bluuebunny/crossref_metadata_2025 huggingface dataset:
Teaching Residents Frontal Sinus Anatomy Using a Novel 3-Dimensional Conceptualization Planning Software-Based Module
Authors: Chen Philip G. , Bassiouni Ahmed , Taylor Christine B. , Psaltis Alkis J. , Alrasheed Abdulaziz , Wrobel Bozena , Tewfik Marc A. , McMains K. Christopher
Published: September 2018

Background

The Frontal Sinus Masterclass (FSMC) is an effective method for teaching frontal sinus anatomy. A third party developed new software using the same 3-dimensional building block concept. The authors sought to determine whether the use of the software for the educational module yielded similar results to the original FSMC, which used wooden blocks.

Methods

The study was performed at a sinus course for residents. A precourse test assessed the ability to decipher frontal sinus anatomy prior to the course. Computed tomography (CT) scans of the sinuses were evaluated in triplanar view, and participants attempted to reconstruct the anatomy using the new software. Subsequently, the course instructor explained the anatomy and showed a short corresponding surgical video of the frontal sinusotomy. Cases progressed in anatomical difficulty and inflammatory load. A postcourse test determined knowledge after the course.

Results

In sum, 50 residents completed the pre- and postcourse tests. Overall scores increased from 60.5% to 65.2% ( P = .004). Subanalysis also demonstrated improved ability to locate the frontal drainage pathway from 32.5% to 46% ( P = .011) and label the frontal recess cell structures from 64% to 67.6% ( P = .045).

Conclusion

There is minimal literature on proven methods for teaching frontal sinus anatomy. Objectively, participants of the modified FSMC simulation training using new software improved their ability to recognize cells of the frontal recess on CT scans. They especially exhibited better localization of the frontal sinus drainage pathway. Subjectively, participants reported benefit from the course and felt they would be better surgeons.
Family physicians’ knowledge, attitudes, and behaviors regarding the weight effects of added sugar
Authors: Mackey Christian , Plegue Melissa A , Deames Marian , Kittle Matthew , Sonneville Kendrin R , Chang Tammy
Published: September 2018

Background and objectives:

Added sugar consumption is a major risk factor for negative health outcomes and family physicians play an important role in educating patients regarding nutrition behaviors, such as consumption of added dietary sugar. The aim of this study was to describe the knowledge, attitudes, and behaviors of family physicians regarding added dietary sugar.

Methods:

An online questionnaire was administered to family physician members of the Council of Academic Family Medicine organizations, which support teaching physicians that train family physicians throughout the United States. Survey items underwent rigorous pilot and cognitive testing prior to administration. Descriptive statistics and Pearson’s chi-square test were performed to evaluate physician’s dietary counseling for patients with overweight and obesity.

Results:

Among practicing family physician members (n = 1196), 72% reported providing dietary counseling to the majority (⩾50%) of their patients with overweight and obesity. Most (90%) believed that their counseling was ineffective for the majority of patients. Frequency of counseling was significantly associated with beliefs about counseling effectiveness (p-value < 0.001). Nearly all physicians (97%) advised against consuming sugary beverages, while advising patients to limit foods with added sugar was less common (82%).

Discussion:

Dietary counseling is often, but not always, provided to patients with overweight and obesity by family physicians in our sample, though most physicians believed their counseling is ineffective. National attention to added sugar as a risk for poor health should serve as a catalyst for renewed efforts from primary care educators and clinicians to engage in innovative practices to empower at-risk patients to improve their nutrition.
Humans are the most significant global geomorphological driving force of the 21st century
Authors: Cooper Anthony H , Brown Teresa J , Price Simon J , Ford Jonathan R , Waters Colin N
Published: September 2018

The transformation of the Earth’s land surface by mineral extraction and construction is on a scale greater than natural erosive terrestrial geological processes. Mineral extraction statistics can be used as a proxy to measure the size of the total anthropogenic global sediment flux related to mineral extraction and construction. It is demonstrated that the annual direct anthropogenic contribution to the global production of sediment in 2015 was conservatively some 316 Gt (150 km3), a figure more than 24 times greater than the sediment supplied annually by the world’s major rivers to the oceans. The major long-term acceleration in anthropogenic sediment flux started just after the Second World War and anthropogenic sediment flux overtook natural fluvial sediment flux in the mid-1950s. Humans are now the major global geomorphological driving force and an important component of Earth System processes in landscape evolution. The changing magnitude of anthropogenic sediments and landforms over time are significant factors in the characterisation of the proposed new epoch of geological time – the Anthropocene.
Pain Deterioration Within 1 Year Predicts Future Decline of Walking Ability: A 7-Year Prospective Observational Study of Elderly Female Patients With Knee Osteoarthritis Living in a Rural District
Authors: Yamaguchi Naoki , Takahashi Tsuneari , Ueno Takashi , Hiyama Shuhei , Ogawa Masaya , Matsumura Tomohiro , Sasanuma Hideyuki , Takeshita Katsushi
Published: September 2018

Introduction:

Knee osteoarthritis (KOA) is commonly a main cause of locomotive syndrome. Consequently, appropriate timing of intervention is clinically important.

Materials and Method:

Fifty female patients of a primary care clinic in a rural district fulfilled the criteria for KOA and were recruited and underwent knee medical checkups. They initially underwent physical examination bilaterally of knees by an orthopedic surgeon, radiological evaluation, and they answered the outcome of Japanese Knee Osteoarthritis Measurement (JKOM). They were asked to answer JKOM 1 and 7 years after the initial checkup. Fourteen patients were lost to follow-up due to death or moving to a nursing home. Thirty-six patients were finally included and divided into 2 age-matched groups according to walking ability at the 7-year follow-up: group A, walking ability did not decline (n = 24), and group B, walking ability did decline (n = 12). The walking ability was measured as per ordinal classification as: 5 (walking without any aid), 4 (walking with a crutch), 3 (walking using walker), 2 (walking only possible in parallel bars), and 1 (wheelchair). We completed between-group comparisons of each of the 3 subsections of the JKOM (pain, limitation in mobility related to daily activity, and restriction of participation in social life and health perception), during each period.

Results:

There were significant differences in JKOM pain score (12.9 vs 18.3, P = .0058) and total score (41.3 vs 55.8, P = .0093) between the groups at 1-year follow-up, even though base scores did not differ.

Discussion:

Clinicians should pay attention to changes in perceived knee pain and should not continue prolonged conservative therapy in patients exhibiting rapid deterioration.

Conclusion:

Female patients with KOA whose pain deteriorated within 1 year may require early intervention to prevent future decline in walking ability.
Butterfly Vertebrae: A Systematic Review of the Literature and Analysis
Authors: Katsuura Yoshihiro , Kim Han Jo
Published: September 2018

Study Design:

Systematic review (Level 4)

Objective:

To summarize the demographics, clinical presentations, and conditions associated with butterfly vertebrae.

Methods:

A systematic search was performed of multiple databases. A total of 279 articles were identified for screening. Case series or case reports of butterfly vertebrae with adequate clinical detail were complied.

Results:

Eighty-two total articles (109 patients) were selected for final inclusion. Sixty-one percent of patients presented with a single butterfly vertebra, while 39% were multiple. The most common location for butterfly vertebrae was T1. Fifty-six percent of cases were associated with a syndrome, the most common being spondylocostal dysostosis. The presence of multiple butterfly vertebra was strongly associated with a syndrome or additional anomalies ( P < .001). Overall, the most common presenting complaint was low back pain. Seventy percent of patients had associated spinal disease. Other organ systems affected included musculoskeletal (43%), craniofacial (30%), neurologic (27%), cardiovascular (24%), genitourinary (23%), gastrointestinal (22%), laboratory abnormality (16%), and endocrine (9%).

Conclusions:

This study is the largest collection of butterfly vertebrae cases to date. Butterfly vertebrae are associated with spinal deformity and multiple butterfly vertebrae may indicate a syndromic illness. Low back pain or disc herniation may occur with lumbar butterfly vertebrae however the etiology of this phenomena has not been rigorously explained. Many diseases and syndromes are associated with butterfly vertebrae.
Multi-Center Studies of the Global Impact of Endometriosis and the Predictive Value of Associated Symptoms
Authors: Nnoaham Kelechi E. , Sivananthan Sivahami , Hummelshoj Lone , Jenkinson Crispin , Webster Premila , Kennedy Stephen H. , Zondervan Krina T.
Published: September 2018

Introduction

Endometriosis can be difficult to diagnose clinically and models that use symptoms to predict whether the disease is present or not are based on limited patient populations. Endometriosis also influences health-related quality of life, but little is known about its impact across the world. We therefore initiated two integrated multi-center studies to collect prospective, standardized, epidemiological data, to 1) examine the global impact of endometriosis and relative effect of risk-factors, and 2) develop a symptom-based diagnostic tool.

Methods

The Global Study of Women's Health (GSWH) and the Women's Health Symptom Survey (WHSS) prospectively recruit 18–45 year old women having a laparoscopy across 23 and 19 centers, respectively, worldwide. Women with a previous surgical diagnosis of endometriosis are excluded. Multi-lingual patient questionnaires and a surgical questionnaire, incorporating validated instruments, are used to collect the data. The GSWH aims to recruit >2,000 women by December 2009; the WHSS to recruit 1,000 women in each of the two model-generating and validation stages.

Results

A six-week pilot study in Oxford, UK, established the feasibility of the study protocols. Of 32 eligible women, 27 participated (response rate - 84.4%); 26% completed the questionnaire online. Endometriosis was found in 47.4%. Extrapolating the recruitment rates from the pilot study, the target sample sizes for the GWSH and WHSS were deemed feasible.

Conclusions

Using standardized data collection, the GSWH and WHSS will provide insight into the global impact of endometriosis and develop a validated, symptom-based, diagnostic tool. They have the potential to provide the basis for future, longitudinal, follow-up studies and a collaborative Endometriosis Biobank implementing standardized collection of DNA and tissue samples
Deep Pelvic Endometriosis: From Diagnosis to Wellness
Authors: Saccardi Carlo , Cocco Andrea , Tregnaghi Alberto , Cosmi Erich , Baldan Nicola , Ancona Ermanno , Litta Pietro S.
Published: September 2018

Purpose

to determine the efficacy of laparoscopic excision of deep pelvic endometriosis (DPE).

Methods

One hundred and two highly symptomatic women with DPE underwent clinical examination, transvaginal ultrasound, nuclear magnetic resonance (NMR) and sonovaginography. Among the 102 women, 50 patients, with severe symptoms, underwent laparoscopic excision of DPE. Endoscopic surgery was performed with complete separation of the rectovaginal space and resection of the node. In the case of vaginal involvement vaginal exeresis was performed, in the case of rectal wall involvement of more than 50%, segmental bowel resection was performed. Operative data as well as dysmenorrhea, dyspareunia, chronic pelvic pain and dyschezia before and 6 and 12 months after surgical treatment were recorded.

Results

Mean operative time was 126.4 ± 34.7 min, mean blood loss was 76.2 ± 22 ml. In 17 (34%) cases we performed excision of the posterior vaginal fornix due to vaginal wall involvement. In six (12%) cases we performed excision of the rectal wall. At 12-month follow-up 39 (78%) women revealed absent or mild dysmenorrhea, 45 (90%) women revealed absent or mild dyspareunia, 46 (92%) women revealed absent or mild chronic pelvic pain, 48 (96%) women revealed absent or mild dyschezia.

Conclusions

Surgical management of DPE could be a radical approach for this disease but conservative for the patients, ensuring good improvement in symptoms and good patient satisfaction, and only performing vaginal or rectal exeresis when strictly necessary.
Single Port Access Laparoscopy (SPAL) for Endometrioma Excision
Authors: Angioni Stefano , Mereu Liliana , Maricosu Giovanni , Mencaglia Luca , Melis Gian Benedetto
Published: September 2018

Puropose

To evaluate the feasibility of single port access laparoscopy (SPAL) for the treatment of ovarian endometrioma.

Case Report

Three patients affected by single ovarian endometrioma underwent cyst excision using a laparoendoscopic single port approach with a new multiport, reusable trocar, and flexible, curved and standard laparoscopic instruments.

Results

No conversion to multi-access standard laparoscopic technique was required and no intraoperative or postoperative complications were observed. The mean operative time was 40 minutes.

Conclusions

We conclude that single portal access laparoscopy is feasible, safe and effective for the excision of ovarian endometrioma, with good results in terms of cosmesis, postoperative pain and patient satisfaction. This approach may be indicated in patients with single cysts without dense adherences in the bowel and/or deep infiltrating endometriosis.
Leptin and Antioxidant Profile in Infertile Women with Endometriosis
Authors: Osman Hussein G. , El-Refaey Abdel Aziz A. , Aziz Abdel Aziz F. Abdel , El-Sokkary Ahmed M.A. , El-Saeed Rasha A.
Published: September 2018

Objective

To investigate the role of leptin hormone and oxidative stress in the pathogenesis of endometriosis among infertile women.

Methods

Blood samples and peritoneal fluid were collected from women undergoing laparoscopy. The study group included 24 infertile women with endometriosis, while 14 women with unexplained infertility represented the control group. Leptin hormone levels and three markers of antioxidants, including total antioxidant capacity (TAC), catalase (CAT) enzyme and superoxide dismutase (SOD) enzyme were estimated.

Results

Peritoneal fluid leptin concentrations were significantly higher in infertile endometriotic women compared with the control group. The levels of TAC, CAT and SOD were significantly lower in both serum and peritoneal fluid of infertile endometriotic women compared with controls. There was no significant difference in serum leptin concentrations between the studied groups.

Conclusions

Peritoneal leptin and oxidative stress may be an active factor in the pathogenesis and/or progression of endometriosis.
Evaluation of the Impact of Endometriotic Lesions on Patient'S Pelvic Pain Symptoms
Authors: Saccardi Carlo , Borghero Angela , Cosmi Erich , Conte Lorena , Caserta Donatella , Litta Pietro
Published: September 2018

Purpose

To verify if different endometrial lesions determine the diagnostic symptom panel for a specific symptom.

Methods

We recruited 537 women with endometriosis who underwent laparoscopic surgery. Data on patient characteristics, severity of pelvic pain symptoms, disease stage and anatomical characteristics of endometriotic lesions were collected and analyzed by univariate analysis, followed by multiple logistic regression.

Results

We observed a strong inverse relationship between pain symptoms and, respectively, the age of women at surgery (OR 0.885; p<0.05) and nulliparity (OR 5.6; p<0.05). A significant association between dysmenorrhea and nulliparity (OR 10.1; p< 0.01) and dysmenorrhea and rAFS stage (OR 4.7; p<0.05) was also confirmed. Finally a strong relationship was found between the presence of a rectovaginal endometriotic nodule and pain symptoms: dyspareunia (OR 13.8, p<0.001) and dysmenorrhea (OR 2.3, p<0.05). Significant relationships were found between the presence of peri-annexial adherences and, respectively, bilateral endometrioma (p<0.01) and size of endometrioma (p<0.05); between the presence of pelvic adherential syndrome and, respectively, bilateral ovarian cyst (p<0.01), size of ovarian cyst (p<0.01) and rectovaginal nodule (p<0.01). A strong relationship was found also between a rectovaginal nodule and the presence of entero-uterine adherences (p<0.01) and Douglas obliteration (p<0.01). Conclusions: It was not possible determine a precise relationship between a specific pain symptom and the anatomic-surgical characteristics of endometriotic lesions, even though a strong association was seen between a rectovaginal endometriotic nodule and deep dyspareunia. Typical clinical features of endometriosis are probably determined by the association of different characteristics of lesions and different pathogenic mechanisms.
Progestins for the Treatment of Endometriosis: An Update
Authors: Lazzeri Lucia , Luisi Stefano , Petraglia Felice
Published: September 2018

Endometriosis is a gynecological condition that affects approximately 10% of women of reproductive age, including 25–40% of infertile women. Dysmenorrhea, dyspareunia and chronic pelvic pain are the most common symptoms. Currently available medical therapies for endometriosis do not cure the disease, but are directed at symptom relief, typically utilizing the hormone responsiveness of endometriotic tissue to induce lesion atrophy. Unfortunately, pain relapse after treatment suspension is a common event. Treatment with pharmacological therapies for endometriosis should be conceived in terms of years, thus agents that must be withdrawn after a few months due to poor tolerability or severe metabolic side effects do not greatly benefit women with symptomatic endometriosis. The characteristics of progestins render this class an ideal pharmacological choice for administration over extended periods. The present paper will review the rationale for using progestins and their mechanism of action in endometriosis. Thereafter, the results obtained by various progestins in the treatment of endometriosis will be evaluated (danazol, gestrinone, norethisterone acetate, desogestrel, cyproterone acetate, megestrol acetate, medroxyprogesterone acetate, and levonorgestrel). A progestin called dienogest, recently introduced for the treatment of endometriosis, will be given special focus, describing its mechanism of action and clinical results.
Uterine Lymphatic and Blood Micro-Vessels in Women with Endometriosis through the Menstrual Cycle
Authors: Hey-Cunningham Alison J. , Ng Foong Wei , Busard Milou P.H. , Berbic Marina , Manconi Frank , Young Lawrence , Zevallos Hector Barrera-Villa , Russell Peter , Markham Robert , Fraser Ian S.
Published: September 2018

Purpose

Endometriosis is a common disease, associated with persistent and severe symptoms including infertility and pain, however, pathogenesis remains poorly understood. It has been hypothesized that fragments of viable endometrial tissue shed at menstruation reach the peritoneal cavity and other distant sites by retrograde menstruation and dissemination into the lymphatic system. In this study, uterine lymphatic and blood micro-vessel populations were compared in women with and without endometriosis during the menstrual cycle.

Methods

Paraffin-embedded hysterectomy specimens from premenopausal women with histologically normal endometrium (37 control and 42 endometriosis) were obtained. Immunohistochemical staining was performed with antibodies for D2–40 (lymphatic endothelium), CD31 (pan-endothelial marker), and endoglin (activated endothelial cells in angiogenesis). Lymphatic (LVD) and blood (BVD) micro-vessel density were quantified with an automated cellular imaging system using color and morphometric properties to identify micro-vessels.

Results

Subtle but significant differences in uterine BVD and LVD were detected in endometriosis. LVD was significantly increased in basal layer endometrium of endometriosis patients during the proliferative phase (mean ± SD = 54.3 ± 20.1 vs. 41.4 ± 9.9, p = 0.025). Endoglin-positive BVD was increased in the subepithelial region of endometrium in endometriosis during the secretory phase (19.3 ± 16.6 vs. 6.4 ± 8.2, p = 0.038).

Conclusions

This report for the first time demonstrates that endometrial LVD is altered in women with endometriosis and supports changes in BVD in these women. These alterations are likely to contribute to pathogenesis of endometriosis, through lymphatic spread and increased angiogenic potential of shed endometrial fragments.
Factors Affecting the Preferred Surgical Technique in Pediatric Anterior Cruciate Ligament Reconstruction
Authors: Patel Neeraj M. , Talathi Nakul S. , Talwar Divya , Fabricant Peter D. , Kocher Mininder S. , Ganley Theodore J. , Lawrence J. Todd R.
Published: September 2018

Background:

Despite several well-described operative techniques, the optimal management of anterior cruciate ligament (ACL) injuries in pediatric patients remains unclear.

Purpose:

To identify surgeons’ preferred ACL reconstruction techniques and postoperative protocols for pediatric patients of various ages.

Study Design:

Cross-sectional study.

Methods:

An electronic survey was administered to surgeons in the Pediatric Research in Sports Medicine (PRiSM) society, resulting in a cohort of experienced respondents who performed a relatively high volume of ACL reconstructions in skeletally immature patients. Surgeon and practice demographic information was recorded. The survey presented the scenario of a patient who had a physical examination and imaging consistent with an acute, isolated ACL tear. The respondents were asked to select their preferred reconstruction technique for female and male patients at consecutive skeletal ages from 8 to 15 years. Surgeons were also asked about postoperative protocol.

Results:

Of 103 surgeons, 88 (85%) responded to the survey, the majority of whom (68%) performed more than 25 pediatric ACL reconstructions annually. The greatest variation in technique was from ages 11 to 13 years in female patients and from 11 to 14 years in male patients. The modified MacIntosh was the most frequently used technique for patients aged 8 to 10 years. An all-epiphyseal technique was preferred over a broader age range in male patients than female patients, with peak use at age 11 in both. A partial transphyseal (hybrid) technique was preferred in slightly older patients, with peak use at age 12 in female patients and 13 in male patients. The transphyseal technique was most widely used at age 13 and older in female patients and 14 and older in male patients. The impact of fellowship training (pediatrics, sports, or both) on technique preference was statistically significant for male patients aged 11 to 13 and female patients 11 and 12 (all P < .05). Surgeons with pediatric orthopaedic training tended to prefer an all-epiphyseal reconstruction, while those with both pediatric and sports medicine training preferred the modified MacIntosh.

Conclusion:

The preferred ACL reconstruction technique varied considerably, especially for patients aged 11 to 13 years. The modified MacIntosh reconstruction was favored in patients aged 10 years or younger, while the transphyseal technique was preferred in female patients aged 13 years and older and in male patients 14 years and older. The surgeon’s fellowship training was significantly associated with his or her preferred surgical technique.
So What? Inviting Methodological Zealots to Think More Deeply
Authors: Cooper William H.
Published: September 2018

Teaching our successors about the art of theory building can be a challenge. If you have taught a theory-building course in any of our fields, you may have experienced a common hazard: The seminar can devolve into yet another methods course when the more methodologically inclined take over, focusing the class’s attention on the flaws in tests of our theories. I describe a way of transforming these fault-findings into higher-level learning opportunities by asking a simple question: “So what?” Repeatedly asking questions about whether and how much the faults matter can help students become more thoughtful readers of empirical research by moving them beyond the mechanical application of conventional rules to a deeper appreciation of theory-building processes.
Occupational Mobility among Scheduled Caste Workers: A Study in the Pachambha Village of Kaisarganj Block in Bahraich District, Uttar Pradesh
Authors: Butool Falak
Published: September 2018

Occupational mobility actually modifies the real labour income and in turn changes the socio-economic profile of an individual or a family. The occupational mobility may act as a catalyst in case of Scheduled Caste upliftment because they are subjugated since time immemorial. They are still engaged in low-ranked fixed occupations. If they are able to show upward occupational mobility, then their social and economic status will surely improve. But such studies on the occupational mobility of Scheduled Caste population are meagre. Thus in the present work an attempt is made to study occupational mobility and immobility of the Scheduled Caste population. Regional analysis of occupational mobility is necessary for rational planning and legitimate minimization of regional disparities to foster a healthy and balanced development. The historical social exclusion has had a long-run effect, and its inertia is visible from the collected information as a Scheduled Caste cook in the primary school of the Pachambha village is still working as a sweeper in the school. The Chamar family is in the position to open a tea stall in the village but cannot do so because of the historical inertia of untouchability. The study also shows that the Chamar family of Pachambha village has upgraded their occupation significantly. They are more involved in the skin shearing of animals but not working as cultivators or holding their own shop or involved in a clerical job. But Balmikis and Doms1 of the selected village show considerable rigidity in occupational choice as Balmikis are mostly working as sweepers and Doms are mostly working as labourers or as soop makers2 though they can shift to the agricultural and allied activities by purchasing land from the money earned by the out-migrated sweepers and soldiers of the Indian Army.
Impact of Vancomycin Treatment on Human Mesenchymal Stromal Cells During Osteogenic Differentiation
Authors: Bariteau Jason , Kadakia Rishin , Traub Brian , Willett Nick
Published: September 2018

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Vancomycin is often delivered locally for surgical site infection prophylaxis. Recent reports of possible osteotoxicity have led to uncertainty concerning vancomycin’s safety in the setting of arthrodesis and bone healing. Bone formation during arthrodesis takes place as recruited human mesenchymal stromal cells (hMSCs) proliferate and differentiate into mature osteoblasts. The purpose of this research was to determine the impact of vancomycin treatment on hMSCs during osteogenic differentiation.

Methods:

Human MSCs were cultured in MSC growth media to an appropriate confluence. Cells were cultured for 24 hours to facilitate adherence, after which the media was aspirated and replaced with osteogenic differentiation media (Lonza, Switzerland). Osteogenic differentiation media was supplemented with vancomycin powder to yield solutions with concentrations of 0, 50, 500 & 5000 µg/mL. Fresh vancomycin powder was added with every media change. MSCs viability and proliferation were assessed via live/dead staining with 1 µM calcein-AM and 0.5 µM ethidium homodimer-1 (EthD-1) after 1, 3, and 7 days of differentiation and vancomycin treatment. Mineralization of differentiated cells was assessed via staining with 40 mM alizarin red (ARS; pH 4.1) after 21 days. Semi-quantification of the degree of mineralization was performed by measuring absorbance values at 405 nm using a microplate reader. Microscopy was used for qualitative evaluation.

Results:

Cell viability decreased with increasing vancomycin concentrations. Impairment of hMSC proliferation was also observed with increasing concentrations of vancomycin. MSCs treated with 5000 µg/mL vancomycin demonstrated significantly less cell growth compared to all other treatment groups (P=0.0001). Absorbance measurements from each well stained with alizarin red was used for semi-quantification of the degree of mineralization. As vancomycin concentrations were increased, absorbance levels decreased (Figure). This reduction in mineralization was also demonstrated qualitatively; with alizarin red less apparent in the wells with increasing vancomycin concentrations (Figure).

Conclusion:

Local vancomycin is utilized for prevention of infection, often in procedures that necessitate the formation of new bone. Bone healing requires migration, proliferation and differentiation of hMSCs. This work demonstrates impaired viability and function of hMSCs following vancomycin as well as decreased osteoblastic mineralization. Future work will require in vivo studies aimed at determining relative nonunion rates in the setting of vancomycin prophylaxis. Still, the results of this study suggest that vancomycin may be toxic to hMSCs and caution should be exercised by providers when considering vancomycin in foot and ankle patients requiring bony healing following fracture or arthrodesis.
Effect of Bone Morphogenetic Protein-2/Hydroxyapatite on Ankle Fusion with Bone Defect in an Rabbit Animal Model
Authors: Lee Kwang-Bok , Dang Le Hoang Nam
Published: September 2018

Category:

Basic Sciences/Biologics

Introduction/Purpose:

Revision arthrodesis surgery after total ankle arthroplasty failure has a problem related with large bone defect management after implant removal. Although autogenous bone is a standard method for the reconstruction of bone defects, it often causes complications such as wound problem, infection, fracture, hematoma, persistent pain and a limited amount of bone.Recombinant human bone morphogenetic protein-2 (rhBMP-2) has a powerful osteoinductive ability, it plays essential roles in bone regeneration strategies. The purpose of this study is to evaluate the substitute ability of rhBMP-2 for autologous bone in rabbit ankle fusion model with distal tibia bone defect.

Methods:

Bone defect (5 X 5 X 8 mm) was created in the distal tibia between media and lateral malleolus include cartilage. Ankle fusion was performed by 1 cannulated screw from lateral malleolus and various treatments on bone defect. Fifteen male white New Zealand rabbits were divided into three groups of 5 animals on each groups dependent on treatment method; Group I (control, no treatment into defect), II (autogenous bone treatment), III (rhBMP-2/ hydroxyapatite treatment). Bone formation on defect and the union of the ankle joint was evaluated by X-ray, micro-CT scan and histological at 8 weeks and 12 weeks postoperatively.

Results:

X-ray and micro-CT shows higher bone formation on defect in group II and III than group I at 8 weeks and 12 weeks. According to histological results, completely union between distal tibia and talus in group III, partially union in group II and nonunion in group I.

Conclusion:

These findings indicate the BMP-2/Hydroxyapatite has a bone fusion effect comparable to autogenous bone, and suggest that rhBMP-2/Hydroxyapatite can be used to substitute for autogenous bone in ankle fusion with a bone defect, thereby overcome the limitations of autogenous bone.
Medial Structure Injury During Suture Button Insertion Utilizing “Center-Center” Technique for Syndesmotic Stabilization
Authors: Reb Christopher , Brandao Roberto , Van Dyke Bryan , Berlet Gregory , Prissel Mark
Published: September 2018

Category:

Ankle

Introduction/Purpose:

The “Center-Center” technique for syndesmosis fixation has been described as an improved and reliable technique for proper reduction of the syndesmosis during ankle fracture repair. Concurrently, the use of a flexible suture button is becoming an established means of syndesmotic stabilization. The purpose of this cadaveric study was to assess for medial structure injury during the placement of a suture button utilizing the “Center-Center” technique for ankle syndesmotic repair at 3 insertion intervals.

Methods:

Simulated open syndesmosis repair was performed on 10 cadaveric specimens. Three intervals were measured at 10 mm, 20 mm, and 30 mm proximal to the level of the distal tibial articular surface along the fibula. Proper longitudinal alignment of the “Center-Center” technique was completed under fluoroscopic guidance and was marked on the medial aspect of the tibia. The 3 intervals were drilled in the appropriate technique trajectory. The suture button was passed through each drill-hole interval. Using a digital caliper, the distance was measured from each suture button aperture with respect to the anterior tibial tendon, posterior tibial tendon, greater saphenous vein and nerve by single observer.

Results:

The average distance from the suture button to each anatomic structure was -2.61 ± 3.75 mm for the greater saphenous vein, -3.44 ± 6.82 mm for the saphenous nerve, 15.09 ± 4.02 mm for the anterior tibial tendon, and -21.70 ± 4.89 mm for the posterior tibial tendon. Direct impingement of the greater saphenous vein was seen in 11/30 (36.6%) interval measurements. Six of the 11 (54.5%) entrapment intervals occurred at the 10 mm drill hole.

Conclusion:

The results of the present study suggest the use of the “Center-Center” technique for syndesmotic repair with suture button application does involve risk of injury to the greater saphenous vein and saphenous nerve. These injuries could manifest as persistent lower extremity edema and paresthesias for injury to the saphenous vein and nerve respectively. The “Center-Center” technique with suture button fixation may warrant a minimal medial open dissection, prior to quadricortical drilling, for optimal placement to prevent neurovascular injury.
Improved Reduction of the Tibiofibular Syndesmosis with Tightrope Compared to Screw Fixation
Authors: Taylor Michel , Sanders David , Tieszer Christina
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Flexible fixation of the tibio-fibular syndesmosis is designed to allow increased ankle motion and to potentially improve clinical outcomes compared to screw fixation. Flexible fixation has also been suggested to improve the rate of anatomic reduction. This randomized, multi-center study was designed to compare the rate of malreduction following treatment of high fibular fractures associated with syndesmosis injury with open reduction and internal fixation with either two fully threaded screws or one knotless Tightrope device.

Methods:

101 patients from eleven sites were randomized and underwent operative fixation of their AO/OTA 44-C injury between June 2015-16. All patients demonstrated radiographic syndesmosis diastasis or instability following malleolar bony fixation. Open syndesmosis reduction was performed in all cases. Fixation was randomized to either Tightrope (T) or screws (S). Surgical techniques and rehabilitation were standardized. Follow-up at 2 and 6 weeks, 3, 6 and 12 months. The primary outcome measure was the rate of malreduction based on bilateral ankle CT scan results at 3 months post fixation. Secondary outcome measures included adverse events, reoperation, and validated functional outcomes including the EQ5D, OM Score, FADI, and WPAI. The estimated sample size required to detect a difference in reduction rate was 72 patients, but the estimated sample size required to detect a difference in functional outcome scores was 240 patients, suggesting the study was adequately powered for radiographic results only.

Results:

The rate of malreduction was 39% using screws compared to 15% using Tightrope (p = 0.028). Analysis of CT results was performed using a 2 mm translation or 10 degree rotation threshold for malreduction, and included fibular translation, syndesmosis distance, medial compression; and rotation. Patients in Group T had greater anterior translation compared to the contralateral limb (p=0.007) or Group S (p = 0.04). Group T syndesmoses also had greater diastasis compared to control limb (p=.005) and less fibular medialization compared to Group S (p = 0.05). Functional outcome measures demonstrated significant improvements but no differences between groups. FADI scores at each time interval were equivalent. The reoperation rate was higher in the screw group compared to Tightrope (30% vs 4%, p= 0.02).

Conclusion:

Treatment of tibio-fibular syndesmosis injury with the knotless flexible Tightrope device achieves lower rates of malreduction and reoperation compared to screw fixation.
Isolated Intermetatarsal Ligament Release as Primary Surgical Management for Morton’s Neuroma
Authors: Abdelaziz Mohamed , Whitelaw Kathryn , Waryasz Gregory , Guss Daniel , Johnson Anne , DiGiovanni Christopher
Published: September 2018

Category:

Midfoot/Forefoot

Introduction/Purpose:

While the precise pathoetiology of Morton’s neuroma remains unclear, nerve inflammation as a result of chronic entrapment from the overlying intermetatarsal ligament (IML) may play a role. Traditional surgical management involved common digital nerve transection with neuroma excision, but this procedure risks unpredictable formation of a stump neuroma and potential worsening of symptoms. Accordingly, the senior author has over the past six years espoused isolated IML release and common digital nerve decompression in lieu of nerve transection or neuroma excision as an alternative treatment strategy. We hypothesized that IML release offers effective pain relief and high patient satisfaction level as a surgical treatment for recalcitrant Morton’s neuroma without the risk of stump neuroma formation or symptom exacerbation.

Methods:

Medical records for all consecutive patients treated surgically with isolated single interspace IML release for symptomatic and recalcitrant Morton’s neuroma over a four year period at a large academic medical center were examined. Any adult patient with clinically diagnosed Morton’s neuroma who had failed at least three months of conservative treatment and who then underwent single-webspace IML decompression were included. Any patient who had less than three months postoperative follow up, had undergone revisional neuroma surgery, or had undergone additional procedures at the time of the IML release were excluded. Overall patient satisfaction as well as pre- and post-operative Visual Analog Pain Scale (VAS) assessments were recorded for all patients.

Results:

Eleven patients underwent isolated, single interspace IML decompression for Morton’s neuroma over this time frame. One of these patients had a neuroma localized to the second web space and 10 were localized to the third web space. Average follow-up was 10.8± 9 (3-32) months (Table 1). VAS pain scores averaged 6.4 ± 1.9 (4-9) preoperatively and decreased to an average of 1.5 ± 1.6 (0-5) at final follow up (P = 0.003). All patients reported significant pain improvement and an overall satisfaction with the procedure (would undergo it again). No patients returned to the operating room, there were no postoperative infection nor worsening of pain, and no other complications were reported.

Conclusion:

Isolated single interspace IML release of chronically symptomatic Morton’s neuroma shows promising short-term results regarding pain relief and overall patient satisfaction, with few complications and no demonstrated risk of recurrent neuroma formation, permanent numbness, or postoperative symptom exacerbation. The authors’ collective experience with this approach has been positive enough over the past six years to result in the entire abandonment of the practice of neuroma excision in this patient population.
The Influence of Diabetes Mellitus on Ankle Fracture Treatment
Authors: Aiyer Amiethab , Hillam Jeffery , Smyth Niall , Kaplan Jonathan
Published: September 2018

Category:

Trauma

Introduction/Purpose:

Diabetes mellitus is an epidemic affecting millions of individuals in the United States. This presents a challenging clinical problem from a surgical perspective, because of concerns for postoperative complications, including delayed wound healing, infection or compromise of fixation/repair constructs. The goal of this paper was to retrospectively review outcomes data from the American College of Surgeons: National Surgical Quality Improvement Program (ACS-NSQIP) to delineate more clearly the impact that diabetes has on operative treatment of ankle fractures, including bimalleolar and lateral malleolar injuries.

Methods:

Patients were identified from the 2006-2015 ACS-NSQIP database. Diabetic and non-diabetic cohorts were evaluated to compare demographics, comorbidities, perioperative details and 30-day outcomes. Univariate analysis was performed using chi-squared or Fisher’s exact and Wilcoxon signed-rank tests. A multivariate logistic regression model was created to identify independent risk factors for complications. Odds ratios were computed at the 95% confidence interval.

Results:

There were a total of 3745 (bimalleolar injuries [1579], lateral malleolar injuries [2166]) patients identified. With regard to treatment of distal fibular or bimalleolar injuries, diabetic patients were more likely to have a longer length of hospital stay (p < 0.05). Based on multivariate analysis, diabetic patients undergoing operative fixation of bimalleolar injuries are at higher risk for superficial incisional surgical site infection (SSI) (OR 3.26; p=0.01), any complication (OR 1.73; p<0.001), myocardial infarction (OR 10.89; p=0.046), and readmission (OR 2.38; p=0.01). In the setting of lateral malleolar fracture operative fixation, diabetic patients were at higher risk for any complication (OR 2.48; p=0.002), return to OR for unexpected complications (OR 5.88; p<0.001), and urinary tract infection (OR 4.72; p=0.03)

Conclusion:

Based on upon the results of this study, diabetic patients are at higher risk for postoperative complications after ankle fracture fixation, namely infection and re-operation and readmission to the hospital within 30 days after surgery. This information can help clinicians guide patients appropriately prior to surgery.
The Effect of Depression on Pain Perception and Function in the Foot and Ankle Patient
Authors: Alejandro Shannon , Geswell Matthew , Grandizio Louis , Graham Jove , Cush Gerard
Published: September 2018

Category:

Other

Introduction/Purpose:

Foot and ankle (FA) pain can be found in up to 20% of the adult population.1 Etiologies are multifactorial and include neurologic injury, trauma, deformity, tendinopathies and psychological factors. The purpose of this investigation is to assess psychological factors contributing to FA pain in surgical and nonsurgical patients. By identifying how psychological factors influence patient reported pain and disability, clinicians may be able to develop interventions to decrease catastrophic thinking and improve psychological well-being prior to considering surgical intervention

Methods:

All patients seen in a FA clinic by a single fellowship trained orthopaedic surgeon from August 2016 to October 2016 were included. All patients completed 5 functional assessments prior to their visit (PHQ-2, VAS Pain Scale, FAAM, PSEQ, PCS). We divided the patients into two groups based on their performance on the PHQ (PHQ < 3, or PHQ = 3), which measures depression. Scores = 3 are indicative of clinical depression. Nonparametric Wilcoxon testing was used to determine whether the distributions of the other scores (VAS Pain Scale, FAAM, PSEQ and PCS) were significantly different between these two groups.

Results:

Of the 225 patients included in our analysis, there were 175 (88%) had PHQ-2 depression scores of < 3 (Group 1) and 50 (22%) had scores = 3 (Group 2). Group 2 demonstrated a statistically significant increase in VAS Pain Scale and PCS. In addition, patients in Group 2 showed statistically significant decreases in FAAM and PSEQ. Patients in Group 2 were statistically more likely to be obese, use tobacco, and be unemployed.

Conclusion:

In patients with common FA complaints, those with clinical depression, as assessed by the PHQ-2, demonstrated increased pain scores, decreased ability to cope with pain, and lower functional outcome scores compared to patients without depression. Tobacco use, obesity and employment status were found to independently affect pain, coping, and function of patients. These data suggest that depression can significantly affect a patient’s ability to cope with pain and to achieve a higher functional outcome. This data suggests patients with depression may have increased difficulty coping with their FA ailment leading to the need for increased counseling regarding expected outcomes.