perforation. No perforations occurred through high posterosuperior drill holes. Of the specimens, 5 had bilateral involvement (4 female and 1 male). Specimens with a perforation had a significantly shorter scapular height (P = .007) and humeral length (P = .01). CONCLUSIONS: The suprascapular nerve is at risk for direct injury during arthroscopic SLAP repairs from penetration of the medial glenoid with arthroscopic drill equipment in cadavers.

Human neutrophil peptides and phagocytic deficiency in bronchiectatic lungs.

RATIONALE: A well-known clinical paradox is that severe bacterial infections persist in the lungs of patients with cystic fibrosis (CF) despite the abundance of polymorphonuclear neutrophils (PMN) and the presence of a high concentration of human neutrophil peptides (HNP), both of which are expected to kill the bacteria but fail to do so. The mechanisms remain unknown. OBJECTIVES: This study examined several possible mechanisms to understand this paradox. METHODS: PMN were isolated from sputum and blood of subjects with and without CF or non-CF bronchiectasis for phagocytic assays. HNP isolated from patients with CF were used to stimulate healthy PMN followed by phagocytic tests. MEASUREMENTS AND MAIN RESULTS: PMN isolated from the sputum of the bronchiectatic patients display defective phagocytosis that correlated with high concentrations of HNP in the lung. When healthy PMN were incubated with HNP, decreased phagocytic capacity was observed in association with depressed surface Fc gamma RIII, actin-filament remodeling, enhanced intracellular Ca(2+), and degranulation. Treatment of PMN with an intracellular Ca(2+) blocker or alpha1-proteinase inhibitor to attenuate the activity of HNP largely prevented the HNP-induced phagocytic deficiency. Intratracheal instillation of HNP in Pallid mice (genetically deficient in alpha1-proteinase inhibitor) resulted in a greater PMN lung infiltration and phagocytic deficiency compared with wild-type mice. CONCLUSIONS: HNP or PMN alone exert antimicrobial ability, which was lost as a result of their interaction. These effects of HNP may help explain the clinical paradox seen in patients with inflammatory lung diseases, suggesting HNP as a novel target for clinical therapy.

Long-term follow-up of tibial shaft fractures treated with intramedullary nailing.

OBJECTIVE: We conducted a study to evaluate the long-term functional outcomes of patients with an isolated tibial shaft fracture treated with locked intramedullary nailing. DESIGN: Prospective cohort and retrospective clinical and radiographic assessment. SETTING: A level 1 trauma and tertiary referral center. PATIENTS/PARTICIPANTS: We identified 250 eligible patients with isolated tibia fractures from the Center's prospectively enrolled orthopaedic trauma database between 1987 and 1992. A total of 56 patients agreed to participate. We had a median follow-up of 14 years, with a range from 12 to 17 years. INTERVENTION: All enrolled patients were initially acutely treated with locked intramedullary nailing of their tibia. MAIN OUTCOME MEASUREMENTS: All enrolled patients were evaluated with the SF-36 and Short Musculoskeletal Functional Assessment functional questionnaires and an injury-specific questionnaire focusing on knee pain and symptoms of venous insufficiency. A subgroup of patients were evaluated radiographically and by physical examination. RESULTS: The mean normalized SF-36 scores (physical composite score-PCS 48.9, mental composite score-MCS 51.8) and the mean normalized Short Musculoskeletal Functional Assessment scores (50.7) (bothersome index, functional index) were not statistically different (P > 0.05) from reference population norms. Of the questionnaire group (n = 56), only 15 (26.7%) denied knee pain with any activity whereas 41 patients (73.2%) had at least moderate knee pain. With respect to swelling, 19 (33.9%) reported asymmetrical swelling affecting the injured limb. However, of the 33 physically examined patients, only 6 (18.2%) had objective evidence of venous stasis. Knee range of motion was equivalent to the unaffected side in all but two patients (93.9%) whereas 14 (42.4%) had a restricted range of motion of the ankle. Nine patients (27.3%) had persistent quadriceps atrophy, and the same rate was observed for calf atrophy. Twenty-five patients (75.8%) had no tenderness to anterior knee palpation. Of the 31 radiographically examined patients, 11 patients (35.4%) showed evidence of arthritis despite the absence of radiographic malalignment. Five patients (16.1%) had at least mild osteoarthritis of at least one knee compartment, 5 (16.1%) had at least mild osteoarthritis of the tibio-talar joint, and 1 (3.2%) had osteoarthritis of both, despite the absence of malunion. Self-reported knee pain was not correlated with the presence of a tibial nail or radiographic nail prominence. Similarly, knee tenderness on examination was not correlated with these factors. CONCLUSIONS: At a median 14 years after tibial nailing of isolated tibial fractures, patients' function is comparable to population norms, but objective and subjective evaluation shows persistent sequelae which are not insignificant. This study is the first to describe the long-term functional outcomes after tibial shaft fractures treated with intramedullary nailing nails. It may allow surgeons to better inform patients on the expected long-term function after intramedullary nailing of a tibia fracture. It may also prove useful when comparing intramedullary nailing nailing to other treatment techniques.

Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures.

OBJECTIVE: To evaluate the functional outcomes and long-term effects on muscle strength of femoral shaft fractures treated with intramedullary (IM) antegrade nailing using a standard piriformis start point. DESIGN: Retrospective Outcome Study. SETTING: Tertiary Level Teaching Hospital and Referral Centre for the Province of British Columbia. PATIENTS/PARTICIPANTS: Twenty-one patients (7 female, 14 male; mean age 34.5 years, range 16-56 years) with isolated femoral shaft fractures who were treated with standard antegrade reamed interlocking IM nailing and who had a minimum 1-year follow-up were identified through the Orthopaedic Trauma Database. All patients had isokinetic muscle testing of their hip abductors, hip extensors, and knee extensors using the KinCom muscle testing machine. Of the patients, 10 underwent formal gait lab analysis. All of the patients answered a questionnaire and completed the Short Form (SF)-36 and Musculoskeletal Functional Assessment outcome measures. INTERVENTION: Antegrade reamed interlocking IM nailing of femoral shaft fractures using a standard trochanteric fossa (also referred to as piriformis fossa) starting point. MAIN OUTCOME MEASUREMENTS: Examination of muscle strength, using 2 different objective measures (KinCom and gait analysis). The KinCom muscle testing machine was used for isokinetic muscle testing of hip abductors, hip extensors, and knee extensors. Outcome questionnaires were used to evaluate function (Musculoskeletal Functional Assessment) and general health (SF-36). RESULTS: Isokinetic muscle testing showed a statistically significant lower peak torque generation by the hip abductors (P=0.003) and hip extensors (P=0.046) from the uninjured contralateral side. The gait lab analysis did not show important changes in gait pattern. Scores for the SF-36 were 51.77+/-7.55 and 53.73+/-8.70. Scores for the Short Musculoskeletal Functional Assessment (S-MFA) were 7.74 and 8.66. Both scores did not indicate any significant disability. CONCLUSIONS: Antegrade reamed interlocking IM nailing of femoral shaft fractures using a standard trochanteric fossa starting point is associated with a mild hip abductor muscle-strength deficit. Gait pattern returns to normal following femoral shaft fracture treated with this technique, and functional outcomes are good.

Oxidized low-density lipoprotein inhibits endothelium-dependent vasodilation by an antioxidant-sensitive, lysophosphatidylcholine-independent mechanism.

Previous studies have shown that oxidized low-density lipoprotein (LDL) can impair endothelial function and that this can be overcome in vivo by administration of vitamin E. However, it is unclear whether this effect of oxidized LDL is due to lysophosphatidylcholine or other components of oxidized LDL, and it is also uncertain if the protective effect of vitamin E is related to its antioxidant action. The objectives of the current study were to define how much of the effect of extensively oxidized LDL on endothelium-dependent relaxation (EDR) was in fact due to lysophosphatidylcholine, to determine if the effect of oxidized LDL involved oxidant stress to the endothelium, and, if so, to ascertain if this could be blocked by oxyradical scavengers or antioxidants. Endothelial function was assessed by measuring vasodilation in preconstricted rat mesenteric artery rings in response to acetylcholine. In the presence of 100 microg/mL oxidized LDL, 25-fold higher concentrations of acetylcholine were required for the same degree of vasorelaxation. Similar concentrations of native LDL or acetyl LDL had no effect, but 100 microg/mL phospholipase A(2)-treated LDL or 20 microM lysophosphatidylcholine produced a similar inhibition of EDR. Removal of more than 90% of lysophosphatidylcholine from oxidized LDL did not affect its ability to inhibit EDR, nor did treatment of oxidized LDL with borohydride. This effect of oxidized LDL was blocked by preincubation of arterial rings with vitamin E, probucol, or BO-653 (a potent lipophilic antioxidant), but not by superoxide dismutase. In contrast, the inhibition of EDR by lysophosphatidylcholine was unaffected by antioxidants. Calphostin C prevented the inhibition of EDR by oxidized LDL and lysophosphatidylcholine. These studies demonstrate that at least part of the effect of oxidized LDL on EDR is independent of lysophosphatidylcholine, lipid peroxides, and superoxide release but appears to involve intracellular oxidative stress and protein kinase C activation.