Treatment and Outcomes of Missed Perilunate Dislocations: A Case Series.

Background Perilunate dislocations are devastating injuries that occur relatively rarely, accounting for only 7% of injuries to the carpus. Unfortunately, approximately 25% of these injuries are missed on initial evaluation. Acutely diagnosed perilunate dislocations may be successfully treated with ligament and osseous repair, depending on the injury pattern. Chronic dislocations, however, are primarily treated with salvage procedures. This case series was performed to investigate the outcomes of patients who sustained a perilunate dislocation that was diagnosed in a delayed fashion and look for any treatment patterns that could be more widely applied to future patients. Methods Patients presenting to a single institution between 2016 and 2018 with a perilunate injury that either presented in a delayed fashion or was missed on initial assessment were identified and their characteristics were evaluated. The surgical management of these patients was assessed as was their postoperative course at their 2-week, 6-week, 3-month, and 6-month clinic follow-up visits. Results Eight patients were identified with perilunate dislocations that were diagnosed in a delayed fashion. On average, these dislocations were diagnosed 133 days following the date of injury. All patients were males and 7/8 of them were between 17 and 20 years of age at the time of their injury (mean age: 25.5). They were treated with either primary repair, wrist fusion, proximal row carpectomy, or scaphoid excision and four-corner fusion (SEFCF). Both pain and range of motion improved following surgical management of these injuries. Conclusion Perilunate dislocations are rare injuries that are notorious for being diagnosed late, at which point primary repair is oftentimes no longer feasible. Salvage procedures are able to improve the range of motion and pain of patients who are found to have chronic dislocations. Our case series highlights the importance of treating each missed perilunate injury individually and avoiding a "one-size-fits-all" approach.

Evaluation of a 30-day-mortality risk calculator for patients undergoing surgical fixation of fragility hip fractures.

INTRODUCTION: Hip fractures often occur in medically complex patients and can be associated with high perioperative mortality. Mortality risk assessment tools that are specific to hip fracture patients have not been extensively studied. The objective of this study is to evaluate a recently published 30-day mortality risk calculator (Hip Fracture Estimator of Mortality Amsterdam [HEMA]) in a group of patients treated at a university health system. MATERIALS & METHODS: 625 patients treated surgically for hip fractures between 2015 and 2020 at our institution were retrospectively reviewed. Patients younger than age 65, periprosthetic fractures, revision procedures, and fractures treated non-operatively were excluded. Univariate and multivariate analyses were used to determine significant relationships between variables and 30-day mortality after surgery. Additional patient-specific risk factors not included in the original risk calculator were also evaluated. RESULTS: The observed 30-day mortality was 5.6%. HEMA score was significantly associated with 30-mortality, though our cohort had significantly lower mortality rates in high-risk patients than expected based on the HEMA tool. In analyzing patient characteristics not included in HEMA score, history of dementia and elevated troponin were significantly associated with 30-day mortality. DISCUSSION: The HEMA score reliably stratifies risk for 30-day mortality after hip fracture, though overestimates mortality in high-risk patients treated at a tertiary care center with a multidisciplinary team. The HEMA score may be enhanced by considering additional variables, including troponin level and history of dementia. LEVEL OF EVIDENCE: IV.

Effect of epidural spinal cord stimulation after chronic spinal cord injury on volitional movement and cardiovascular function: study protocol for the phase II open label controlled E-STAND trial.

INTRODUCTION: Spinal cord injury (SCI) leads to significant changes in morbidity, mortality and quality of life (QOL). Currently, there are no effective therapies to restore function after chronic SCI. Preliminary studies have indicated that epidural spinal cord stimulation (eSCS) is a promising therapy to improve motor control and autonomic function for patients with chronic SCI. The aim of this study is to assess the effects of tonic eSCS after chronic SCI on quantitative outcomes of volitional movement and cardiovascular function. Our secondary objective is to optimise spinal cord stimulation parameters for volitional movement. METHODS AND ANALYSIS: The Epidural Stimulation After Neurologic Damage (ESTAND) trial is a phase II single-site self-controlled trial of epidural stimulation with the goal of restoring volitional movement and autonomic function after motor complete SCI. Participants undergo epidural stimulator implantation and are followed up over 15 months while completing at-home, mobile application-based movement testing. The primary outcome measure integrates quantity of volitional movement and similarity to normal controls using the volitional response index (VRI) and the modified Brain Motor Control Assessment. The mobile application is a custom-designed platform to support participant response and a kinematic task to optimise the settings for each participant. The application optimises stimulation settings by evaluating the parameter space using movement data collected from the tablet application and accelerometers. A subgroup of participants with cardiovascular dysautonomia are included for optimisation of blood pressure stabilisation. Indirect effects of stimulation on cardiovascular function, pain, sexual function, bowel/bladder, QOL and psychiatric measures are analysed to assess generalisability of this targeted intervention. ETHICS AND DISSEMINATION: This study has been approved after full review by the Minneapolis Medical Research Foundation Institutional Review Board and by the Minneapolis VA Health Care System. This project has received Food and Drug Administration investigational device exemption approval. Trial results will be disseminated through peer-reviewed publications, conference presentations and seminars. TRIAL REGISTRATION NUMBER: NCT03026816.

Association of Knee Pain and Crouch Gait in Individuals With Cerebral Palsy.

BACKGROUND: Crouch gait (ie, excessive knee flexion) is commonly seen in patients with cerebral palsy (CP) and has been inconsistently linked with knee pain. The definitive cause of knee pain is unknown, but may result from increased joint forces due to crouch gait kinematics. Our purpose was to determine whether knee pain is positively associated with knee flexion in gait among a large sample of ambulatory individuals with CP. We hypothesized that knee pain prevalence would increase as knee flexion increased. METHODS: In this retrospective study, pain questionnaire and 3-dimensional gait analysis data from 2015 to 2018 were extracted from the medical records of individuals with CP who had a clinical gait analysis. The pain questionnaire asked caregivers/patients to indicate the location of pain and when it occurs. A multivariate logistic regression was performed with minimum knee flexion in stance, patella alta, age, and sex as predictors of knee pain. RESULTS: Among the 729 participants included in the analysis, 147 reported knee pain (20.1%). The odds of knee pain were not associated with minimum knee flexion in stance or sex. However, the odds of knee pain increased 73.2% when patella alta was present (P=0.008) and tended to increase 2.2% as age increased (P=0.059). CONCLUSIONS: The data suggest that there is not a meaningful association between crouch gait and knee pain. Having patella alta was associated with pain. Further studies that use validated pain questionnaires are needed to understand the multifactorial etiology of knee pain within ambulatory individuals with CP. LEVEL OF EVIDENCE: Level III-case-control study.

Knee pain and crouch gait in individuals with cerebral palsy: what impact does crouch-related surgery have?

AIM: To investigate the effect of crouch-related surgery on knee pain in individuals with cerebral palsy. METHOD: We retrospectively identified individuals with two three-dimensional gait analyses at baseline and follow-up visits. All individuals walked in crouch gait at baseline. Visits were 9 months to 42 months apart. Baseline knee pain, age, crouch-related surgery (yes/no), and minimum knee flexion at follow-up were entered into a logistic regression to predict follow-up knee pain. RESULTS: Thirty-two individuals (21 males, 11 females; mean [SD] age 12y 10mo [2y 5mo]; 8y 1mo-18y 7mo) received crouch-related surgery, while 19 were managed non-surgically. At baseline, knee pain prevalence was 38% in the surgical group and 21% in the non-surgical group. At follow-up, 34% of the surgical group and 16% of the non-surgical group had knee pain (odds ratio: 2.809, p=0.285). INTERPRETATION: Crouch-related surgery does not appear to decrease knee pain prevalence compared to a comparison group, based on this preliminary study. Further investigation of the roles of these procedures is indicated with regards to this patient-reported outcome. What this paper adds Approximately 38% of individuals undergoing crouch-related surgery had knee pain. Approximately 42% of individuals with baseline knee pain who had surgery still had knee pain 1 year postoperatively. Approximately 50% of those with baseline knee pain managed non-surgically still had knee pain 1 year later. Crouch-related surgery tended not to decrease knee pain prevalence 1 year postoperatively.

Dolor de rodilla y marcha en cuclillas en personas con parálisis cerebral: ¿qué impacto tiene la cirugía indicadas para esta deformidad? OBJETIVO: Investigar el efecto de la cirugía relacionada con la marcha en cuclillas con el dolor de rodilla en personas con parálisis cerebral. MÉTODO: Identificamos retrospectivamente a los individuos con dos análisis tridimensionales de la marcha al inicio y en las visitas de seguimiento. Todos los individuos caminaron en cuclillas al inicio del estudio. Las visitas fueron de 9 a 42 meses de diferencia. El dolor al inicio, edad, la cirugía relacionada con este tipo de marcha (sí / no) y la flexión mínima de la rodilla en el seguimiento, se ingresaron en una regresión logística para predecir el dolor de rodilla de seguimiento. RESULTADOS: Treinta y dos individuos (21 varones, 11 mujeres; media [DE] edad 12 años 10 meses [2 años 5 meses]; 8 años 1 mes - 18 años 7 meses) recibieron cirugía para corregir esta alteración, mientras que 19 fueron manejados sin cirugía. Al inicio del estudio, la prevalencia del dolor de rodilla fue del 38% en el grupo quirúrgico y del 21 por ciento en el grupo no quirúrgico. En el seguimiento, el 34% del grupo quirúrgico y el 16% del grupo no quirúrgico tenían dolor de rodilla (odds ratio: 2,809, p = 0,285). INTERPRETACIÓN: Según este estudio preliminar, la cirugía relacionada para la marcha en cuclillas, no parece disminuir la prevalencia del dolor de rodilla en comparación con un grupo de comparación. Se sugiere una investigación adicional de las funciones de estos procedimientos con respecto a los resultados informados por pacientes.

Dor no joelho e marcha agachada em indivíduos com paralisia cerebral: qual o impacto da cirurgia relacionada à marcha agachada? OBJETIVO: Investigar o efeito de cirurgia relacionada à marcha agachada na dor no joelho de indivíduos com paralisia cerebral. MÉTODO: Identificamos retrospectivamente indivíduos com duas análises tridimensionais da marcha em visitas de linha de base e acompanhamento. Todos os indivíduos apresentavam marcha agachada na linha de base. As visitas tiveram de 9 a 42 meses de distância. A dor no joelho, idade, cirurgia relacionada à marcha agachada (sim/não) na linha de base, e flexão mínima do joelho no acompanhamento foram inseridas em uma regressão logístia para predizer a dor no joelho no acompanhamento. RESULTADOS: Trinta e dois indivíduos (21 do sexo masculino, 11 do sexo feminino; média [DP] de idade 12a 10m [2a 5m]; 8a 1m-18a 7m) receberam cirurgia relacionada à marcha agachada, enquanto 19 tiveram manejo não-cirúrgico. Na linha de base, a prevalência de dor no joelho era 38 por cento no grupo cirúrgico, e 21 por cento no grupo não-cirúrgico. No acompanhamento, 34 por cento do grupo cirúrgico e 16 por cento do grupo não cirúrgico tiveram dor no joelho (taxa de risco: 2,809, p=0,285). INTERPRETAÇÃO: A cirurgia relacionada à marcha agachada não parece diminuir a prevalência de dor no joelho em relação a um grupo de comparação, com base neste estudo preliminar. Mais investigações sobre o papel destes procedimentos são indicadas, com relação a este desfecho relatado pelos pacientes.

5-HT2C receptors in the BNST are necessary for the enhancement of fear learning by selective serotonin reuptake inhibitors.

Selective serotonin reuptake inhibitors (SSRIs) are widely prescribed to treat anxiety and depression, yet they paradoxically increase anxiety during initial treatment. Acute administration of these drugs prior to learning can also enhance Pavlovian cued fear conditioning. This potentiation has been previously reported to depend upon the bed nucleus of the stria terminalis (BNST). Here, using temporary inactivation, we confirmed that the BNST is not necessary for the acquisition of cued or contextual fear memory. Systemic administration of the SSRI citalopram prior to fear conditioning led to an upregulation of the immediate early gene Arc (activity-regulated cytoskeleton-associated protein) in the oval nucleus of the BNST, and a majority of these neurons expressed the 5-HT2C receptor. Finally, local infusions of a 5-HT2C receptor antagonist directly into the oval nucleus of the BNST prevented the fear memory-enhancing effects of citalopram. These findings highlight the ability of the BNST circuitry to be recruited into gating fear and anxiety-like behaviors.

Musculoskeletal Involvement in SSc Is Associated with Worse Scores on Short Form-36 and Scleroderma Health Assessment Questionnaire and Lower Tumor Necrosis Factor-α Gene Expression in Peripheral Blood Mononuclear Cells.

BACKGROUND: Systemic sclerosis (SSc) is characterized by a wide variety of symptoms and disease manifestations including joint pain, gastrointestinal dysfunction, interstitial lung disease, and cardiomyopathy. QUESTIONS/PURPOSES: Using the Scleroderma Health Assessment Questionnaire (SHAQ) and Short Form-36 (SF-36) we explored how patient-reported physical health, mental health, and functional status related to these clinical characteristics and to cytokine levels utilizing the Hospital for Special Surgery Scleroderma Registry. METHODS: In a cross-sectional study of 185 patients meeting the 2013 ACR/EULAR criteria for SSc, we compared disease features and patient-reported outcomes (PROs). Interleukin-6 (IL-6), interleukin-1ß (IL1ß), and tumor necrosis factor-α (TNFα) levels were assessed by luminex and ELISA assays in a subset of 32 patients. The Pearson correlation coefficient, Spearman correlation coefficient, two-sample t test or Wilcoxon rank sum test, ANOVA or Kuskal-Wallis test, and Pearson chi-squared or Fisher's exact test were performed as applicable to detect the association between disease manifestations, PROs, and blood biomarkers. RESULTS: The modified Rodnan skin score (MRSS) was positively correlated with SHAQ scores. Patients who had musculoskeletal involvement scored worse on both the SHAQ and SF-36. Lower levels of TNFα expression in PBMCs were also correlated with musculoskeletal involvement. No other significant correlations were found between clinical factors, PROs, and cytokine data. CONCLUSION: Musculoskeletal outcomes are a major determinant of quality of life and function in patients with SSc. These results emphasize the importance of musculoskeletal outcomes in clinical studies of SSc.