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Purpose To determine the proximity and potential risks to distal leg anatomy from anterior to posterior (A-P) applied distal tibia locking screws for tibial nailing. Design Retrospective. Setting ACS level I trauma center. Patients/participants Twenty consecutive adult patients undergoing computed tomograms with intravenous contrast (computed tomography angiograms) on uninjured legs. Main outcome measurements Simulated 5-mm distal interlocking screws placed in the A-P axis of an ideally placed tibial nail at 10-mm increments from the tibial plafond (10-40 mm) were studied in relation to the distal leg's anterior anatomy. Results All A-P screws (80/80, 100%) impacted the tibialis anterior tendon, extensor hallucis longus tendon, and/or anterior tibial neurovascular (NV) bundle between 10 and 40 mm cranial to the plafond. The NV bundle was impacted in 53% of cases. The medial extent of the tibialis anterior tendon was greatest 10 mm cranial to the plafond and averaged 27 degrees (95% confidence interval, 22-33 degrees) medial to the A-P line. The maximum lateral border of the foot's common extensors, found 40 mm cranial to the plafond, averaged 71 degrees (95% confidence interval, 62-80 degrees) lateral to the A-P line. Discussion The anterior tibial NV bundle and foot and ankle extensor tendons are at high risk from A-P-directed distal locking screws. The tendinous anatomy of the distal leg is at risk between 33 degrees medial and 80 degrees lateral to the A-P axis of a tibial nail. Distal locking screws placed from the A-P direction should be thoughtfully applied and an open approach should be strongly considered.

Actinomycosis is a relatively uncommon bacterial disease of childhood, especially when presenting as deep-seated infections. Only 10% of affected patients are younger than 18 years of age. In children, cervical actinomycosis is the most common form of clinical presentation, and among the abdominopelvic form, renal abscesses are rare. We describe an uncommon and severe case of a five-year-old Costa Rican girl with thoracic and renal actinomycosis who required a complete nephrectomy.

To report on the immediate postoperative alignment of distal tibia fractures (within 5 cm of the tibial plafond) treated with suprapatellar intramedullary nail (IMN) insertion compared with the infrapatellar technique. Primary outcomes include alignment on both the anteroposterior and lateral radiographic views.Retrospective cohort study.Two urban level I trauma centers.A total of 266 skeletally mature patients with a distal tibia fracture were treated with an IMN. One hundred thirty-two patients underwent this procedure through a suprapatellar technique.Intramedullary nail placement.Alignment.The 2 treatment groups were evenly matched with respect to age, gender, fracture grade, and the presence of open fracture. Within the suprapatellar group, the fibula was intact, fixed, and remained fractured in 6 (4.5%), 22 (16.7%), and 104 (78.8%) cases, respectively. The fibula was intact, repaired, and remained fractured in 9 (6.7%), 32 (23.9%), and 93 (69.4%) cases, respectively, in the infrapatellar group. There was no difference in the rate of fibular fixation between the groups (P = 0.2). Primary angular malalignment of ≥5 degrees occurred in 35 (26.1%) patients with infrapatellar IMN insertion and in 5 (3.8%) patients who underwent suprapatellar IMN insertion (P0.0001).This is the largest patient series directly comparing the suprapatellar with infrapatellar IMN insertion technique in the treatment of distal tibia fractures. In the treatment of distal tibia fractures, suprapatellar IMN technique results in a significantly lower rate of malalignment compared with the infrapatellar IMN technique.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Anxiety disorders affect approximately 40 million Americans ages 18 and over (NIMH, 2015). Although qualitative and small-scale quantitative neurofeedback (NF) studies show reduction in anxiety symptoms, large-scale studies and quantitative electroencephalogram (qEEG) driven protocols are non-existent. This retrospective pilot study intended to assess whether qEEG guided amplitude NF is viable in symptom reduction of anxiety. Methods: Nineteen clients were assessed for anxiety, 14 were included in the data. Demographics include age ranges from 11–61 (M = 31.71, SD = 16.33), 9 male and 5 female; six identified as Caucasian, five as Hispanic/Latino, and three Caucasian/Hispanic ethnicity. Pre- and post-assessments included the Zung Self-Rating Anxiety Scale, Screen for Child Anxiety Related Disorders (SCARED), and the Achenbach System of Empirically Based Assessment (ASEBA). Clients received 30-min qEEG guided NF treatment sessions, twice a week. The range of attended session was 7–28 (M = 12.93, SD = 6.32). Results: Enhancement in clients’ well-being was evidenced by statistically significant improvement in symptom measures scores. Although improvements for the two most anxiety-related categories on the ASEBA were not significant, other anxiety-related categories did show significant improvement. Yet, qEEG findings were not statistically significant. Directions for future research are discussed.

GV is a 76-year-old man who complains of severe left hip pain after a fall from standing height. He was transferred to the emergency department by EMS. On presentation, he demonstrates a GCS of 15 and denies any loss of consciousness. On primary survey, his airway is patent, and he is hemodynamically stable. On secondary survey, he demonstrates severe pain with passive range of the left hip. His secondary survey is otherwise negative.

To determine whether certain patterns of pelvic ring injury are associated with more frequent intrauterine fetal demise (IUFD).Retrospective review.Level 1 trauma center.Of 44 pregnant patients with pelvic and/or acetabular fractures, 40 had complete records that allowed determination of fetal viability. χ2 tests were used for categorical variables (Fisher exact tests when expected cell counts were fewer than 5), and t tests were used for continuous variables.Fetal or maternal death.Sixteen patients had isolated acetabular fractures, 25 had isolated pelvic ring injuries, and 3 had acetabular fractures with concomitant pelvic ring injuries. Maternal and fetal mortality were 2% and 40%, respectively. No patients with isolated acetabular fractures experienced IUFD, compared with 68% (15/22) of those with isolated pelvic ring injuries (P0.0001). Eight (53%) of 15 IUFDs were associated with lateral compression (LC)-I pelvic ring injuries (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 61-B2). Of the 13 LC-I pelvic ring injuries, 8 (62%) resulted in IUFD. Pelvic ring stability, Young-Burgess classification, and operative treatment were not associated with IUFD. Maternal Glasgow Coma Scale (average 13.2) and Injury Severity Score (average 18.2) at admission were predictive of IUFD.The most frequent pelvic fractures in gravid trauma patients are LC-I. Although the rate of maternal mortality was low, the risk of IUFD was quite high (40%). LC-I pelvic ring injuries often had catastrophic outcomes, with IUFD in 62% of cases.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives We hypothesize that the anatomic center of the distal tibia is just lateral and anterior to the center of the distal tibia articular surface in the coronal and sagittal planes, respectively, and that placement of the nail along this axis results in improved rates of malalignment when treating distal tibia fractures. Design Retrospective study. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. Setting One Level I and one Level II trauma center. Patients/participants Two hundred three distal tibia fractures treated with intramedullary nailing (IMN) (primary cohort) whose main fracture line extended within 5 cm of the plafond to evaluate the rate of malalignment with distal nail placement. Additionally, we retrospectively reviewed a secondary cohort of 15 patients with proximal tibia fractures treated with intramedullary nailing for evaluation of passive anatomic distal nail position. Main outcome measures Primary malalignment ≤5 degrees on the anteroposterior (AP), mortise, and lateral planes were evaluated in distal tibia fractures on perioperative radiographs. Results Primary Cohort: 85 patients met inclusion criteria for evaluation in the coronal plane. Overall malalignment in the coronal plane was 17.6%. There was a 2.9% (1/34) fracture malalignment rate when the nail was placed lateral to the center of the joint versus 27.5% (14/51) when placed medial to the center of the joint, with all occurring in valgus. This achieved statistical significance (P = 0.04). Correlation was highest when measuring the trajectory on mortise view using the talus as reference point. When evaluating the sagittal plane, there were 64 patients that met inclusion criteria with a 48% malalignment rate. Malalignment was greatest when the nail was placed in the anterior quadrant 100% (4/4), versus 50% (22/44) in the anterior middle, and 31.3% (5/16) in the posterior middle quadrant. This achieved statistical significance (P = 0.05). No nails were placed in the most posterior quadrant. Secondary Cohort: 15 patients met inclusion criteria for distal nail placement. The position of the nail in the coronal plane was measured on both the anteroposterior and mortise ankle radiographs using both the plafond and talus as a reference, whereas sagittal nail placement was measured on the lateral ankle radiographs. In the coronal plane, the mean passive distal position of the nail when referenced from the lateral cortex was 45.2% of the tibia plafond and 45.5% the width of the talus, or just lateral to the center of each. In the sagittal plane, passive nail placement was 40% the sagittal width of the joint measured from the anterior cortex, or just anterior to the center of the joint. Conclusions This is the first patient series that defines optimal tibial nail placement in the treatment of distal tibia fractures. Distal placement of the nail just lateral to the center of the talus and plafond, or along mechanical axis of the tibia, results in significantly reduced rates of malalignment on the coronal plane when compared to nail placement medial to the center of the talus or plafond. Fluoroscopic judgment of distal nail trajectory was improved on the mortise view using the talus as a reference when compared to using the anteroposterior view. On the sagittal plane, anatomic passive nail placement is just anterior to the center of the plafond. However, nonanatomic nail placement just posterior to the center of the plafond had a lower incidence of malalignment compared with nails placed anterior to the center of the plafond. Further study of appropriate nail positioning on the sagittal plane is needed.

Primary Lisfranc fracture/dislocation is a midfoot injury that results in disruption of the main plantar-stabilizing ligaments of the arch of the midfoot and may result in posttraumatic arthritis and deformity. It may be treated with open reduction internal fixation (ORIF) and/or primary arthrodesis. Primary arthrodesis and ORIF have been shown to have similar clinical outcomes; however a lower reoperation rate may exist with the former. Obtaining an anatomic reduction, regardless of the method of fixation, is crucial to good clinical outcomes.

Background Traumatic disruption of the pelvic ring is a significant cause of life-threatening hemorrhage. For those patients who survive the initial injury, these fractures are associated with long periods of immobilization and intense rehabilitation. There is little published information available regarding long-term functional outcomes in these patients. This study evaluated the impact of severe pelvic fractures on those long-term outcomes. Methods All patients with severe pelvic fractures over an 18-year period were identified. Severe pelvic fractures were defined as those with vascular disruption, open-book component with symphysis diastasis, or sacroiliac disruption with vertical shear. Functional outcome was measured using the Boston University Activity Measure for Post-Acute Care to assess mobility (normal, >84) and daily activity (normal, >84). Multiple linear regression analysis was used to identify predictors of functional outcome after severe pelvic fracture. Results From January 1996 to September 2014, 401 patients were identified: 240 (60%) men and 161 (40%) women. Overall mortality was 29%. Of the 285 survivors, follow-up was obtained in 145 patients (51%). Mean follow-up was 8.3 years, with a maximum of 20 years. Mean age and Injury Severity Score were 53 years and 27, respectively. Mean Activity Measure for Post-Acute Care scores for mobility and daily activity were 55 and 63, respectively; both signifying significant impairment when compared with normal. Multiple linear regression analysis using age, traumatic brain injury, transfusions, Injury Severity Score, ventilator days, presence of associated lower-extremity fractures, and time to operative pelvic fixation identified time to pelvic fixation as the only predictor of decreased mobility (β = -0.74, p = 0.04) and activity (β = -0.21, p = 0.03) following severe pelvic fracture. Conclusions Prolonged time to operative pelvic fixation led to worse long-term functional outcomes in patients with severe pelvic ring disruption. Early fixation of the pelvic ring is the only potentially modifiable risk factor for decreased functional outcomes in patients with severe pelvic fractures. Level of evidence Therapeutic study, level IV.

CH is a 50-year-old male pedestrian struck by a car with a chief complaint of right leg pain. Given the mechanism of injury, he was brought in by ambulance as trauma activation and evaluated using the Advanced Trauma Life Support (ATLS) protocol. Subsequent secondary and tertiary surveys were notable for an isolated closed fracture of the right proximal tibia without neurovascular deficit (Fig. 8.1a, b). He was placed in a long-leg splint for stabilization until definitive fixation; his compartments were serially monitored by clinical exam; and a CT scan evaluation for fracture extension into the tibial plateau was negative (Fig. 8.2a, b).

Spindle cell carcinoma of the breast, a variant of metaplastic carcinoma, includes a wide spectrum of lesions with histomorphologic and nuclear features ranging from overtly malignant to mildly atypical. Spindle cell carcinomas with mildly atypical features may resemble fasciitis, fibromatosis, or myofibroblastic tumors and therefore are often misinterpreted as such. A recent study has suggested that spindle cell carcinomas with a dominant fibromatosis-like phenotype, unlike spindle cell carcinomas in general, have no propensity for distant metastasis and should be termed "tumors" rather than "carcinomas." To investigate the question of fibromatosis-like spindle cell breast carcinoma (FLSpCCs) metastatic potential, we studied cases of FLSpCC seen at the University of Texas M.D. Anderson Cancer Center between 1987 and 2000. Clinical, pathologic, and immunophenotypic features were reviewed, with emphasis on biologic behavior and predictors of clinical outcome. Our series included 24 women who ranged in age from 55 to 85 years (mean 66 years). Tumor size ranged from 1.0 to 5 cm (mean 2.8 cm). Most tumors were grossly well defined but had microscopic infiltrative borders. Tumors showed a dominant fibromatosis-like or myofibroblastic-like growth pattern with prominent collagenization. Inflammatory infiltrate was noted in the majority of tumors. Cytokeratin-positive cells were seen in all cases and usually appeared as cords or sheets of polygonal cells; isolated cytokeratin-positive cells were rare. In most tumors immunoreactivity for smooth muscle actin (SMA) was confined to the cytokeratin-negative cells. In five cases intense co-expression of cytokeratin and SMA was noted. None of the tumors showed immunoreactivity for smooth muscle heavy chain myosin, estrogen receptors, progesterone receptors, or HER-2/neu. Ki-67 expression was noted in fewer than 5% of tumor cells. Treatment consisted of local excision (seven cases) or modified radical mastectomy (13 cases). Treatment was unknown in four cases. In patients who underwent axillary nodal dissection, no lymph node metastases were found. Two of the six patients who underwent local excision developed local recurrence. Two patients who underwent modified radical mastectomy developed lung metastases within 2 years after the initial diagnosis. The metastatic tumors were histologically similar to the primary tumors. Our findings indicate that FLSpCCs have the potential for local recurrence and distant metastasis and should be treated accordingly. Because FLSpCCs may be underdiagnosed as benign, the use of immunohistochemical studies, especially for cytokeratins and SMA, is essential in the evaluation of any spindle cell proliferations of the breast.

We demonstrate that a bilayer composite hydrogel composed of corneal stroma crosslinked to poly(ethylene oxide) provides a substrate suitable for wound healing behavior of corneal epithelial cells and for formation and maintenance of a stable multilayered epithelium. Potential diffusion-limitation of nutrients or regulatory molecules across the hydrogel was investigated experimentally with a new in vitro ocular assay, using epithelial cell migration as an index of molecular diffusion limitations. Corneal epithelial cells explanted on the composite hydrogel in vitro exhibited morphology similar to those in vivo, and migrated effectively over the stromal surface. Importantly, our system yielded multilayered epithelium like that found in normal corneal tissue under conditions that closely simulate the in vivo physiologic arrangement. In addition, our results indicate that molecules of substantially greater molecular weight than glucose appear to control the cell migration rate. Thus, engineering design of this composite hydrogel system may allow it to be useful in corneal wound healing applications.

This position paper provides a strawman reference model which can be used to compare and reason about an application program's interface (API) to an Object-Oriented Data Base system (OODBs), with an emphasis on object manipulation from an object-oriented programming language binding. 1 We begin with an introduction of OODBs and describe the broad domain for an OODB reference model as well as the specific sub-domain we will discuss. Next, we describe some goals of the reference model for the specific sub-domain. A descriptive reference model is then described as consisting of a collection of design choices that can be used for comparing existing and future application program interfaces to OODBs. Finally, based on the descriptive reference model, we define a functional reference model that provides a much more precise description of the interface provided by one such OODB, Zeitgeist, being developed at Texas Instruments.

Objectives: The purpose of this cadaveric study was to evaluate whether there is any damage to the gluteus medius tendon when reaming through a modified medial trochanteric portal for antegrade intramedullary femoral nailing. Methods: Ten cadaver hips were used in this study. A guidewire was placed in the modified medial trochanteric portal using the assistance of C-arm fluoroscopy and a 14-mm reamer was advanced over the wire. After the reaming was complete, each hip was dissected and the gluteus medius muscle and tendon were inspected to evaluate the amount of intrasubstance and medial tendon damage. Results: Precise localization of the modified medial trochanteric portal was achieved in 9 of 10 cadaver hips. Of those nine hips, the use of the modified medial trochanteric portal did not result in any visible damage to the tendinous insertion of the gluteus medius or the medial aspect of the tendon in any of the specimens. Conclusions: There is no damage to the gluteus medius tendon with the use of the modified medial trochanteric portal. Although the clinical implications of this finding are not known with certainty, the use of the modified medial trochanteric entry portal for antegrade femoral nailing could possibly result in less postoperative morbidity because it does not damage the gluteus medius tendon as compared to the traditional more lateral trochanteric portal.

As far back as the ninth century BCE in Greece, a talent was a form of currency. In the 21st century, talents remain currency as the special gifts of knowledge, skills, and personal characteristics that individuals bring to organizations. Talent management, also known as human capital management, HCM, is a focus of leadership studies that increasingly strives to acknowledge and measure the tangible contributions that individuals make to the bottom line. In this symposium, we offer a position paper by Ted Harro and Leslie Miller who detail an innovative approach to address how leaders of organizations can create a consistent, positive flow of talent necessary to support success. Our respondents, Karen Kirwan, Dave Wondra, and Edward Perez, each add their perspectives to this timely discussion.

PURPOSE: We studied the efficacy of using radial keratotomy incisions as a surgical method of increasing outflow facility in enucleated bovine eyes. METHODS: Each freshly enucleated bovine eye (n=23) was cannulated to a system measuring the rate of flow into the eyes. Preoperatively, corneal thickness measurements were determined for all treated eyes. Radial keratotomy was performed in 13 eyes and a control set of eyes (n=10) had no surgical manipulation. The intraocular pressure was set at 16.9mm Hg. A clear zone of 10 mm was used for each eye with the incision depth set at 100% of the pachymetric reading. One set of experimental eyes had incisions that remained in the clear cornea, and the other set had incisions that reached 2 mm beyond the limfaus into sclera. Preoperative outflow measurements were performed on each eye. Postoperative measurements were made after 10 incisions and 20 incisions. All eyes were checked for perforation after surgery and discarded if a perforation was found. RESULTS: No eye included in the analysis was perforated. The preoperative (baseline) total flow rate was 27.90 ± 3.72 µ 1/min at 16.9 mmHg. The flow rate increased by 23.5% (over baseline) with 20 radial keratotomy incisions. A paired i-test was used to statistically compare the outflow measurements before radial keratotomy and after the first and second set of radial incisions. The increases in flow were found to be statistically significant (P CONCLUSION: Assuming the flow measurements (flow rate) in these experiments parallel outflow facility, radial keratotomy increases the outflow facility in enucleated bovine eyes. [J Refract Surg 1998;14:641-645]