Operative Fixation of a Humeral Shaft Periprosthetic Fracture After IlluminOss: A Case Report.

CASE: An 82-year-old man sustained a periprosthetic fracture after IlluminOss photodynamic bone stabilization system (PBSS) stabilization for an impending pathologic fracture. Nonoperative management was unsuccessful, and he subsequently underwent operative fixation, which featured lag screw fixation of the spiral distal humeral shaft fracture and osteotomy followed by plate fixation of the pathologic humeral shaft fracture. CONCLUSION: This is the first article to report this complication with IlluminOss PBSS stabilization and details regarding revision surgery.

The Watson Extraction System for removal of well-fixed femoral stems: A retrospective review of 10 cases.

Background: Revision of well-fixed cementless femoral stems is a challenging and time-consuming aspect of revision hip arthroplasty. The Watson Extraction System (WES) is a novel, size-specific 3-D fabricated instrument that mimics the outer geometry of the implanted femoral stem. The device acts to cut circumferentially around the stem as it is impacted into place, effectively disrupting the bone-implant interface. Methods: This is a retrospective review assessing the experience of 3 fellowship-trained adult reconstruction surgeons who used the WES to extract 10 well-fixed femoral stems during rTHA between 11/7/2020 and 11/7/2022. Outcomes and measures included: ability to remove the stem without a femoral osteotomy, femoral stem extraction time, incidence of femoral fracture, stem type used for reconstruction, blood loss, total surgical time, post-operative complications. Results: No femoral osteotomies were required. The mean time for stem extraction was 7 min (range, 2-13), and there were 2 (20%) intra-operative femoral fractures. The stem type utilized for reconstruction included: 4 (40%) modular, tapered style stems, 3 (30%) antibiotic spacers, 2 (20%) primary style stems, and 1 (10%) ream and broach proximally porous stem. The mean blood loss was 425 ml (range, 200-800), total surgical time was 160 min (range, 107-232), and duration of follow-up was 7 months (range, 2-22 months). Conclusion: The WES may mitigate the need for femoral osteotomy, reduce femoral stem extraction and overall intraoperative time, and decrease blood loss in rTHA. Further, reduced bone loss with use of this device may permit final reconstruction with a primary style stem.

Total Hip Arthroplasty With Subtrochanteric Osteotomy for Developmental Hip Dysplasia: A Long-term Follow-up Study.

Background: Total hip arthroplasty (THA) for developmental hip dysplasia (DDH) often requires a subtrochanteric shortening derotational osteotomy (SDO) to limit leg lengthening, mitigate risk of peripheral nerve palsy, and reduce excessive femoral anteversion. Few studies exist detailing long-term clinical outcomes and survivorship. The aim of this study is to analyze the long-term outcomes and survivorship of an SDO-THA cohort. Methods: We retrospectively reviewed all patients who underwent cementless THA with femoral osteotomy due to Crowe I-IV DDH between 1991 and 2001. Primary outcome measures included revision surgery for any reason and functional outcome measures using modified Harris Hip scores. Secondary outcome measures included mode of implant failure and radiographic assessment for osteotomy union, polyethylene wear, osteolysis, and implant loosening. Results: Our review resulted in 24 SDO-THA cases in 20 patients with a mean follow-up of 19 years (range, 8-27 years). Overall survivorship was 67%. All 8 failures were treated with acetabular revision at a mean time to revision of 11 years (range, 1-25 years). Of the failures, there were 5 cases due to polyethylene wear (62.5%), 2 cases due to acetabular loosening (25%), and 1 case due to recurrent instability (12.5%). The mean postoperative modified Harris Hip score was 76 (range, 52-91) with long-term improvement of 43 points maintained (P < .001). Conclusions: THA with SDO can produce durable long-term outcomes for the patient with DDH. It is important to consider some common reasons for revision, namely polyethylene wear and osteolysis, acetabular loosening, and recurrent acetabular dislocations.

Simultaneous Limb Lengthening With Ankle Fusion Using an Internal Lengthening Nail.

We reviewed 18 limbs in 17 patients who underwent ankle fusion with simultaneous tibial lengthening with a magnetic internal lengthening nail. All patients had preoperative limb length discrepancy (LLD) (mean 4.9 cm (2.6-7.6 cm)) with ankle deformity. The ankle was fused from medial or lateral approaches using screws/plate constructs placed adjacent to the retrograde Precise nail. Lengthening was carried out by a distal 1/3 tibial osteotomy. Clinical and radiographic measures were performed after a mean follow-up of 20 months (12-37 months). The mean amount of lengthening performed was 4 cm (1.8-7.2 cm). The final mean LLD was 1 cm (0.7-1.1 cm), which was statistically significant (p<0.01) as compared to preoperative. The foot was plantigrade in all cases. The mean foot rotation was 10° (5-15°) external, relative to the knee. At final follow-up all patients reported minimal to no pain, and all claimed to be walking more functionally than before surgery. Ankle fusion and limb lengthening was achieved in all cases. Combining both treatments by using an internal lengthening nail was very effective and avoided leaving patients with a dysfunctional LLD or of having a separate limb lengthening procedure. This is the first report of such a combined treatment of ankle fusion with internal tibial lengthening nail.

Can the Absence of Hypertension Refine the Risk Assessment of Older Adults for Future Cardiovascular Events?

We sought to determine if the absence of hypertension in older adults can be used to identify those at lower risk of atherosclerotic cardiovascular disease (ASCVD). We identified participants ≥75 years old free of cardiovascular disease (CVD) in the National Institutes of Health Pooled Cohorts with and without hypertension. We assessed the association between systolic blood pressure (BP), diastolic BP, and cardiovascular events using multivariable modeling. The association between predicted ASCVD risk and observed events was compared. Of 2,667 adults aged ≥75 years, 67.9% had hypertension. Lower systolic BP correlated with lower CVD event rates. ASCVD predicted risk score and systolic BP were both independently associated with ASCVD event rates. Among adults with similar ASCVD predicted risk estimates, those without (vs with) hypertension had lower observed event rates across the predicted risk spectrum. The absence of hypertension may help refine the risk stratification of older adults, particularly those with intermediate predicted risk.

Intubation of prehospital patients with curved laryngoscope blade is more successful than with straight blade.

OBJECTIVE: Direct laryngoscopy can be performed using curved or straight blades, and providers usually choose the blade they are most comfortable with. However, curved blades are anecdotally thought of as easier to use than straight blades. We seek to compare intubation success rates of paramedics using curved versus straight blades. METHODS: Design: retrospective chart review. SETTING: hospital-based suburban ALS service with 20,000 annual calls. SUBJECTS: prehospital patients with any direct laryngoscopy intubation attempt over almost 9years. First attempt and overall success rates were calculated for attempts with curved and straight blades. Differences between the groups were calculated. RESULTS: 2299 patients were intubated by direct laryngoscopy. 1865 had attempts with a curved blade, 367 had attempts with a straight blade, and 67 had attempts with both. Baseline characteristics were similar between groups. First attempt success was 86% with a curved blade and 73% with a straight blade: a difference of 13% (95% CI: 9-17). Overall success was 96% with a curved blade and 81% with a straight blade: a difference of 15% (95% CI: 12-18). There was an average of 1.11 intubation attempts per patient with a curved blade and 1.13 attempts per patient with a straight blade (2% difference, 95% CI: -3-7). CONCLUSIONS: Our study found a significant difference in intubation success rates between laryngoscope blade types. Curved blades had higher first attempt and overall success rates when compared to straight blades. Paramedics should consider selecting a curved blade as their tool of choice to potentially improve intubation success.

Restoring p53 function in human melanoma cells by inhibiting MDM2 and cyclin B1/CDK1-phosphorylated nuclear iASPP.

Nearly 90% of human melanomas contain inactivated wild-type p53, the underlying mechanisms for which are not fully understood. Here, we identify that cyclin B1/CDK1-phosphorylates iASPP, which leads to the inhibition of iASPP dimerization, promotion of iASPP monomer nuclear entry, and exposure of its p53 binding sites, leading to increased p53 inhibition. Nuclear iASPP is enriched in melanoma metastasis and associates with poor patient survival. Most wild-type p53-expressing melanoma cell lines coexpress high levels of phosphorylated nuclear iASPP, MDM2, and cyclin B1. Inhibition of MDM2 and iASPP phosphorylation with small molecules induced p53-dependent apoptosis and growth suppression. Concurrent p53 reactivation and BRAFV600E inhibition achieved additive suppression in vivo, presenting an alternative for melanoma therapy.

Epigenetic inactivation of 14-3-3 sigma in oral carcinoma: association with p16(INK4a) silencing and human papillomavirus negativity.

In vitro studies have identified 14-3-3sigma as a regulator of senescence in human keratinocytes. To assess its contribution to squamous neoplasia, we have analyzed genetic and epigenetic changes in this gene in squamous cell carcinomas (SCCs) and dysplastic lesions of the oral cavity. No mutations were detected in the coding sequence of 14-3-3sigma in 20 oral carcinomas, and there was loss of heterozygosity in only 7 of 40 informative cases. In contrast to the absence of genetic change, aberrant methylation within 14-3-3sigma was detected in 32 of 92 squamous cell carcinomas and in 3 of 6 oral dysplasias and was associated with reduced or absent expression at both mRNA and protein levels. Methylation was not detected in matched, normal epithelial tissue controls. Carcinomas in which 14-3-3sigma was methylated were significantly more likely to lack DNA sequences from human papillomavirus and to have coincident methylation of p16(INK4a) than cases that expressed 14-3-3sigma. Methylation was detected in SCC, both wild-type and mutant for p53, but was more commonly detected in cancers with wild-type p53. These results implicate coincident epigenetic abrogation of function in both sigma and p16(INK4a) in a subset of SCCs of the oral cavity.

Coincident inactivation of 14-3-3sigma and p16INK4a is an early event in vulval squamous neoplasia.

The structure and expression of 14-3-3 sigma(sigma) was analysed in squamous carcinomas (SCC) of the vulva and in the vulval pre-malignant lesion vulval intraepithelial neoplasia (VIN). Sequence analysis of the sigma coding region did not detect mutations in any case of SCC or VIN III and loss of heterozygosity (LOH) occurred in only 2 out of 27 informative cases. In contrast to the absence of genetic change, methylation-specific PCR (MSP) analysis revealed dense CpG methylation within the sigma gene in approximately 60% of cases of vulval SCC, but methylation was not detected in matched, normal epithelial tissue. Methylation was associated in all cases with reduced or absent expression of sigma mRNA. There was no correlation between sigma methylation and HPV or p53 status. Analysis of pre-malignant vulval intraepithelial neoplasia (VIN) revealed that sigma methylation was detectable early in neoplastic development. Co-incident methylation, accompanied by loss of expression, of sigma and p16INK4a was commonly detected in both SCC and VIN III, suggesting that epigenetic silencing of these two genes is an early and important event in vulval neoplasia.