Increased Ca2+ signaling through CaV 1.2 induces tendon hypertrophy with increased collagen fibrillogenesis and biomechanical properties.

Tendons are tension-bearing tissues transmitting force from muscle to bone for body movement. This mechanical loading is essential for tendon development, homeostasis, and healing after injury. While Ca2+ signaling has been studied extensively for its roles in mechanotransduction, regulating muscle, bone, and cartilage development and homeostasis, knowledge about Ca2+ signaling and the source of Ca2+ signals in tendon fibroblast biology are largely unknown. Here, we investigated the function of Ca2+ signaling through CaV 1.2 voltage-gated Ca2+ channel in tendon formation. Using a reporter mouse, we found that CaV 1.2 is highly expressed in tendon during development and downregulated in adult homeostasis. To assess its function, we generated ScxCre;CaV 1.2TS mice that express a gain-of-function mutant CaV 1.2 in tendon. We found that mutant tendons were hypertrophic, with more tendon fibroblasts but decreased cell density. TEM analyses demonstrated increased collagen fibrillogenesis in the hypertrophic tendons. Biomechanical testing revealed that the hypertrophic tendons display higher peak load and stiffness, with no changes in peak stress and elastic modulus. Proteomic analysis showed no significant difference in the abundance of type I and III collagens, but mutant tendons had about two-fold increase in other ECM proteins such as tenascin C, tenomodulin, periostin, type XIV and type VIII collagens, around 11-fold increase in the growth factor myostatin, and significant elevation of matrix remodeling proteins including Mmp14, Mmp2, and cathepsin K. Taken together, these data highlight roles for increased Ca2+ signaling through CaV 1.2 on regulating expression of myostatin growth factor and ECM proteins for tendon collagen fibrillogenesis during tendon formation.

Increased Ca 2+ signaling through Ca V 1.2 induces tendon hypertrophy with increased collagen fibrillogenesis and biomechanical properties.

Tendons are tension-bearing tissues transmitting force from muscle to bone for body movement. This mechanical loading is essential for tendon development, homeostasis, and healing after injury. While Ca 2+ signaling has been studied extensively for its roles in mechanotransduction, regulating muscle, bone and cartilage development and homeostasis, knowledge about Ca 2+ signaling and the source of Ca 2+ signals in tendon fibroblast biology are largely unknown. Here, we investigated the function of Ca 2+ signaling through Ca V 1.2 voltage-gated Ca 2+ channel in tendon formation. Using a reporter mouse, we found that Ca V 1.2 is highly expressed in tendon during development and downregulated in adult homeostasis. To assess its function, we generated ScxCre;Ca V 1.2 TS mice that express a gain-of-function mutant Ca V 1.2 channel (Ca V 1.2 TS ) in tendon. We found that tendons in the mutant mice were approximately 2/3 larger and had more tendon fibroblasts, but the cell density of the mutant mice decreased by around 22%. TEM analyses demonstrated increased collagen fibrillogenesis in the hypertrophic tendon. Biomechanical testing revealed that the hypertrophic Achilles tendons display higher peak load and stiffness, with no changes in peak stress and elastic modulus. Proteomics analysis reveals no significant difference in the abundance of major extracellular matrix (ECM) type I and III collagens, but mutant mice had about 2-fold increase in other ECM proteins such as tenascin C, tenomodulin, periostin, type XIV and type VIII collagens, around 11-fold increase in the growth factor of TGF-ß family myostatin, and significant elevation of matrix remodeling proteins including Mmp14, Mmp2 and cathepsin K. Taken together, these data highlight roles for increased Ca 2+ signaling through Ca V 1.2 on regulating expression of myostatin growth factor and ECM proteins for tendon collagen fibrillogenesis during tendon formation.

Technique and Early Outcomes for High-Energy Calcaneus Fractures Treated With Staged External Fixation to Combined Open Reduction Internal Fixation and Subtalar Arthrodesis.

OBJECTIVE: (1) To present an effective surgical technique for the treatment of open and high-energy calcaneal fractures with significant soft tissue injuries. (2) To present complications with this technique and to evaluate patient-reported outcomes of staged external fixation followed by delayed reconstruction with open reduction internal fixation (ORIF) and subtalar arthrodesis. DESIGN: Retrospective case series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twelve patients with 13 calcaneus fractures associated with open traumatic wounds (10 patients) or other severe soft tissue injury (ie, fracture blisters) between April 2013 and December 2019. INTERVENTION: All patients were treated with staged ankle-spanning external fixation and delayed reconstruction with ORIF with subtalar arthrodesis. MAIN OUTCOME MEASURES: Patient-Reported Outcomes Measurement Information System (PROMIS) outcomes are presented via the domains of physical function (PF), pain interference (PI), and depression (D) in addition to visual analog score. Complications with the injury and surgical procedure were reported as well. RESULTS: Patients underwent initial stabilization on average 1.3 days (range, 0-12 days) from injury with stage II occurring on average 31.1 days (range, 18-42 days) from external fixation. Mean time to radiographic union was 5.6 months (range, 4-10 months). One-year mean PROMIS outcomes were as follows: PF final average of 37.4 with an average improvement of 12.2 (P < 0.01), PI final average of 62.2 with average improvement of 5.6 (P = 0.01), and D final average of 52.1 with average improvement of 6 (P = 0.12). Mean final visual analog score pain score was 3.6 with an average improvement of 2.25 (P = 0.01). CONCLUSION: Staged treatment with initial external fixation followed by ORIF and subtalar arthrodesis in the setting of highly comminuted calcaneus fractures with significant soft tissue compromise effectively addresses both bony and soft tissue concerns while providing for positive outcomes postoperatively with regards to pain and function. There were minimal complications noted for this complex injury. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Tibial torsion correlates with talar morphology.

BACKGROUND: There is limited literature on axial rotation of the ankle or variations in anatomy of the talus. We aim to evaluate the rotational profile of the distal tibia and its relationship to talus morphology, radiographic foot-type, and tibiotalar tilt in arthritic ankles. METHODS: Preoperative imaging was reviewed in 173 consecutive patients with ankle arthritis. CT measurements were used to calculate tibial torsion and the talar neck-body angle (TNBA). Tibiotalar tilt and foot-type were measured on weightbearing plain radiographs. RESULTS: Measurements indicated mean external tibial torsion of 29.2±9.1˚ and TNBA of 35.2±7.5˚ medial. Tibiotalar tilt ranged from 48˚ varus to 23.5˚ valgus. A moderate association between increasing external tibial torsion and decreasing TNBA was found (ρ=-0.576, p<.0001). Weak relationships were found between external tibial torsion and varus tibiotalar tilt (ρ=-0.239, p=.014) and plantarflexion of the talo-first metatarsal angle (ρ=-0.218, p<.025). CONCLUSION: We observed a statistically significant correlation between tibial torsion and morphology of the talus, tibiotalar tilt, and first ray plantarflexion. This previously unreported association may provide information regarding the development of foot and ankle deformity and pathology. LEVEL OF EVIDENCE: Level III.

Proximal Femoral Shortening and Varus Collapse After Fixation of "Stable" Pertrochanteric Femur Fractures.

OBJECTIVES: To evaluate and compare femoral neck shortening and varus collapse in stable pertrochanteric femur fractures treated with sliding hip screws (SHSs) or cephalomedullary nails (CMNs). DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: A total of 290 patients were included in the study. The average age was 82 years, and most were women. All sustained low-energy pertrochanteric femur fractures (OTA/AO A1.1, 1.2, 1.3, 2.2) treated operatively with SHSs or CMNs. Minimum radiographic follow-up was 3 months, with an average of 28 (range 3-162) months. INTERVENTION: CMN or SHS fixation. MAIN OUTCOME MEASURES: Varus collapse of the femoral neck-shaft angle and proximal femoral shortening. RESULTS: Both implants allowed some varus collapse. Univariate analysis demonstrated a significantly greater portion of patients with SHSs progressed to varus collapse >5 degrees (P = 0.02), mild horizontal shortening >5 mm (P < 0.01), and severe horizontal shortening >10 mm (P < 0.01). There was no statistical difference in vertical shortening (P = 0.3). There was no difference in implant failure (P = 0.5), with failure rates of 3% for cephalomedullary implants and 5% for SHS constructs. CONCLUSIONS: The SHS group experienced greater varus collapse and horizontal shortening. There was no difference in overall implant failure. These findings suggest that the CMN is a superior construct for maintenance of reduction in stable pertrochanteric fractures, which may lead to improved functional outcomes as patients recover. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Peritalar Kinematics With Combined Deltoid-Spring Ligament Reconstruction in Simulated Advanced Adult Acquired Flatfoot Deformity.

BACKGROUND: Adult acquired flatfoot deformity (AAFD) is a complex and progressive deformity involving the ligamentous structures of the medial peritalar joints. Recent anatomic studies demonstrated that the spring and deltoid ligaments form a greater medial ligament complex, the tibiocalcaneonavicular ligament (TCNL), which provides medial stability to the talonavicular, subtalar, and tibiotalar joints. The aim of this study was to assess the biomechanical effect of a spring ligament tear on the peritalar stability. The secondary aim was to assess the effect of TCNL reconstruction in restoration of peritalar stability in comparison with other medial stabilization procedures, anatomic spring or deltoid ligament reconstructions, in a cadaveric flatfoot model. METHODS: Ten fresh-frozen cadaveric foot specimens were used. Reflective markers were mounted on the tibia, talus, navicular, calcaneus, and first metatarsal. Peritalar joint kinematics were captured by a multiple-camera motion capture system. Mild, moderate, and severe flatfoot models were created by sequential sectioning of medial capsuloligament complex followed by cyclic axial loading. Spring only, deltoid only, and combined deltoid-spring ligament (TCNL) reconstructions were performed. The relative kinematic changes were compared using 2-way analysis of variance (ANOVA). RESULTS: Compared with the initial condition, we noted significantly increased valgus alignment of the subtalar joint of 5.1 ± 2.3 degrees (P = .031) and 5.8 ± 2.7 degrees (P < .01) with increased size of the spring ligament tear to create moderate to severe flatfoot, respectively. We noted an increased tibiotalar valgus angle of 5.1 ± 2.0 degrees (P = .03) in the severe model. Although all medial ligament reconstruction methods were able to correct forefoot abduction, the TCNL reconstruction was able to correct both the subtalar and tibiotalar valgus deformity (P = .04 and P = .02, respectively). CONCLUSION: The TCNL complex provided stability to the talonavicular, subtalar, and tibiotalar joints. The combined deltoid-spring ligament (TCNL) reconstructions restored peritalar kinematics better than isolated spring or deltoid ligament reconstruction in the severe AAFD model. CLINICAL RELEVANCE: The combined deltoid-spring ligament (TCNL) reconstruction maybe considered in advanced AAFD with medial peritalar instability: stage IIB with a large spring ligament tear or stage IV.

Impact of Knee Scooter Flexion Position on Venous Flow Rate.

BACKGROUND:: The knee scooter is a commonly used mobility device in the setting of unilateral below-knee immobilization. The bent-knee posture has been shown to decrease venous flow in a seated position, but the knee scooter differs as the patient is weightbearing through the affected extremity. Our goal was to investigate the effects of knee scooter positioning on popliteal venous flow. METHODS:: Duplex ultrasonography was performed to obtain venous diameter and flow velocity of the popliteal vein on healthy subjects over the age of 18 without immobilization. Measurements were performed on the left knee of each subject while standing and with the same knee flexed on the knee scooter, by 2 physicians trained in ultrasound techniques. Mean velocity, peak velocity, vessel diameter, and volumetric flow rate were calculated and t tests were performed for each variable. A power analysis was performed, determining that 9 subjects would provide 80% power with an alpha of 0.05. A total of 13 subjects participated in the study. Mean age was 33 (range 20-56) years, with 6 females and 7 males. RESULTS:: Measurements of subjects while standing and on the knee scooter demonstrated a significant decrease in mean velocity (6.5 vs 3.2 cm/s, P < .01) and volumetric flow rate (227.8 vs 106.2 mL/min, P < .01) while subjects were using the scooter. Vessel diameter (0.82 vs 0.78 cm, P = .15) and peak velocities (19.8 vs 14.7 cm/s, P = .19) were not significantly different between standing and kneeling positions. CONCLUSION:: Our findings demonstrated a statistically significant decrease in volumetric flow rate in subjects using a knee scooter device with a flexed knee. Although venous stasis is a known risk factor for DVT, flow rate thresholds for increased thrombus formation are not well defined. The duration of scooter use, or flexed knee positioning, may have some effect on the degree of stasis. This finding should caution orthopedists to consider the risk attributed to the knee scooter as part of their overall patient assessment. LEVEL OF EVIDENCE:: Level II, therapeutic, comparative study.

Risk factors for reoperation, readmission, and early complications after below knee amputation.

BACKGROUND: Many patients undergoing below knee amputations (BKA) return for subsequent unplanned operations, hospital readmission, or postoperative complications. This unplanned medical management negatively impacts both patient outcomes and our healthcare system. This study primarily investigates the risk factors for unplanned reoperation following BKA. METHODS: Below knee amputations from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from the years 2012-2014 were identified by CPT code 27880 for amputation through the tibia and fibula. Our query identified 4631 BKA cases, including 30 day complications. Multivariate logistic regression modeling was performed on several patient demographic and disease factors to assess for independent predictors of unplanned reoperation. Secondary outcomes of unplanned and related readmissions (related to the procedure), major complications, minor complications, and mortality were also included in the analysis. RESULTS: Of 4631 BKAs identified, 9.63% (446/4631) underwent unplanned reoperations and 8.75% (405/4631) had unplanned and related readmissions. Major complications were experienced by 12.8% (593/4631) and minor complications by 8.7% (401/4631). Thirty day mortality rate was 5.14% (238/4631). The most common procedures for unplanned operations were thigh amputations (128/446, 28.7%), debridement/secondary closure (114/446, 25.6%), and revision leg amputations (46/446, 10.32%). Factors associated with an increased risk of unplanned reoperation included patients transferred from another facility (Adjusted Odds Ratio [AOR] = 1.28; p = .04), recent smokers (AOR = 1.34; p = .02), bleeding disorder (AOR = 1.30; p = .02), and preoperative ventilator use (AOR = 2.38; p = .01). CONCLUSION: Patients that were ongoing/recent smokers, had diagnosed bleeding disorders, required preoperative ventilator use, or were transferred in from another facility were associated with the highest risks of reoperation following BKA. This patient population experiences high rates of reoperation, readmission, complication, and mortality.

Risk Factors Associated With Cephalomedullary Nail Cutout in the Treatment of Trochanteric Hip Fractures.

OBJECTIVES: To evaluate the association of cephalomedullary nail cutout in trochanteric femur fractures with the presence of the following radiographic variables: lateral wall fracture, posteromedial fragment, angular malreduction, residual basicervical fracture gapping, screw placement, and tip-apex distance. DESIGN: Retrospective review. SETTING: Academic medical center. PATIENTS: A total of 362 patients were included in the study. The average age was 83 years and the majority was female. All sustained low-energy trochanteric femur fractures treated operatively with cephalomedullary nails. Minimum radiographic follow-up was 3 months, with an average of 11 (range 3-88) months. INTERVENTION: Cephalomedullary nailing with either a lag screw or helical blade. MAIN OUTCOME MEASURES: Cutout of the lag screw or helical blade. RESULTS: A total of 22 (6%) cutouts occurred. Univariate analysis showed significantly (P ≤ 0.01) more frequent cutout with fracture of the lateral wall, posteromedial fragment, residual gapping (>3 mm) at basicervical component, neck-shaft malreduction >5 degrees varus or 15 degrees valgus, and tip-apex distance >25 mm, and superior screw/blade positioning. There was no difference with unstable fracture pattern (P = 0.58) or fellowship training (P = 0.21). Multivariate regression analysis demonstrates that lateral wall fracture (Odds ratios [OR] = 8.0, 95% confidence interval [CI], 2.4-27.1), neck-shaft malreduction (OR = 4.3, CI, 1.3-14.7), and residual basicervical gapping (OR = 3.6, CI, 1.0-13.0) were associated with fixation cutout. CONCLUSIONS: Risk factors for cutout of trochanteric fractures in our study can be viewed as modifiable or nonmodifiable factors. Statistically significant factors included lateral wall fracture (nonmodifiable) as well as basicervical gapping and malreduction (modifiable). LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Topical rosiglitazone is an effective anti-scarring agent in the cornea.

Corneal scarring remains a major cause of blindness world-wide, with limited treatment options, all of which have side-effects. Here, we tested the hypothesis that topical application of Rosiglitazone, a Thiazolidinedione and ligand of peroxisome proliferator activated receptor gamma (PPARγ), can effectively block scar formation in a cat model of corneal damage. Adult cats underwent bilateral epithelial debridement followed by excimer laser ablation of the central corneal stroma to a depth of ~160 µm as a means of experimentally inducing a reproducible wound. Eyes were then left untreated, or received 50 µl of either 10 µM Rosiglitazone in DMSO/Celluvisc, DMSO/Celluvisc vehicle or Celluvisc vehicle twice daily for 2 weeks. Cellular aspects of corneal wound healing were evaluated with in vivo confocal imaging and post-mortem immunohistochemistry for alpha smooth muscle actin (αSMA). Impacts of the wound and treatments on optical quality were assessed using wavefront sensing and optical coherence tomography at 2, 4, 8 and 12 weeks post-operatively. In parallel, cat corneal fibroblasts were cultured to assess the effects of Rosiglitazone on TGFß-induced αSMA expression. Topical application of Rosiglitazone to cat eyes after injury decreased αSMA expression and haze, as well as the induction of lower-order and residual, higher-order wavefront aberrations compared to vehicle-treated eyes. Rosiglitazone also inhibited TGFß-induced αSMA expression in cultured corneal fibroblasts. In conclusion, Rosiglitazone effectively controlled corneal fibrosis in vivo and in vitro, while restoring corneal thickness and optics. Its topical application may represent an effective, new avenue for the prevention of corneal scarring with distinct advantages for pathologically thin corneas.