Republication of "Ankle Fracture-Dislocations: A Review".

Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.

Outcome of the Wagner Cone femoral component for difficult anatomical conditions during total hip arthroplasty.

PURPOSE: Total hip arthroplasty (THA) in patients with small or unusual proximal femoral anatomy is challenging due to sizing issues, control of version, and implant fixation. The Wagner Cone is a monoblock, fluted, tapered stem with successful outcomes for these patients; however, there is limited information on subsidence, a common finding with cementless stems. METHODS: We retrospectively reviewed our cases using the modified Wagner Cone (Zimmer, Warsaw, IN) implanted over a 13-year period (2006-2019) in patients with small or abnormal proximal femoral anatomy. We performed 144 primary THAs in 114 patients using this prosthesis. Mean follow-up was 4.5 ± 3.4 years (range, 1-13 years). Common reasons for implantation were hip dysplasia (52%) and osteoarthritis in patients with small femoral proportions (22%). Analysis of outcomes included assessment of stem subsidence and stability. RESULTS: Survival was 98.6% in aseptic cases; revision-free survival was 97.9%. Femoral subsidence occurred in 84 cases (58%). No subsidence progressed after 3 months. Of those that subsided, the mean distance was 2.8 ± 2.0 mm. There was less subsidence in stems that stabilized prior to six weeks (2.2 ± 1.4 mm) compared to those that continued until 12 weeks (3.9 ± 1.6, p = 0.02). Harris Hip, UCLA, and WOMAC scores significantly improved from pre-operative evaluation (p < 0.001*, p < 0.003*, p ≪ 0.001*); there was no difference in outcome between patients with and without subsidence (p = 0.430, p = 0.228, p = 0.147). CONCLUSION: The modified Wagner Cone demonstrates excellent clinical outcomes in patients with challenging proximal femoral anatomy. Subsidence is minor, stops by 3 months, and does not compromise clinical outcome.

Migration Patterns for Revision Total Knee Arthroplasty in the United States as Reported in the American Joint Replacement Registry.

BACKGROUND: Revision total knee arthroplasty (TKA) is associated with a higher complication rate and a greater cost when compared to primary TKA. Based on patient choice, referral, or patient transfers, revision TKAs are often performed in different institutions by different surgeons than the primary TKA. The aim of this study is to evaluate the effect of hospital size, teaching status, and revision indication on the migration patterns of failed primary TKA in patients 65 years of age and older. METHODS: All primary and revision TKAs reported to the American Joint Replacement Registry from January 2012 through March 2020 were included and merged with the Centers for Medicare and Medicaid Services database. Migration was defined as a patient having a primary TKA and revision TKA performed at separate institutions by different surgeons. RESULTS: In total, 9167 linked primary and revision TKAs were included in the analysis. Overall migration rates were significantly higher from small (<100 beds; P = .019), non-teaching institutions (P = .002) driven primarily by patients diagnosed with infection. Infection patients had significantly higher migration rates from small (46.8%, P < .001), non-teaching (43.5%, P < .001) institutions, while migration rates for other causes of revision were statistically similar. Most patients migrated to medium or large institutions (84.7%) for revision TKA rather than small institutions (15.3%, P < .001) and to teaching (78.3%) rather than non-teaching institutions (21.7%, P < .001). CONCLUSION: There is a diagnosis-dependent referral bias that affects the migration rates of infected primary TKA from small non-teaching institutions leading to a flow of more medically complex patients to medium and large teaching institutions for infected revision TKA.

Anterior Percutaneous-Assisted Total Hip Arthroplasty: Surgical Technique and Early Outcomes.

BACKGROUND: Percutaneous-assisted arthroplasty was introduced to minimize complications traditionally associated with minimally invasive techniques, such as component malposition and periprosthetic fracture. Proponents of percutaneous-assisted techniques have more than 15 years of clinical utilization with good outcomes. This study reports our early experience, and outcomes, with an anterior percutaneous-assisted total hip arthroplasty (AnteriorPath). METHODS: A retrospective evaluation of a single-surgeon experience with the first 46 patients undergoing AnteriorPath using a cannula for acetabular cup instrumentation was compared with a similar-sized cohort undergoing traditional direct anterior (DA) total hip arthroplasty. Patients needed at least 2 postoperative visits for inclusion. Baseline preoperative characteristics, operative time, component positioning, and 6-week all-cause complications were evaluated. P values <.05 were considered statistically significant. RESULTS: Longer operative times were experienced with the AnteriorPath vs DA THA (93.6 minutes ± 38.6 vs 79.6 minutes ± 23.2, respectively, P = .0503). There were no significant differences in component abduction (40.14° DA vs 41.95° AnteriorPath, P = .1058). A statistically significant difference was found in component anteversion (32.8° DA vs 27.25° AnteriorPath, P = .0039). There were higher rates of short-term complications in patients undergoing DA THA (9.09% DA vs 2.5% AnteriorPath). CONCLUSIONS: Early experience with an AnteriorPath demonstrates similar short-term outcomes compared with traditional DA THA. The use of a percutaneous technique has also allowed for a smaller incision, in-line acetabular cup reaming and impaction under direct visualization, and limited trauma to surrounding soft tissues. Further long-term studies with a larger sample size are needed to evaluate the potential benefits and complications of this novel technique.

Risk Adjustment in the California Joint Replacement Registry: Is Patient Complexity Accurately Assessed in Academic Versus Nonacademic Hospitals?

BACKGROUND: We sought to report on the differences in observed versus expected arthroplasty outcomes between academic and nonacademic hospitals in a large joint registry. We utilized the California Joint Replacement Registry's data and risk adjustment model. METHODS: Observed versus expected hip and knee arthroplasty complications were utilized to assess hospital and surgeon risk-adjusted complication rates (RACRs). Based on a hospital and surgeon RACR, each was assigned a performance rating ("worse," "expected," "better"). Associations between academic status and performance ratings, rates of individual complications, prevalence of risk factors associated with increased complication rates, and differences in complication rates were calculated. RESULTS: A higher percentage of academic providers had "worse" than expected ratings, whereas a higher percentage of nonacademic providers had "expected" and "better" than expected ratings (P = .011) based on the observed versus expected complication rates. There was a higher incidence of patients with congestive heart failure and an elevated American Society of Anesthesiologists classification in academic institutions (P = .0001). The complication rate was higher in academic institutions for all total knee arthroplasties (P < .0016). CONCLUSIONS: We identified disparities in RACRs between nonacademic and academic institutions. This may reflect the difficulty of fully adjusting for medical risk and surgical complexity in a large arthroplasty database.

Anatomy, Classification, and Management of Ankle Fractures Involving the Posterior Malleolar Fragment: A Literature Review.

The posterior malleolar fragment is frequently involved in rotational ankle fractures, but diagnosis and definitive management remains controversial. Ankle fractures with a posterior malleolar component that are not identified and treated in a timely manner may contribute significantly to future comorbidities, including continued pain, instability, and the development of arthritis. This article highlights the anatomic features of posterior malleolar ankle fractures, the classification schemes used, and discusses the various nonsurgical and surgical methods currently used. LEVEL OF EVIDENCE: Level V, expert opinion.

Citation analysis of the 100 most common articles regarding distal radius fractures.

PURPOSE: Bibliometric studies are increasingly being utilized as a tool for gauging the impact of different literature within a given field. The purpose of this study was to identify the most cited articles related to the management of distal radius fractures to better understand how the evidence of this topic has been shaped and changed over time. METHODS: We utilized the ISI web of science database to conduct a search for the term "distal radius fracture" under the "orthopaedics" research area heading, and sorted the results by number of times cited. The 100 most cited articles published in orthopedic journals were then analyzed for number of citations, source journal, year of publication, number of authors, study type, level of evidence, and clinical outcomes utilized. RESULTS: The 100 most cited articles identified were published between 1951 and 2009. Total number of citations ranged between 525 and 67, and came from ten different orthopedic journals. The largest number of articles came from J Hand Surg Am and J Bone Joint Surg Am, each with 32. Consistent with previous analyses of orthopedic literature, the articles were primarily clinical, and of these, 53/76 were case series. The vast majority were evidence level IV. Only a small percentage of articles utilized patient reported outcome measures. CONCLUSIONS: These data show that despite distal radius fractures being a common fracture encountered by physicians, very few of the articles were high quality studies, and only a low proportion of the studies include patient reported outcome measures. Surgeons should take this lack of high-level evidence into consideration when referencing classic papers in this field. CLINICAL RELEVANCE: Analysis of the 100 most cited distal radius fracture articles allows for delineation of which articles are most common in the field and if a higher level of evidence correlates positively with citation quantity.

Preoperative Patient-Recorded Outcome Measures Predict Patient Discharge Location Following Unicondylar Knee Arthroplasty.

BACKGROUND: Advantages of unicondylar knee arthroplasty (UKA) over total knee arthroplasty include rapid recovery and shorter lengths of stay following surgery. Patients requiring extended postoperative care fail to recognize these benefits. Patient-reported outcome measures have proved useful in predicting outcomes following joint arthroplasty. The purpose of this study was to identify and report preoperative patient-reported outcome measures and clinical variables that predict discharge to skilled nursing facilities following UKA. METHODS: A prospective cohort of 174 patients was used to collect 36-Item Short Form scores and objective clinical data. Univariate and multivariate analysis with backward elimination were conducted to find a predictive risk model. RESULTS: The predictive model reported (78.7% concordance, receiver operating characteristic curve c-statistic 0.719, P = .0016) demonstrates that risk factors for discharge to skilled nursing facilities are: older age (odds ratio 4.18; 95% confidence interval [CI] 1.256-13.911, P = .019), bilateral UKA procedures (odds ratio 1.887; 95% CI 1.054-3.378, P = .0326) and lower patient-reported preoperative 36-Item Short Form physical function scores (odds ratio 0.968; CI 0.938-1, P = .0488). CONCLUSION: The information presented here regarding possible patient disposition following UKA could aid informed decision-making regarding patients' short-term needs following surgery and help streamline preoperative planning.

Lumbar corpectomy for correction of degenerative scoliosis from osteoradionecrosis reveals a delayed complication of lumbar myxopapillary ependymoma.

Osteoradionecrosis is a known complication following radiation therapy, presenting most commonly in the cervical spine as a delayed consequence of radiation that is often necessary in the management of head and neck cancers. In contrast, osteoradionecrosis has rarely been described in the lumbar spine. Here we describe, to our knowledge, the first reported case of lumbar spine osteoradionecrosis, after adjuvant radiation for a primary spinal cord tumor, leading to progressive degenerative scoliosis which required subsequent operative management. Established guidelines recommend that mature bone can tolerate a dose of up to 6000 cGy without injury. However, once bone has been exposed to radiation over this level progressive soft tissue changes may lead to devascularization, leaving the bone vulnerable to osteonecrosis, specifically when manipulated. Radiation necrosis can be progressive and lead to eventual mechanical instability requiring debridement and surgical fixation. In the setting of the lumbar spine, osseous necrosis can lead to biomechanical instability, deformity, pain, and neurologic deficit.

Evaluation of Internet Information About Rotator Cuff Repair.

The content and quality of Internet websites are not governed or regulated. Therefore, patients who consult the Internet may receive outdated or incorrect medical information. Researchers have analyzed the quality of web information about various orthopedic surgeries, but no such analysis has been performed on websites covering rotator cuff repair. We conducted a study to evaluate and analyze rotator cuff repair information available to the general public through the Internet; to assess changes in the quality of information over time; to determine if sites sponsored by academic institutions offered higher-quality information; and to assess whether the readability of the material varied according to DISCERN scores. Two Internet searches were conducted, in 2011 and 2014. The 3 most commonly used search engines were used to search for rotator cuff repair. The first 50 websites from each search engine were evaluated for authorship and content. The DISCERN instrument was used to analyze the quality of each website's health information. The 2011 search revealed 21% of websites were associated with an academic institution, 38% were authored by a hospital or physician group, and 11.5% were industry-sponsored. The 2014 search revealed a similar distribution of contributors. The highest DISCERN scores were given to academic institution websites (51.6) and public education websites (49). There was no correlation between readability and DISCERN scores. Websites associated with academic institutions produced the highest-quality medical information. Over the past few years, authorship and content have changed little with respect to Internet information about rotator cuff repair.

Preparedness of neurosurgery graduates for neuroendovascular fellowship: a national survey of fellowship programs.

OBJECT: Endovascular interventions have become an essential part of a neurosurgeon's practice. Whether endovascular procedures have been effectively integrated into residency curricula, however, remains uncertain. The purpose of this study was to assess the preparedness of US neurosurgery graduate trainees for neuroendovascular fellowship. METHODS: A multidomain, global assessment survey was sent to all directors/faculty of neuroendovascular fellowship programs involved in training of US neurosurgery graduates. Surveyees were asked to assess trainees as they entered fellowship. RESULTS: The response rate was 78% (25/32). Of respondent program directors, 38% reported that new fellows did not know the history and imaging of the patient and 50% were unable to formulate an appropriate treatment plan. As many as 79% of fellows were unfamiliar with endovascular devices and 75% were unfamiliar with angiographic equipment. Furthermore, 58% of fellows were unable to perform femoral access, 54% were unable to perform femoral closure, 79% were unable to catheterize a major vessel, 86% were unable to perform a 4-vessel angiogram, and 100% were unable to catheterize an aneurysm. Additionally, program directors reported that over 50% of fellows could not recognize neurovascular anatomy and 54% could not recognize/classify vascular abnormalities. There was an overall agreement that fellows demonstrated professionalism and interest in research and had good communication/clinical skills. CONCLUSIONS: The results of this study suggest potential gaps in the training of neurosurgery residents with regard to endovascular neurosurgery. In an era of minimally invasive therapies, changes in residency curricula may be needed to keep pace with the ever-changing field of neurosurgery.

An evaluation system for experimental silicon and silicon carbide super gate turn off thyristors.

This paper describes the design and implementation of a small-scale pulsed power system specifically intended to evaluate the suitability of experimental silicon and silicon carbide high power Super Gate Turn Off thyristors for high action (500 A(2) s and above) pulsed power applications where energy is extracted from a storage element in a rapid and controlled manner. To this end, six of each type of device was placed in a controlled three phase rectifier circuit which was in turn connected to an aircraft ground power motor-generator set and subjected to testing protocols with varying power levels, while parameters such as offset firing angle were varied.

ESET histone methyltransferase regulates osteoblastic differentiation of mesenchymal stem cells during postnatal bone development.

To investigate the effects of histone methyltransferase ESET (also known as SETDB1) on bone metabolism, we analyzed osteoblasts and osteoclasts in ESET knockout animals, and performed osteogenesis assays using ESET-null mesenchymal stem cells. We found that ESET deletion severely impairs osteoblast differentiation but has no effect on osteoclastogenesis, that co-transfection of ESET represses Runx2-mediated luciferase reporter while siRNA knockdown of ESET activates the luciferase reporter in mesenchymal cells, and that ESET is required for postnatal expression of Indian hedgehog protein in the growth plate. As the bone phenotype in ESET-null mice is 100% penetrant, these results support ESET as a critical regulator of osteoblast differentiation during bone development.

Automated modular high energy evaluation system for experimental thyristor devices.

A high energy, modular, completely automated test bed with integrated data acquisition and characterization systems was successfully designed in order to perform both safe operating area as well as very high volume reliability testing on experimental silicon carbide Super Gate Turn Off (SGTO) thyristors. Although the system follows a modular design philosophy, with each functional block acting as a peripheral to a main control module and can be adapted to arbitrary power and pulse width levels, for the specific SGTO devices initially evaluated it was configured to have the device discharge variable current levels of up to 6 kA into a 0.5 Ω resistive load with a relatively square pulse fixed at 100 µs full width at half maximum delivering energy levels up to 1.8 kJ to the load.

Mesenchyme-specific knockout of ESET histone methyltransferase causes ectopic hypertrophy and terminal differentiation of articular chondrocytes.

The exact molecular mechanisms governing articular chondrocytes remain unknown in skeletal biology. In this study, we have found that ESET (an ERG-associated protein with a SET domain, also called SETDB1) histone methyltransferase is expressed in articular cartilage. To test whether ESET regulates articular chondrocytes, we carried out mesenchyme-specific deletion of the ESET gene in mice. ESET knock-out did not affect generation of articular chondrocytes during embryonic development. Two weeks after birth, there was minimal qualitative difference at the knee joints between wild-type and ESET knock-out animals. At 1 month, ectopic hypertrophy, proliferation, and apoptosis of articular chondrocytes were seen in the articular cartilage of ESET-null animals. At 3 months, additional signs of terminal differentiation such as increased alkaline phosphatase activity and an elevated level of matrix metalloproteinase (MMP)-13 were found in ESET-null cartilage. Staining for type II collagen and proteoglycan revealed that cartilage degeneration became progressively worse from 2 weeks to 12 months at the knee joints of ESET knock-out mutants. Analysis of over 14 pairs of age- and sex-matched wild-type and knock-out mice indicated that the articular chondrocyte phenotype in ESET-null mutants is 100% penetrant. Our results demonstrate that expression of ESET plays an essential role in the maintenance of articular cartilage by preventing articular chondrocytes from terminal differentiation and may have implications in joint diseases such as osteoarthritis.

ESET histone methyltransferase is essential to hypertrophic differentiation of growth plate chondrocytes and formation of epiphyseal plates.

The ESET (also called SETDB1) protein contains an N-terminal tudor domain that mediates protein-protein interactions and a C-terminal SET domain that catalyzes methylation of histone H3 at lysine 9. We report here that ESET protein is transiently upregulated in prehypertrophic chondrocytes in newborn mice. To investigate the in vivo effects of ESET on chondrocyte differentiation, we generated conditional knockout mice to specifically eliminate the catalytic SET domain of ESET protein only in mesenchymal cells. Such deletion of the ESET gene caused acceleration of chondrocyte hypertrophy in both embryos and young animals, depleting chondrocytes that are otherwise available to form epiphyseal plates for endochondral bone growth. ESET-deficient mice are thus characterized by defective long bone growth and trabecular bone formation. To understand the underlying mechanism for ESET regulation of chondrocytes, we carried out co-expression experiments and found that ESET associates with histone deacetylase 4 to bind and inhibit the activity of Runx2, a hypertrophy-promoting transcription factor. Repression of Runx2-mediated gene transactivation by ESET is dependent on its H3-K9 methyltransferase activity as well as its associated histone deacetylase activity. In addition, knockout of ESET is associated with repression of Indian hedgehog gene in pre- and early hypertrophic chondrocytes. Together, these results provide clear evidence that ESET controls hypertrophic differentiation of growth plate chondrocytes and endochondral ossification during embryogenesis and postnatal development.

Evaluation of information available on the Internet regarding anterior cruciate ligament reconstruction.

Searching the Internet is one of the most popular methods for acquiring information related to health. The Internet offers physicians and patients easy access to a wide range of medical material from anywhere in the world. For many patients, this information helps formulate decisions related to their health and health care. An important caveat is that virtually anything can be published on the Internet. Although academic publications require rigorous peer review, Internet websites have no regulatory body monitoring quality and content. With a lack of external regulation, the information retrieved may be incorrect or outdated. The Internet can be a valuable asset for educating patients, but because of significant variability physicians should be familiar with the quality of information available. This article discusses both the strengths and weaknesses of information available on the Internet regarding anterior cruciate ligament repair.

LICSS - a chemical spreadsheet in microsoft excel.

BACKGROUND: Representations of chemical datasets in spreadsheet format are important for ready data assimilation and manipulation. In addition to the normal spreadsheet facilities, chemical spreadsheets need to have visualisable chemical structures and data searchable by chemical as well as textual queries. Many such chemical spreadsheet tools are available, some operating in the familiar Microsoft Excel environment. However, within this group, the performance of Excel is often compromised, particularly in terms of the number of compounds which can usefully be stored on a sheet. SUMMARY: LICSS is a lightweight chemical spreadsheet within Microsoft Excel for Windows. LICSS stores structures solely as Smiles strings. Chemical operations are carried out by calling Java code modules which use the CDK, JChemPaint and OPSIN libraries to provide cheminformatics functionality. Compounds in sheets or charts may be visualised (individually or en masse), and sheets may be searched by substructure or similarity. All the molecular descriptors available in CDK may be calculated for compounds (in batch or on-the-fly), and various cheminformatic operations such as fingerprint calculation, Sammon mapping, clustering and R group table creation may be carried out.We detail here the features of LICSS and how they are implemented. We also explain the design criteria, particularly in terms of potential corporate use, which led to this particular implementation. CONCLUSIONS: LICSS is an Excel-based chemical spreadsheet with a difference:• It can usefully be used on sheets containing hundreds of thousands of compounds; it doesn't compromise the normal performance of Microsoft Excel• It is designed to be installed and run in environments in which users do not have admin privileges; installation involves merely file copying, and sharing of LICSS sheets invokes automatic installation• It is free and extensibleLICSS is open source software and we hope sufficient detail is provided here to enable developers to add their own features and share with the community.

Biceps tenotomy versus tenodesis: clinical outcomes.

PURPOSE: We present a systematic review of the current literature regarding the use of the 2 most common surgical treatments for lesions of the long head of the biceps brachii, tenotomy or tenodesis. Currently, there is no consensus management in the literature because most studies lack high levels of evidence. METHODS: PubMed was systematically reviewed for eligible articles relating to biceps tenotomy or tenodesis. Level I to IV evidence and English-language studies reporting on the clinical outcomes of these 2 procedures were included. The primary clinical outcome measurements for each study were determined and were normalized and reported as the percentage of "excellent/good" versus "poor" results based on criteria laid out in each study. RESULTS: Sixteen studies met the inclusion criteria. All articles reviewed were of Level IV evidence, except for one Level II prospective cohort study.(10) All studies, a total of 433 tenodesis procedures resulted in an excellent/good outcome in 74% of patients, with an 8% rate of cosmetic deformity. A total of 699 tenotomy procedures resulted in an excellent/good outcome in 77% of patients, with a 43% occurrence of cosmetic deformity. Postoperative bicipital pain was found in 43 of 226 cases (19%) of tenotomy and 18 of 74 cases (24%) of tenodesis. The 4 studies that compared the procedures directly did not show any significant clinical differences between the groups other than a cosmetic deformity being present more frequently after tenotomy. CONCLUSIONS: Tenotomy and tenodesis have comparably favorable results in the literature, with the only major difference being a higher incidence of cosmetic deformity with biceps tenotomy. However, there is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii. The lack of prospective, randomized trials limits our ability to recommend 1 technique over the other. There is a great need for controlled trials to investigate the differences between these 2 procedures. Individual patient factors and needs should guide the surgeon on which procedure to use. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.