Arthrodesis of the first metatarsophalangeal joint-A biomechanical comparison of four fixation techniques.

BACKGROUND: Arthrodesis of the first metatarsophalangeal joint is a commonly performed orthopaedic procedure. The optimum method of fixation and joint surface preparation has yet to be determined. METHODS: This study compared four fixation techniques: Biomechanical grade sawbones were used. The dorsal plate used was a titanium, anatomically contoured locked plate. Testing was performed using an Instron machine applying force from the plantar aspect of the fused joint. Each fused sample was tested to failure. Stiffness, as calculated from the force-displacement curve, and ultimate load tolerated were recorded for each sample. The method of failure of each sample was also documented. RESULTS: Constructs arthrodesed using dorsal plate with separate screw groups, regardless of method of joint preparation, were the stiffest (p<0.001). The weakest construct was dorsal plate alone without interfragmenary screw. There was no difference in stiffness between planar and cup-cone joint preparation (p=0.99). Maximum load tolerated was similar when comparing Crossed Screws with dorsal plate with screw with either cup-cone or planar reaming (p=0.93, p=0.89 respectively). Dorsal plating alone tolerated a significantly lower maximum load than Plate with Screw Groups or Crossed Screws (p<0.001). CONCLUSION: This study confirms that an IFS combined with a dorsally positioned locked-plate is the ideal construct, with the joint preparation technique of little consequence.

Biofabrication of soft tissue templates for engineering the bone-ligament interface.

Regenerating damaged tissue interfaces remains a significant clinical challenge, requiring recapitulation of the structure, composition, and function of the native enthesis. In the ligament-to-bone interface, this region transitions from ligament to fibrocartilage, to calcified cartilage and then to bone. This gradation in tissue types facilitates the transfer of load between soft and hard structures while minimizing stress concentrations at the interface. Previous attempts to engineer the ligament-bone interface have utilized various scaffold materials with an array of various cell types and/or biological cues. The primary goal of this study was to engineer a multiphased construct mimicking the ligament-bone interface by driving differentiation of a single population of mesenchymal stem cells (MSCs), seeded within blended fibrin-alginate hydrogels, down an endochondral, fibrocartilaginous, or ligamentous pathway through spatial presentation of growth factors along the length of the construct within a custom-developed, dual-chamber culture system. MSCs within these engineered constructs demonstrated spatially distinct regions of differentiation, adopting either a cartilaginous or ligamentous phenotype depending on their local environment. Furthermore, there was also evidence of spatially defined progression toward an endochondral phenotype when chondrogenically primed MSCs within this construct were additionally exposed to hypertrophic cues. The study demonstrates the feasibility of engineering spatially complex soft tissues within a single MSC laden hydrogel through the defined presentation of biochemical cues. This novel approach represents a new strategy for engineering the ligament-bone interface. Biotechnol. Bioeng. 2017;114: 2400-2411. © 2017 Wiley Periodicals, Inc.

Intramedullary nails for extracapsular hip fractures in adults.

BACKGROUND: Intramedullary nails may be used for the surgical fixation of extracapsular hip fractures in adults. This is an update of a Cochrane review first published in 2005 and last updated in 2008. OBJECTIVES: To assess the effects (benefits and harms) of different designs of intramedullary nails for treating extracapsular hip fractures in adults. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (6 January 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 12, 2013), MEDLINE (1966 to November Week 3, 2013), MEDLINE In-Process & Other Non-Indexed Citations (3 January 2014), EMBASE (1988 to 2014, Week 1) and the World Health Organization (WHO) International Clinical Trials Registry Platform (accessed January 2014). SELECTION CRITERIA: All randomised or quasi-randomised trials comparing different types, or design modifications, of intramedullary nails in the treatment of extracapsular hip fractures in adults. DATA COLLECTION AND ANALYSIS: At least two review authors independently selected studies, assessed risk of bias and extracted data. We performed limited meta-analysis using the fixed-effect model. MAIN RESULTS: We included eight new trials, testing seven new comparisons in this update. Overall, we included 17 trials, testing 12 comparisons of different cephalocondylic nail designs. The trials involved a total of 2130 adults (predominantly female and older people) with mainly unstable trochanteric fractures.All trials were at unclear risk of bias for most domains, with the majority at high risk of detection bias for subjective outcomes. The three quasi-randomised trials were at high risk for selection bias.Four trials (910 participants) compared the proximal femoral nail (PFN) with the Gamma nail. There was no significant difference between the two implants in functional outcome (the very low quality evidence being limited to results from single trials), mortality (low quality evidence: 86/415 versus 80/415; risk ratio (RR) 1.08, 95% confidence interval (CI) 0.82 to 1.41), serious fixation complications (operative fracture of the femur, cut-out, non-union and later fracture of the femur) nor re-operations (low quality evidence: 45/455 versus 36/455; RR 1.25, 95% CI 0.83 to 1.90).Two trials (185 participants) provided very low quality evidence of a lack of clinically significant difference in outcome (functional score, mortality, fracture fixation complications and re-operation) between the ACE trochanteric nail and the Gamma nail.Two trials (200 participants) provided very low quality evidence of a lack of significant difference in outcome (mobility score, pain, fracture fixation complications or re-operations) between the proximal femoral nail antirotation (PFNA) nail and the Gamma 3 nail.Seven of the nine trials evaluating different comparisons provided very low quality evidence of a lack of significant between-group differences in all of the reported main outcomes for the following comparisons: ACE trochanteric nail versus Gamma 3 nail (112 participants); gliding nail versus Gamma nail (80 participants); Russell-Taylor Recon nail versus long Gamma nail (34 participants, all under 50 years); proximal femoral nail antirotation (PFNA) nail versus Targon PF nail (80 participants); dynamically versus statically locked intramedullary hip screw (IMHS) nail (81 participants); sliding versus non-sliding Gamma 3 nail (80 participants, all under 60 years); and long versus standard PFNA nails (40 participants with reverse oblique fractures).The other two single comparison trials also provided very low quality evidence of a lack of significant between-group differences in all of the main outcomes with single exceptions. The trial (215 participants) comparing the ENDOVIS nail versus the IMHS nail found low quality evidence of poorer mobility in the ENDOVIS nail group, where more participants in this group were bedridden after their operation (29/105 versus 18/110; RR 1.69, 95% CI 1.00 to 2.85; P = 0.05). The trial (113 participants) comparing the InterTan nail versus the PFNA II nail found very low quality evidence that more PFNA II group participants experienced thigh pain (3/47 versus 12/46; RR: 0.24, 95% CI 0.07 to 0.81). AUTHORS' CONCLUSIONS: The limited evidence from the randomised trials undertaken to date is insufficient to determine whether there are important differences in outcome between different designs of intramedullary nails used in treating extracapsular hip fractures. Given the evidence of superiority of the sliding hip screw compared with intramedullary nails for extracapsular hip fractures, further studies comparing different designs of intramedullary nails are not a priority. Any new design should be evaluated in a randomised comparison with the sliding hip screw.

Aggressive plasmablastic lymphoma of the thoracic spine presenting as acute spinal cord compression in a case of asymptomatic undiagnosed human immunodeficiency virus infection.

BACKGROUND CONTEXT: Plasmablastic lymphoma (PBL) is a rare aggressive variant of diffuse large B-cell lymphoma. PURPOSE: We describe a rare case of an aggressive PBL presenting as acute spinal cord compression requiring thoracic decompression and fusion, in a case of previously undiagnosed human immunodeficiency virus (HIV) infection. STUDY DESIGN: A case report. PATIENT SAMPLE: A patient with PBL of the thoracic spine. OUTCOME MEASURES: Preoperative magnetic resonance imaging, pathologic findings from the operative specimen, and serum HIV testing confirmed the diagnosis. METHODS: We present the case of a 33-year-old Caucasian woman with a 10-day history of thoracic back pain and a 1-day history of sudden-onset bilateral lower limb weakness and paresthesia from below the level of the umbilicus (American Spinal Injury Association [ASIA] Grade C). Magnetic resonance imaging demonstrated an extradural mass extending from T3 to T6 within the left posterior canal, resulting in significant cord compression. A complete debulking of the tumor mass and an instrumented posterior thoracic fusion was performed. RESULTS: Histopathologic examination of the specimen revealed tumor cells of PBL, and subsequent HIV testing was positive. She was treated with intravenous and intrathecal chemotherapy to prevent recurrence. Her lower limb neurologic status improved to ASIA Grade D over the subsequent 2 weeks. CONCLUSIONS: We report the case of an aggressive PBL presenting as acute spinal cord compression requiring urgent surgical intervention, on a background of undiagnosed HIV infection.

Cannabis and hyperemesis.

The adverse effects of marijuana are well documented, as well as its positive therapeutic uses. Cannabis has traditionally been associated with an antiemetic action following acute ingestion and synthetic cannabinoids have an established use as antiemetics for chemotherapy induced nausea. However, there has been limited recognition of chronic cannabis use as a cause of cyclic vomiting syndrome. Cannabinoid hyperemesis was first identified by Allen er al in 2004. Compulsive bathing was also described as part of the clinical picture. This same syndrome has been confirmed a number of times in the medical literature in the interim. The condition has, to our knowledge, never been reported, in a psychiatric patient.

Noways tired: perspectives of clinicians of color on culturally competent crisis intervention.

The authors demonstrate through case material the clinical benefits of utilizing a culturally competent approach to crisis intervention. The focus here is on intervention with racial/ethnic minorities, in particular Black Americans, Latino Americans and Asian Americans; but the authors also address the importance of culturally competent crisis intervention praxis for all clients.