Enhancing wrist arthroscopy: artificial intelligence applications for bone structure recognition using machine learning.

INTRODUCTION: Wrist arthroscopy is a rapidly expanding surgical discipline, but has a long and challenging learning curve. One of its difficulties is distinguishing the various anatomical structures during the procedure. Although artificial intelligence has made significant progress in recent decades, its potential as a valuable tool in surgery training is largely untapped. MATERIALS AND METHODS: The objective of this study was to develop an algorithm that could accurately recognize the anatomical bone structures of the wrist during arthroscopy. We prospectively included 20 wrist arthroscopies: 10 in patients and 10 in cadavers. For each surgery, we extracted and labeled images of the various carpal bones. These images were used to create a database for training, validating and testing a structure recognition algorithm. The primary criterion used was a Dice loss detection and categorization score for structures of interest, with a threshold greater than 80%. RESULTS: The database contained 511 labeled images (4,088 after data augmentation). We developed a Deeplabv3+ classification algorithm with a U-Net architecture. After training and testing our algorithm, we achieved an average Dice loss score of 89% for carpal bone recognition. CONCLUSION: This study demonstrated reliable detection of different carpal bones during arthroscopic wrist surgery using artificial intelligence. However, some bones were detected more accurately than others, suggesting that additional algorithm training could further enhance performance. Application in real-life conditions could validate these results and potentially contribute to learning and improvement in arthroscopic wrist surgery. LEVEL OF EVIDENCE: IV.

A prognostic classification of proximal humerus fractures: the cephalic extension staging.

PURPOSE: Recent publications emphasized the role of dorsomedial metaphyseal extension of humeral head as predictor of ischemia after complex proximal humerus fractures (PHFs). We evaluated on preoperative 3D CT scan of PHFs the surface of this metaphyseal extension and its prognostic value on the occurrence of avascular necrosis (AVN). METHODS: We followed a series of 25 fixations of complex PHF which had a preoperative 3D CT scan and measured the surface area of the posterior metaphyseal extension (PME) of the head. Using approximations, we calculated the ratio between the PME surface area (PMS) and the articular surface area of the head (HS). The PMS/HS ratio was analyzed against the risk of AVN. RESULTS: The measurement of the PMS/HS ratio emphasizes the significance of PME. The incidence of AVN is correlated with the magnitude of PME. Therefore, we include the PME as a fifth element in the characterization of complex PHFs and we propose a 4-stage prognostic classification based on the number of extensions of the humeral head. The head may have 3 extensions: posteromedial (PME), lesser tuberosity (LTE) and greater tuberosity (GTE). The risk of AVN decreases with the number of extensions of the head. CONCLUSION: Our study demonstrates a correlation between the occurrence of AVN and the size of PME in complex PHF cases. We propose a four-stage classification system to facilitate treatment decision-making between fixation and prosthesis.

Correlation between dorsal capsulo-scapholunate septum (DCSS) lesion and predynamic scapholunate instability.

OBJECTIVE: Scapholunate instability is the most common ligament injury of the wrist. In case of predynamic instability, diagnosis can be difficult, even under arthroscopy. Scapholunate instability is not the result of an isolated injury to the scapholunate interosseous ligament. Scapholunate stability is dependent not only on the scapholunate ligament, but on a complex that is comprising intrinsic and extrinsic ligaments. The dorsal capsule-scapholunate septum (DCSS) is one of the secondary stabilizers of the scapholunate complex. The objective of the present study was to investigate the correlation between DCSS lesion and predynamic scapholunate instability. METHOD: A prospective multicenter study included patients who underwent wrist arthroscopy for traumatic wrist. Arthroscopic DCSS lesion stage and instability according to European Wrist Arthroscopy Society stage were assessed. RESULTS: Twenty-seven subjects were included. We found a significant correlation between pathological DCSS and predynamic scapholunate instability and a correlation between DCSS lesion severity and instability level. CONCLUSION: Isolated DCSS lesion should be considered a predictive factor for predynamic instability.

Patient Expectations and Therapeutic Alliance Affect Pain Reduction Following Lidocaine Infusion in an Interdisciplinary Chronic Pain Clinic.

Pain experience is affected by both ascending nociceptive signals and descending modulation. Expectations can affect pain experience and augment treatment-induced analgesia through descending inhibitory modulation of pain. This open-label, prospective cohort study examined the association between participant expectation ratings and pain reduction in adult participants with chronic pain receiving an intravenous lidocaine infusion. We aimed to explore whether: 1) participants' expectations of treatment efficacy were associated with pain reduction over 8 weeks after infusion; and 2) participants' therapeutic alliance was associated with expectations and/or pain reduction. We recruited 70 participants with chronic pain scheduled for lidocaine infusion. Study measures included pain intensity (pre-treatment, post-treatment, and daily for 8 weeks), treatment expectations (EXPECT), and therapeutic alliance (Trust in Physician and Working Alliance Inventory-Short Revised). Baseline treatment expectations were significantly correlated with pain reduction (r = .42, P < .01). Therapeutic alliance was significantly correlated with expectations (r = .27, P < .05) and pain reduction (r = .38, P < .01). This study quantifies the contribution of: 1) treatment expectations; and 2) therapeutic alliance to the magnitude of lidocaine-induced pain reduction. Results generate the hypothesis that focused efforts to augment treatment expectations and therapeutic alliance could serve to improve pain treatment outcomes. PERSPECTIVE: This study evaluates the relationship between pain reduction and ratings of: 1) treatment expectations; and 2) therapeutic alliance following an intravenous lidocaine infusion. Results generate the hypothesis that focused efforts to augment treatment expectations and therapeutic alliance could serve to improve pain treatment outcomes.

A pH-Activatable Nanoprobe Labels Diverse Histologic Subtypes of Human Lung Cancer During Resection.

BACKGROUND: Intraoperative molecular imaging (IMI) uses tumor-targeted optical contrast agents to improve identification and clearance of cancer during surgery. Recently, pH-activatable contrast agents have been developed but none has been tested in lung cancer. Here, we report the successful clinical translation of pegsitacianine (ONM-100), a pH-activatable nanoprobe, for fluorescence-guided lung cancer resection. METHODS: We first characterized the pH setpoint for pegsitacianine fluorescence activation in vitro. We then optimized the specificity, dosing, and timing of pegsitacianine in murine flank xenograft models of lung adenocarcinoma and squamous cell carcinoma. Finally, we tested pegsitacianine in humans undergoing lung cancer surgery as part of an ongoing phase 2 trial. RESULTS: We found that the fluorescence activation of pegsitacianine occurred below physiologic pH in vitro. Using preclinical models of lung cancer, we found that the probe selectively labeled both adenocarcinoma and squamous cell carcinoma xenografts (mean tumor-to-background ratio [TBR] > 2.0 for all cell lines). In the human pilot study, we report cases in which pegsitacianine localized pulmonary adenocarcinoma and pulmonary squamous cell carcinoma (TBRs= 2.7 and 2.4) in real time to illustrate its successful clinical translation and potential to improve surgical management. CONCLUSIONS: This translational study demonstrates the feasibility of pegsitacianine as an IMI probe to label the two most common histologic subtypes of human lung cancer.

A Study of Hand Flap Viability when Using a Wide Awake Local Anesthesia No Tourniquet (WALANT) Technique.

Objectives Flap surgery using a wide awake local anesthesia no tourniquet (WALANT) technique has historically been avoided because of technical challenges and concerns regarding the vasoconstriction caused by the necessary injection of epinephrine alongside the local anesthetic. The objective of our work was to evaluate the viability of the hand flaps performed using a WALANT technique compared with those performed under regional with a tourniquet. Materials and Methods Seventy-four patients were enrolled in a prospective comparative single-center study and subsequently divided into two groups: 36 patients in the locoregional anesthesia group and 38 patients in the WALANT group. Flap viability was evaluated on day 2 and day 10 using predetermined criteria. Results We did not find any significant difference in outcomes assessed for flap viability between the two groups postoperatively. Conclusion There was no evidence to suggest that vascularization of the flaps was compromised by the injection of epinephrine. The WALANT technique may, therefore, potentially be able to be safely deployed within this population.

Evaluation of intraoperative bleeding in shoulder arthroscopy with preoperative injection of epinephrine saline: a retrospective comparative study.

BACKGROUND: Several studies report the positive effects of epinephrine saline irrigation in shoulder arthroscopy. Cardiovascular adverse effects have been described. The Wide Awake Local Anesthesia No Tourniquet limits bleeding. The aim of this study is to evaluate the effects of epinephrine saline infiltrations of the shoulder on arthroscopic visual comfort. METHOD: We carried out a retrospective comparative study in 2 groups of patients. We included all patients admitted to the department for a rotator cuff surgery. Our exclusion criteria were any other surgical indication and patient refusal. The protocol consisted in making 3 preoperative shoulder infiltrations of 20 mL of epinephrine saline at 0.005 mg/mL. Injections were performed in all patients in group 1, and no specific treatment was performed in group 2 (control group). Data collection was performed the same way in both groups. The main judgment criterion was the evaluation of the surgeon's overall visual comfort using the visual analog scale (VAS) at the end of the procedure. We also evaluated the intraoperative discomfort related to bleeding every 15 minutes by an objective scale (the visual numeric rating scale [VNRS]), as well as the cumulative bleeding time, operating time, the quantity of irrigation fluid used, the blood pressure at the times of the bleeding, the mean blood pressure during the surgery, and the presence of thromboembolic and cardiovascular adverse events. RESULTS: We included 30 patients in group 1 and 30 patients in the control group. The mean VAS value at the end of the intervention was significantly higher in group 1 than in the control group: VAS = 10 in group 1 vs. VAS = 5 in group 2 (P < .0001) (higher is better). We also observed a significant decrease in VNRS between the 2 groups: VNRS = 0.25 in group 1 vs. VNRS = 1.00 in group 2 (P < .0001) (lower is better). The bleeding time was significantly lower in patients in group 1 (1 minute 39 seconds) compared with patients in group 2 (9 minutes 57 seconds) (P < .0001). No significant difference was demonstrated concerning the operating times, the quantity of irrigation fluid used, and the blood pressure data of the 2 groups. No adverse effects were observed. CONCLUSION: The infiltration of low doses of epinephrine as performed in Wide Awake Local Anesthesia No Tourniquet procedures seems effective in improving visualization in arthroscopy by reducing the bleeding. It can be a simple, efficient, and cost-effective technique with no iatrogenic risk to improve the surgeon's comfort in arthroscopic procedures.

Computational version of the correlation light-field camera.

Light-field cameras allow the acquisition of both the spatial and angular components of the light-field. The conventional way to perform such acquisitions leads to a strong spatio-angular resolution limitation but correlation-enabled plenoptic cameras have been introduced recently that relax this constraint. Here we use a computational version of this concept to acquire realistic light-fields images using a commercial DSLR Camera lens as an imaging system. By placing the image sensor in the focal plane of a lens, within the camera we ensure the acquisition of pure angular components together with the spatial information. We perform an acquisition presenting a high spatio-angular rays resolution obtained through a trade off of the temporal resolution. The acquisition reported is photo-realistic and the acquisition of diffraction limited features is observed with the setup. Finally, we demonstrate the refocusing abilities of the camera.

Hand wounds: An analysis of topography and related damage to underlying structures.

INTRODUCTION: Hand wounds account for 35 to 51% of hand traumas. Damage to underlying anatomical structures depends on the location of the wound. The objective of this study is to describe the topographic distribution of hand wounds allowing for subsequent evaluation of the link between affected surface area and underlying lesion. METHODS: We retrospectively reviewed the medical records of 1058 patients with a total of 1319 wounds over a period of 2 years. Wound location was described according to the cutaneous projection of IFSSH zones for flexors and extensors. Any associated deep lesions were evaluated. Topographical distribution was modeled graphically using a heat-map. We compared the proportion of underlying lesions between each cutaneous zone. Sub-group analysis for lesions' rate regarding zone groups were performed. RESULTS: 58.9% of wounds were located on the palmar surface and 41.1% on the dorsal surface. 71% of wounds affected only the digits. The index finger was the most affected. The most damaged region was zone 2 for palmar wounds and zone 3 for dorsal wounds. 45.5% of wounds resulted in injury to a significant underlying anatomical structure. This frequency was 36.4% and 58.5% for palmar and dorsal wounds respectively. More than 50% of wounds in palmar zone 5 and dorsal zones 1, 3, 5, 6 and 7 presented at least one lesion. A lesion of major structure was more frequently found in palmar zone 5 (p <0.001). Dorsally, no zone predominated. Subgroup analysis for dorsal wounds revealed that wounds overlying joints had more major lesions including more tendons injuries and more articular violations with zone 3 presenting a rate of 68%. CONCLUSION: We provided the first graphical representation for the topographical distribution of hand wounds. Dorsal wounds have a higher association with injury to underlying structures. These results generally support surgical exploration of all hand wounds regardless of their location. LEVEL OF EVIDENCE: IV Study type: Epidemiological study.

Quantum imaging with a photon counting camera.

Classical light sources emit a randomly-timed stream of individual photons, the spatial distribution of which can be detected with a camera to form an image. Quantum light sources, based on parametric down conversion, emit photons as correlated photon-pairs. The spatial correlations between the photons enables imaging systems where the preferential selection of photon-pairs allows for enhancements in the noise performance over what is possible using classical light sources. However, until now the technical challenge of measuring, and correlating both photons has led to system complexity. Here we show that a camera capable of resolving the number of individual photons in each pixel of the detector array can be used to record an image formed from these photon-pair events and hence achieve a greater contrast than possible using a classical light source. We achieve an enhancement in the ratio of two-photon events compared to one-photon events using spatially correlated SPDC light compared to uncorrelated illumination by a LED. These results indicate the potential advantages of using photon counting cameras in quantum imaging schemes and these advantages will further increase as the technology is developed. Operating in photon sparse regimes such systems have potential applications in low-light microscopy and covert imaging.

Four Questions Nurses Can Ask to Predict PTSD 1 Year After a Motor Vehicle Crash.

BACKGROUND: The role of nurses in screening for posttraumatic stress disorder is crucial in trauma units. OBJECTIVES: To create and evaluate an easy and brief tool for nurses to predict chronic posttraumatic stress disorder 1 year after a motor vehicle crash. METHODS: We performed a 1-year follow-up multicenter study from 2007 to 2015, including 274 patients injured in a motor vehicle crash who were hospitalized in an orthopedic trauma unit. Nurses administered the DEPITAC questionnaire. Posttraumatic stress disorder was measured by the Post-Traumatic Stress Disorder Checklist of symptoms during the first year following the crash. A multivariable logistic regression model was implemented to select items significantly associated with posttraumatic stress disorder to improve the DEPITAC questionnaire. Predictive performance to predict posttraumatic stress disorder 1 year after the motor vehicle crash was examined for these different models. RESULTS: Of 274 patients studied, a total of 75.9% completed the questionnaire at 1 year of follow-up. We found that only two questions and two simple elements of the patient's medical record (other injury or a person dying during the crash, perception of vital threat, number of children, and length of stay in trauma) predicted posttraumatic stress disorder 1 year after a motor vehicle crash. CONCLUSIONS: The brevity of this evaluation, simple scoring rules, and screening test performance suggest that this new screening tool can be easily administered in the acute care setting by nurses.

Spiropyrimidinetriones: a Class of DNA Gyrase Inhibitors with Activity against Mycobacterium tuberculosis and without Cross-Resistance to Fluoroquinolones.

Described here is a series of spiropyrimidinetrione (SPT) compounds with activity against Mycobacterium tuberculosis through inhibition of DNA gyrase. The SPT class operates via a novel mode of inhibition, which involves Mg2+-independent stabilization of the DNA cleavage complex with DNA gyrase and is thereby not cross-resistant with other DNA gyrase-inhibiting antibacterials, including fluoroquinolones. Compound 22 from the series was profiled broadly and showed in vitro cidality as well as intracellular activity against M. tuberculosis in macrophages. Evidence for the DNA gyrase mode of action was supported by inhibition of the target in a DNA supercoiling assay and elicitation of an SOS response seen in a recA reporter strain of M. tuberculosis. Pharmacokinetic properties of 22 supported evaluation of efficacy in an acute model of M. tuberculosis infection, where modest reduction in CFU numbers was seen. This work offers promise for deriving a novel drug class of tuberculosis agent without preexisting clinical resistance.

COVID-19 and the cardiovascular system: an update.

As COVID-19 continues to cause an increasing number of deaths worldwide, it is important that providers stay abreast with new research related to the pathophysiology of COVID-19 disease presentation states and clinical management. It is now well recognized that COVID-19 affects extrapulmonary organs, particularly the cardiovascular system. For example, cardiogenic shock has been increasingly observed in patients with COVID-19, owing to the various mechanisms involved and the affinity of the SARS-CoV-2 virus to cells comprising the cardiovascular system. In this review, we have briefly discussed the link between the cardiovascular system and COVID-19 infection, focusing on underlying mechanisms including but not limited to cytokine storm, direct virus-induced myocarditis, and ST-elevation myocardial infarction leading to cardiogenic shock. We have highlighted the cardiovascular risk factors associated with disease prognostication in COVID-19 patients. We have also briefly discussed vasopressors and inotropes used for treating shock and presented their mechanism of action, contraindications, and side effects in the hopes of providing a quick reference to help the provider optimize management of COVID-19 patients presenting with cardiovascular complications such as shock.

A Rare Colon Polypectomy Diagnosis: Description of a Unique Investigational Journey and Literature Review of Burkitt Lymphoma.

The presentation of Burkitt lymphoma (BL) is variable and highly dependent on its subtype. It often presents with non-specific symptoms and may appear in the jaw, bone marrow, liver, spleen, kidneys, ovaries, and gastrointestinal tract. This case describes a 50-year-old male who presented with abdominal pain and was eventually found to have Burkitt lymphoma, diagnosed by biopsy of a cecal polyp. Herein, we explore the diagnostic journey to BL and review the literature regarding its unique manifestations and thus the diagnostic challenge it can present.

Jones type fifth metatarsal fracture fixation in athletes: A review and current concept.

Jones type fifth metatarsal fracture is a common occurrence among athletes at all levels. These fractures may occur due to several mechanisms, but inversions and twisting injuries are considered some of the leading causes in sports. However, while Jones fracture incidences are frequent in the sporting world, there is still a lack of consensus on how such fractures should be effectively managed. There are numerous treatment options for patients with fifth metatarsal Jones fractures. The role of nonoperative treatment remains controversial, with concerns about delayed union and nonunion. Surgical stabilization of metatarsal Jones fractures is therefore often recommended for athletes, as it is often associated with a low number of complications and a higher rate of union than nonoperative management. This review will focus on literature regarding the prevalence of Jones type fifth metatarsal fracture, alongside the efficacy of both conservative and surgical treatment within this population.

Mixed Reality Assisted Percutaneous Scaphoid Fixation: A Proposed New Surgical Technique.

The success of percutaneous fixation of non or minimally displaced scaphoid waist fractures is reliant on optimal placement of the screw. This can be challenging for surgeons to achieve, potentially involving a large volume of intraoperative imaging, and surgical time. Mixed reality (MR) is a new technology that allows the projection of holographic imagery within the surgeon's field of vision intraoperatively. This imagery can include surgical planning data and 3D reconstructions of a patient's anatomy that can be used in order to aid the surgeon in achieving accuracy. We describe a technique for how this novel technology might be used in the future to fix scaphoid fractures-MR assisted percutaneous scaphoid fixation. This is done using cadaveric modeling. MR assisted percutaneous scaphoid fixation may have the potential to aid surgeons in achieving an optimal guidewire placement with the ability to reduce surgical time and radiation exposure.

The Glenoid Vault Outer Cortex a new more accurate radiological reference for shoulder arthroplasty.

INTRODUCTION: Correct positioning of the glenoid component is an important determinant of outcome in shoulder arthroplasty. We describe and assess a new radiological plane of reference for improving the accuracy of glenoid preparation prior to component implantation - the Glenoid Vault Outer Cortex (GvOC) plane. METHODS: One hundred and five CT scans of normal scapulae were obtained. Forty six females and 59 males aged between 22 and 30 years. The accuracy of the GvOC plane was then compared against the current "gold standard" - the scapular border (SB). Measurements of glenoid inclination, version, rotation, and offset were obtained using both the GvOC and SB planes. These were then compared to actual values. RESULTS: The mean difference between version obtained using the GvOC plane and the actual value was 1.8° (-2 to 5, SD 1.6) as compared to 6.7° (-2 to 17, SD 4.3) when the SB plane was used, (p < 0.001). The mean difference between estimates of inclination obtained using the GvOC plane and the actual were 1.9° (-4 to 6, SD 1.6) as compared to 11.2° (-4 to 25, SD 6.1) when the SB plane was used, (p < 0.001). CONCLUSIONS: The GvOC plane produced estimates of glenoid version and inclination closer to actual values with lower variance than when the SB plane was used. The GvOC may be a more accurate and reproducible radiological method for surgeons to use when defining glenoid anatomy prior to arthroplasty surgery.

Comparison of "Bilboquet" device and locking plate for surgical treatment of proximal humerus complex fractures at two years follow-up.

PURPOSE: Surgical treatment of three or four part fractures of the proximal humerus is complex. Different conservative techniques have been described. The main goal of this study was to compare the clinical and radiological outcomes of Bilboquet and locking plate at two year follow-up. METHODS: This is a retrospective, comparative study, with a continuous series of 41 patients. Bony fixation was achieved with a Bilboquet device in 22 patients or a locking plate in 19 patients. Patient evaluation included clinical data: shoulder range of motion, Constant-Murley shoulder score and DASH (Disabilities of the Arm, Shoulder and Hand) score, and imaging using standard shoulder X-rays. RESULTS: Of the 41 patients included, 1 patient was lost to follow-up in the locking plate group. At a mean follow-up of 24 months patients in Bilboquet group showed a Constant score higher than in locking plate (p = 0.02). Range of motion and DASH score were not significantly different between the two groups. avascular necrosis occured in three patients of Bilboquet group (14%) versus in two patients in the locking plate group (11%) (p > 0.5). Complication and reintervention rate were non-significantly higher in the locking plate group than in the Bilboquet group (37 vs 14%). CONCLUSION: Bilboquet and locking plate give good functional outcomes in complex proximal humerus fractures. However, the Bilboquet device appears to provide better functional results than locking plate at mid-term follow-up.

A Central Amygdala-Globus Pallidus Circuit Conveys Unconditioned Stimulus-Related Information and Controls Fear Learning.

The central amygdala (CeA) is critically involved in a range of adaptive behaviors, including defensive behaviors. Neurons in the CeA send long-range projections to a number of extra-amygdala targets, but the functions of these projections remain elusive. Here, we report that a previously neglected CeA-to-globus pallidus external segment (GPe) circuit plays an essential role in classical fear conditioning. By anatomic tracing, in situ hybridization and channelrhodopsin (ChR2)-assisted circuit mapping in both male and female mice, we found that a subset of CeA neurons send projections to the GPe, and the majority of these GPe-projecting CeA neurons express the neuropeptide somatostatin. Notably, chronic inhibition of GPe-projecting CeA neurons with the tetanus toxin light chain (TeLC) completely blocks auditory fear conditioning. In vivo fiber photometry revealed that these neurons are selectively excited by the unconditioned stimulus (US) during fear conditioning. Furthermore, transient optogenetic inactivation or activation of these neurons selectively during US presentation impairs or promotes, respectively, fear learning. Our results suggest that a major function of GPe-projecting CeA neurons is to represent and convey US-related information through the CeA-GPe circuit, thereby regulating learning in fear conditioning.SIGNIFICANCE STATEMENT The central amygdala (CeA) has been implicated in the establishment of defensive behaviors toward threats, but the underlying circuit mechanisms remain unclear. Here, we found that a subpopulation of neurons in the CeA, which are mainly those that express the neuropeptide somatostatin, send projections to the globus pallidus external segment (GPe), and this CeA-GPe circuit conveys unconditioned stimulus (US)-related information during classical fear conditioning, thereby having an indispensable role in learning. Our results reveal a previously unknown circuit mechanism for fear learning.