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Background: For the younger, more active patient with flexible symptomatic progressive collapsing foot deformity (PCFD), joint-sparing procedures may be preferred to preserve functional motion. Isolated talonavicular (TN) arthrodesis has been described for treatment of rigid and flexible PCFD for patients that are older and less active whose deformity is still correctable through the TN joint. The purpose of this study was to evaluate radiographic and clinical outcomes in patients with PCFD treated with isolated triplanar correction with a TN joint arthrodesis., Methods: Forty-nine patients (53 feet) with flexible PCFD underwent isolated TN arthrodesis. Weightbearing radiographs were performed pre- and postoperatively, and measurements included lateral talar-first metatarsal angle, calcaneal pitch, TN coverage angle, and the anteroposterior (AP) talar-first metatarsal angle. The Foot and Ankle Ability Measure (FAAM) and Veterans-Rand 12-Item Health Survey (VR-12) scores were also collected., Results: Thirty-five females and 14 males were evaluated with a mean age of 63 years, at an average follow-up of 41.3 months. Significant improvements were found radiographically. Lateral radiographs demonstrated improvements in lateral talar-first metatarsal angle from 25.2 degrees preoperatively to 9.5 degrees postoperatively ( P  < .001) and calcaneal pitch from 14.9 degrees preoperatively to 17.5 degrees postoperatively ( P  < .001). AP radiographs showed the TN coverage angle improving from 35.0 degrees to 4.9 degrees postoperatively ( P  < .001) and AP talar-first metatarsal angle improving from 17.3 degrees to 5.9 degrees postoperatively ( P  < .001). Clinical outcomes were improved in the FAAM pain score (48.6 to 39.2, P  = .130), FAAM ADL score (53.8 to 69.2, P  = .002), FAAM Sport score (29.5 to 40.7, P  = .099), and the overall FAAM score (47.7 to 63.1, P  = .006). Patient satisfaction with medical care was 85.2/100 postoperatively., Conclusion: Isolated TN arthrodesis is a viable surgical option for older, lower-demand patients with flexible PCFD. This study demonstrated significant improvements in radiographic alignment and FAAM scores. Comparative studies with other surgical procedures should be performed to determine which is the best technique for older, lower-demand patients with flexible PCFD., Level of Evidence: Level III, retrospective cohort study., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online., (© The Author(s) 2024.)

Purpose: Patients with carpometacarpal (CMC) osteoarthritis (OA) often present with metacarpophalangeal (MP) hyperextension and/or thenar atrophy. This study hypothesizes that MP fusion (MPF) performed at the time of CMC arthroplasty (CMCA) for patients who have moderate-to-severe thenar atrophy, MP hyperextension >30°, or MP arthritis will have greater long-term pinch strength and improvements in the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score from preoperative values when compared with the unoperated side or those who had CMCA only., Methods: This study involved a retrospective review of long-term results from patients who underwent either CMCA or CMCA/MPF. The QuickDASH score, the pain visual analog scale (VAS), and an average of three pinch readings from each thumb were measured on the Baseline pinch gauge and recorded with a correction for hand dominance in right-handed patients., Results: Fifty-three female patients with 70 operated thumbs were included in the study. The mean age was 67.2 years. There were 29 CMCAs and 41CMCA/MPFs. The mean follow-up was 6.3 years (range 2-16.9 years). At the latest follow-up, the mean CMCA/MPF pinch strength (11.3 lbs) was significantly stronger than that of CMCA (8.0 lbs) and carpometacarpal osteoarthritis thumbs (8.9 lbs). There was no significant difference in pinch strength between patients who underwent a CMCA and CMCOA thumbs (8.0 lbs vs 8.9 lbs, respectively). Preoperative QuickDASH demonstrated worse function in the CMCA/MPF group (55.8 vs 36.5). At the latest follow-up, QuickDASH and VAS revealed similar values in both the CMCA/MPF (10.5 and 0.66) and CMCA (18.5 and 0.52) groups., Conclusion: Long-term results demonstrate stronger pinch and greater improvement in QuickDASH scores in patients who underwent CMCA/MPF compared with those who underwent a CMCA or untreated carpometacarpal osteoarthritis thumbs., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Research on improving dancer fitness to enhance performance capacity and prevent injury continues to grow. Fitness research for the adolescent dance team population, however, presents an evidence void., Purpose: Utilizing studio-based assessments, this descriptive quantitative study reveals an initial set of fitness normative values for the female adolescent competitive dance team dancer population., Methods: 115 female dance team dancers ages 12 to 17 participated in a 90-minute field test assessment battery for cardiorespiratory fitness, muscle endurance of the upper body, lower body, and core, and lower extremity power. Descriptive statistics (mean, standard deviation, and interquartile range) created an initial set of quantitative fitness normative values for this population., Results: Dancers' results revealed 29.5mL/O2×min ± 5.7 estimated VO2max, 35 ± 16 push ups, 62 ± 14 half sit ups, 51 ± 13 squats in 1 minute, 190 ± 23 cm broad jump, 445 ± 65 cm right lower extremity triple hop, and 450 ± 69 cm/left lower extremity triple hop., Conclusion: Discussion includes comparison of findings relative to previously established adolescent fitness and dancer normative data. Discussion also suggests implications, study limitations, and future research directions.

Despite the importance of high-latitude surface energy budgets (SEBs) for land-climate interactions in the rapidly changing Arctic, uncertainties in their prediction persist. Here, we harmonize SEB observations across a network of vegetated and glaciated sites at circumpolar scale (1994-2021). Our variance-partitioning analysis identifies vegetation type as an important predictor for SEB-components during Arctic summer (June-August), compared to other SEB-drivers including climate, latitude and permafrost characteristics. Differences among vegetation types can be of similar magnitude as between vegetation and glacier surfaces and are especially high for summer sensible and latent heat fluxes. The timing of SEB-flux summer-regimes (when daily mean values exceed 0 Wm -2 ) relative to snow-free and -onset dates varies substantially depending on vegetation type, implying vegetation controls on snow-cover and SEB-flux seasonality. Our results indicate complex shifts in surface energy fluxes with land-cover transitions and a lengthening summer season, and highlight the potential for improving future Earth system models via a refined representation of Arctic vegetation types., (© 2022. The Author(s).)

Abstract: Despite trends showing increases in the utilization of outpatient (OP) ambulatory surgery centers (ASCs) and decreases in the utilization of inpatient (IP) facilities for total knee arthroplasty (TKA) and total hip arthroplasty (THA), little is known about opioid prescribing for these procedures between each setting. This study evaluated differences in opioid prescribing and consumption between OP ASC and IP settings for elective TKA and THA surgeries over a 1-year period. Data collection also included pain and satisfaction of pain control postsurgery. In an OP ASC, analysis revealed a significant decrease in pills prescribed (p < .001, p < .001) and consumed (p < .001, p < .001) for TKA and THA, respectively. There was a significant decrease in the morphine equivalence units prescribed (p < .001, p < .001) and consumed (p < .001, p < .001) for TKA and THA, respectively. For TKA, pain was significantly lower (p = .018) and satisfaction of pain control was significantly higher (p = .007). For THA, pain (p = .374) and satisfaction of pain control (p = .173) were similar between the settings. Benefits of performing these surgeries in an OP ASC setting are patients having similar or lower levels of pain and having similar or higher satisfaction of pain control. Patients are also prescribed and consume less opioids. This has important implications for healthcare systems., Competing Interests: O.R. O'Neill reports paid consultancy and paid presentations from Medtronic. He also reports stock or stock options in Proventus Software and Responsive Sports. S.D. Anseth reports research support as a principal investigator from Zimmer Biomet. M.R. Giveans reports paid consultancy with MedTrak Inc and Superior Medical Experts. The remaining authors declare no conflicts of interest., (Copyright © 2021 National Association for Healthcare Quality.)

Background: Short- and midterm follow-up studies suggest that arthroscopic labral refixation/preservation leads to superior outcomes compared with labral excision/debridement., Purpose: To update the previous early (16 months) and midterm (mean, 42 months) follow-up of this cohort, which reported better patient-reported outcome measures and lower failure rates in the repair/refixation group., Study Design: Cohort study; Level of evidence, 3., Methods: The authors identified patients who underwent labral debridement/focal labral excision during a period before the development of labral repair techniques. A consecutive group of patients within the labral debridement group thought to be repairable with the authors' current arthroscopic techniques were compared with a group of consecutive patients who underwent labral repair/refixation. In 46 hips, the labrum was focally excised/debrided consistent with pincer- or combined pincer- and cam-type impingement; in 54 hips, the labrum was repaired/refixed. Subjective outcomes were measured with the modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) for pain preoperatively and postoperatively., Results: The mean age was 34.0 years in the debridement group and 28.3 years in the repair/refixation group, with a mean follow-up of 7.3 years (range, 2-13.6 years). At the mean follow-up of 7.3 years, subjective outcomes were significantly improved ( P < .01) for both groups compared with preoperative scores. The mHHS ( P = .008), SF-12 score ( P = .012), and VAS pain score ( P = .002) were all significantly better for the repair/refixation group compared with the debridement group. Although most recent outcomes for both groups fell slightly at the mean follow-up of 7.3 years in comparison with the 16-month and 3.5-year follow-ups, these differences were not significant. However, the failure rate in the debridement group did get significantly worse ( P = .014). Good to excellent results were 47.7% in the debridement group and 86.3% in the refixation group ( P < .001), and failure rates were 30.4% (debridement) and 13% (refixation) ( P = .033). There were 4 revisions in the debridement group and 3 revisions in the refixation group., Conclusion: Longer term, >7-year follow-up comparing focal labral excision/debridement with repair/refixation revealed better patient-reported outcomes and lower failure rates in the labral repair/refixation cohort. Additionally, despite an absolute decrease in patient-related outcome scoring and number of good/excellent results in both groups compared with the 3.5-year report, there was a significantly greater increase in failure rates over time for the excision/debridement group with better maintenance of good to excellent results in the repair/refixation group.

Purpose: Arthrodesis of the distal interphalangeal joint of the fingers and interphalangeal joint of the thumb is a common procedure for multiple diagnoses. The purpose of this study was to evaluate fusion rates and complications in patients who have been previously implanted with an X Fuse superelastic implant (Stryker)., Methods: All patients who underwent distal interphalangeal and/or thumb interphalangeal joint fusion between June 2013 and May 2019 were included by the senior author. A chart review was used to note demographics; hand dominance; and medical and surgical history, including complications, comorbidities, clinical recovery, absence of pain, and functional use. Pre- and postoperative radiographs were evaluated for angular deformity, postoperative correction of that deformity, boney consolidation, and tine cutout., Results: Fifty-three patients (60 fingers; 43 women and 10 men) with a mean age of 62.6 years were included. The surgical diagnoses included hereditary osteoarthritis in 45 patients, rheumatoid arthritis in 4, psoriatic arthritis in 1, swan or mallet fingers in 5, ulnar motor loss instability in 2, and trauma or a fracture in 3. For X Fuse, an implant angle of 0° was used in 51 cases, whereas 15° was used in 9 cases. Bone consolidation was observed in all but 1 patient at an average time of 9.7 weeks (range 4.1-17.6 weeks). The X Fuse superelastic implant in small bones demonstrated minimal complications and a 98% (59/60) fusion rate., Conclusions: The X Fuse superelastic implant produced a reliable fusion, with no implant prominence and a 1.7% (1/60) rate of hardware removal., Type of Study/level of Evidence: Therapeutic IV., (© 2021 The Authors.)

BACKGROUND: Prior literature has reported on the concerning emergence of opioid overprescribing, yet there remains a lack of knowledge in understanding the cost of waste of this over-prescription and underconsumption of opioids. As such, further investigating the cost of waste of opioids following orthopedic surgery is of interest to patients, providers, and payors. In one of the largest private orthopedic practices in the United States, opioid prescribing and consumption patterns were tracked prior to, and after the implementation of, formal prescription guidelines. OBJECTIVES: To (1) establish the cost of waste of unused opioids before the implementation of formal prescription guidelines and (2) examine how the cost of unused opioids may be reduced after implementation of formal internal prescription guidelines. METHODS: Two separate phases (Phase I and Phase II) were implemented at different time intervals throughout a two-year period. Implementation of prescription guidelines occurred between Phases I and II, and data from Phase I (pre-implementation) was compared to that from Phase II (postimplementation). Data collection included type, dosage, quantity of opioids prescribed and consumed after elective outpatient procedures in ambulatory surgery centers, in addition to patient interviews/surveys within two weeks after surgery to measure consumption. From these data, the cost of waste was calculated by taking the total cost of prescribed opioids (sum of each prescription × Average Wholesale Price (AWP) minus 60%) per 1,000 patients, and subtracting the total cost of consumed opioids per 1,000 patients, calculated in a similar manner. Further analysis was performed to describe differences in the cost of waste of individual opioids between each of the phases. RESULTS: In Phase I, prior to implementation of formal internal prescription guidelines, there was a sizable cost of waste of unused opioids (per 1,000 patients, AWP minus 60%) of $11,299.51. The cost of waste in Phase II, after implementation of formal internal prescription guidelines, was $6,117.12, which was a significant decrease of 45.9% ($5,182.39) from Phase I ( P < 0.001). Furthermore, both the average number of morphine equivalent units prescribed and consumed per patient decreased from Phase I to Phase II (294.6 vs 187.8, P < 0.001; and 144.9 vs 96.0, P < 0.001, respectively). Finally, in describing individual medications, there was a significant decrease in cost of waste (per 1,000 patients, AWP minus 60%) between Phases I and II for- Hydrocodone with APAP 5/525 mg ( P < 0.001), Oxycodone CR 10 mg ( P < 0.001), Morphine CR 15 mg ( P =0.001), and Tramadol 50 mg ( P = 0.014). CONCLUSIONS: The results of this study suggest that there is a significant cost of waste associated with differences in prescribed versus consumed opioids following elective orthopedic surgery. This cost of waste was significantly reduced following the introduction and implementation of formal prescription guidelines. DISCLOSURES: This study was funded internally by Revo Health and Twin Cities Orthopedics. Giveans reports consulting fees from Medtrak, Inc., and Superior Medical Experts. The other authors have nothing to disclose.

Dancers seek studio-based conditioning methods that improve fitness to help them meet the demands of their discipline. Heart rate variability (HRV) mobile technology offers one such potential method. The purpose of this prospective randomized controlled trial was to investigate how HRV impacted fitness outcomes over a 4 to 6 week period of supplemental training. The study's cohort, 134 competitive female dancers ages 12 to 35, were randomly assigned to one of three groups: the HRV study group, the Tabata high-intensity control group, or the Vinyasa yoga low-intensity control group. Fitness assessments conducted in the pre- and post-training period included cardiovascular endurance, muscular endurance, and lower extremity power. These assessments were evaluated with ANOVA between group and within group comparisons. Results revealed lower extremity power improvement in the HRV group at a statistically significant level (p < 0.05) and overall trends toward greater muscle endurance. Additional unanticipated findings surfaced in the yoga control group that demonstrated cardiovascular improvements and normalization of right versus left lower extremity power discrepancies. Conclusions support the use of HRV mobile technology to individualize daily conditioning intensity, thereby efficiently improving lower extremity power and overall muscle endurance for dancers while monitoring for signs of overtraining.

Several articles in the literature discuss the positive results of converting a painful ankle fusion to an ankle replacement. Our results confirm that in well-selected cases a conversion to a total ankle replacement is not only possible, but also significantly improves quality of life and reduces pain. The outcome of a total ankle replacement after an ankle fusion depends to a degree on the method of fusion. Less destructive fusion that is arthroscopic has better results than conventional transfibular open fusions. Absence of a fibula should be an absolute contraindication for a conversion., Competing Interests: Disclosure J.C. Coetzee: board or committee member for AAOS and American Orthopedic Foot and Ankle Society; paid consultant for Arthrex, Inc and Integra; paid presenter or speaker for Arthrex, Inc and Integra; IP royalties from Biomet, Arthrex, Inc, and Integra; publishing royalties, financial or material support from Elsevier; editorial or governing board at Foot and Ankle International; stock or stock options from Paragon, Crossroads, and Bio2 Technologies. F. Raduan: paid consultant for Arthrex. R.S. McGaver: nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Diffusion tensor magnetic resonance imaging (DTI) can be used to reconstruct the brachial plexus in 3D via tracts connecting contiguous diffusion tensors with similar primary eigenvector orientations. When creating DTI tractograms, the turning angle of connecting lines (step angle) must be prescribed by the user; however, the literature is lacking detailed geometry of brachial plexus to inform such decisions. Therefore, the spinal cord and brachial plexus of 10 embalmed adult cadavers were exposed bilaterally by posterior dissection. Photographs were taken under standardised conditions and spatially calibrated in MATLAB. The roots of the brachial plexus were traced from the dorsal root entry zone for 5 cm laterally using a 2.5-mm 2 Cartesian grid overlay. The trace was composed of points connected by lines, and the turning angle between line segments (the step angle) was resolved. Our data show that the geometry of the roots increased in tortuosity from C5 to T1, with no significant differences between sides. The 1 st thoracic root had the most tortuous course, turning through a maximum angle of 56° per 2.5 mm (99% CI 44° to 70°). Significantly higher step angles and greater variability were observed in the medial 2 cm of the roots of the brachial plexus, where the dorsal and ventral rootlets coalesce to form the spinal root. Throughout the brachial plexus, the majority of step angles (>50%) were smaller than 20° and <1% of step angles exceeded 70°. The geometry of the brachial plexus increases in tortuosity from C5 to T1. To reconstruct 99% of tracts representing the roots of the brachial plexus by DTI tractography, users can either customise the step angle per root based on our findings or select a universal threshold of 70°., (© 2020 The Authors. Journal of Anatomy published by John Wiley & Sons Ltd on behalf of Anatomical Society.)

Background: Sesamoid injuries can have a significant effect on the ability of athletes to return to play. The literature shows mixed results with sesamoid excisions and the ability to return to sports., Hypothesis/purpose: The purpose was to describe patient-reported outcomes and return to sports in athletes after sesamoidectomy with a proper surgical technique and a well-structured rehabilitation protocol. It was hypothesized that sesamoid excision would demonstrate reproducible and encouraging long-term patient outcomes., Study Design: Case series; Level of evidence, 4., Methods: All patients from a single surgeon's practice who underwent sesamoidectomy between January 2006 and September 2015 were identified. Medial sesamoids were excised through a medial approach, and lateral sesamoids were excised through a plantar approach. The plantar structures were adequately repaired after excision. The Foot Function Index-Revised (FFI-R), 12-Item Short Form Health Survey (SF-12), and visual analog scale (VAS) were collected preoperatively and at subsequent follow-up appointments. A patient satisfaction survey and Single Assessment Numeric Evaluation (SANE) questionnaire were also collected. Athletes were defined as those who participated in sports at a high school level or higher., Results: Of the 108 feet that met the inclusion criteria, 26 werelost to follow-up, leaving 82 feet for analysis at a mean 31.3 ± 26.0 months. There were 72 female patients and 10 male patients included in the final analysis, with a mean age of 44.9 ± 20.2 years. There were 54 medial, 18 lateral, and 10 medial and lateral sesamoid excisions. There were 26 competitive athletes with follow-up appointments (dancer, n = 12; pivot sport athlete, n = 8; runner, n = 6). Both the entire study population and the athletes demonstrated a significant improvement in SF-12, SANE, VAS, and FFI-R cumulative at the latest available follow-up ( P < .05). Among the athletes, 80% were able to return to competitive sports at a mean 4.62 ± 1.01 months after surgery. The median satisfaction score among all patients was 97.5%. There was no difference in the success rate between the different etiologies at any of the follow-up intervals., Conclusion: Chronic sesamoid pain is difficult to treat, but this study confirms that with a meticulous surgical technique and a dedicated postoperative rehabilitation program, encouraging patient-reported outcomes can be expected with a minimal risk of complications. Moreover, in the current study, 80% of competitive athletes were able to return to sports at a mean of 4.62 months after surgery.

Background: Tarsometatarsal (TMT) arthrodesis is commonly performed in the management of midfoot arthritis, trauma, or deformity. The purpose of this study was to collect aggregate data (demographic, surgical, and perioperative outcomes) on patients who previously had a TMT fusion with BME compression staples., Methods: Sixty-six patients underwent TMT fusion with BME compression staples. Outcomes included demographics, surgical information, the Veterans Rand VR-12 Health Survey, Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), Revised-Foot Function Index (FFI-R), Ankle Osteoarthritis Scale (AOS), patient satisfaction survey scores, radiographic fusion rate, level of pain reduction, and complications. Sixty-six patients (68 feet) were analyzed (59 females) with an average age of 64 years (range, 18-83). The mean latest follow-up was 35.9 (range, 6-56.6 months)., Results: The average surgical time was 38.1±14.3 minutes (range, 11-75). All outcomes improved significantly ( P < .001) from preoperative to latest follow-up except for the VR-12 Mental and Physical score. The average time to fusion determined by radiographs was 8.4 weeks (range, 6.1-46.1 weeks). Wound complications were not seen. Indications for subsequent surgeries (26.5%, 18/68 feet) in this current study included pain (n = 14), broken staples, and nonunion (n = 3)., Conclusions: The fusion rate in this study, 89.7%, was similar to values reported in the literature. The patient satisfaction score of 81.9 at latest follow-up is consistent with patient satisfaction for other methods of fusion., Level of Evidence: Level IV, retrospective case series., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J. Chris Coetzee, MD, reports other from DePuy, during the conduct of the study. ICMJE forms for all authors are available online., (© The Author(s) 2020.)

Background: Previous Level I studies show promising results for the use of a hydrogel synthetic cartilage implant (SCI) for the treatment of hallux rigidus. A recent independent retrospective review has put those results into question, however. The purpose of this article is to report patient-reported outcomes and early complications using this implant so as to add to the paucity of data in the literature regarding this implant., Methods: This was a retrospective chart review of patients undergoing hydrogel synthetic cartilage implant for the treatment of hallux rigidus from July 2017 to November 2018. Data collected included patient demographics, radiographic grading, and outcomes: Veterans Rand 12 Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), visual analog scale (VAS), patient satisfaction, and complications. Fifty-four patients (59 feet) with an average age of 57.6 (range, 39-78) years were analyzed. The average latest follow-up was 18.9 (range, 3-31.3) months. Body mass index was 26.7 (range, 18.7-35.2). None were diabetic and 5 were smokers., Results: The mean outcome improvements were 6.5 points (VR-12 Physical), 17.2 points (FAAM ADL), 27.4 points (FAAM Sport), and 18.4 points (VAS) ( P < .01 for each). Scores were significantly improved from preoperatively to most recent follow-up for FAAM ADL (71.0 vs 88.2 points), FAAM Sports (44.6 vs 72.0 points), and VAS (49.4 vs 31.0) ( P < .01). Overall, 72.5% patients would definitely or probably have the operation again. Ten patients (18.5%) went on to have revision surgery. Of these, 7 patients were revised to an arthrodesis, and 1 metal hemiarthroplasty and 2 implants were removed because of infection., Conclusion: Synthetic cartilage implantation for the treatment of hallux rigidus demonstrated improved pain and outcome scores at short-term follow-up. Reoperation and conversion to fusion rates were comparable to prior studies., Level of Evidence: Level IV, case series., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Bryan D. Den Hartog, MD, reports personal fees from Wright Medical outside the submitted work. ICMJE forms for all authors are available online. ICMJE forms for all authors are available online., (© The Author(s) 2020.)

Pediatric anterior cruciate ligament (ACL) reconstructions have a relatively high risk for re-rupture, and a low proportion of these patients report a successful return to sport. With an increasing emphasis on youth participation in pivoting sports, the incidence of these injuries has increased in recent years. A reappreciation of lateral extra-articular stabilizing procedures in high-risk adult populations who undergo ACL reconstruction has demonstrated potential improved outcomes for vulnerable ACL reconstructions. However, the open status of the pediatric physes makes the use of these procedures more challenging. Therefore, the purpose of this Technical Note is to describe the current authors' surgical technique for a combined ACL reconstruction with a lateral extra-articular tenodesis for these high-risk patients with open physes., (© 2020 Published by Elsevier on behalf of the Arthroscopy Association of North America.)

In the past decade, the number of hip arthroscopy procedures has exponentially increased, primarily for the treatment of femoroacetabular impingement syndrome and labral lesions. As the techniques have evolved, so has the acknowledgment of the potential complications, including iatrogenic instability that may result from soft-tissue laxity, subtle dysplastic morphologies, or residual defects from capsulotomies in which the capsular closure is insufficient. In most cases, direct capsular repair or plication can be performed at the conclusion of the procedure; however, larger defects, poor-quality tissue, or cases of gross ligamentous laxity may require reconstruction or augmentation. In such instances, several options exist. The purpose of this technical note is to describe a capsular repair augmentation with a bioinductive implant during revision hip arthroscopy., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Purpose: To report preoperative anatomy, patient-related outcomes measures, and return to dance rates in a cohort of competitive dancers undergoing an arthroscopic hip procedure., Methods: Competitive dancers who underwent an arthroscopic hip procedure between 2008 and 2016 were included. Specific types of dance performed, morphology, and radiographic parameters were documented. Outcomes were evaluated with Modified Harris Hip Score (mHHS), the 12-Item Short Form Health Survey, visual analog scale, and Hip Disability and Osteoarthritis Outcome Scores (HOOS)., Results: There were 63 competitive dancers (77 hips) with a mean age 21.2 years in the current study. Specific types of dance performed included 57 studio dance and 41 high-kick dance, and 28 dancers (44%) were professional-level. Morphology included cam-type femoroacetabular impingement (95%), pincer-type femoroacetabular impingement (40%), anterior inferior iliac spine impingement (subspine) (83%), and mild (borderline) dysplasia (11%). Procedures performed included 95% labral repairs, 5% labral debridements, 99% femoral resections, 49% rim resections, 88% subspine decompressions, and 66% capsular plications. At mean 36 months' follow-up post-arthroscopy, the mean outcome improvements were 25.6 points (mHHS), 18.9 points (HOOS-activities of daily living), 29.9 points (HOOS-Sports), 8.7 points (12-Item Short Form Health Survey), and 3.7 points (visual analog scale) (P < .01 for each). Scores were significantly improved from preoperatively to most recent follow-up for mHHS (60.0 vs 85.6 points), HOOS-activities of daily living (72.5 vs 91.5 points), and HOOS-Sports (49.7 vs 79.6) (P < .01). Sixty-three percent of dancers returned to their previous level of competitive dance, 21% returned to limited or modified dance, and 16% were unable to return to dance, including 1 retirement., Conclusions: A careful arthroscopic approach to address cam-type pathomorphology, highly prevalent subspine impingement, and capsular laxity in competitive dancers can achieve a modest rate of return to sport and good-to-excellent patient-reported outcomes at short- to mid-term (3-year) follow-up. Eighty-four percent of dancers ultimately returned to competitive dance, although only 63% returned to their preinjury competitive level., Level of Evidence: IV, case series., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate radiographic and clinical outcomes after arthroscopic femoroacetabular impingement (FAI) correction in symptomatic adolescent athletes with open physes., Methods: We retrospectively reviewed radiographic and clinical outcomes in patients treated with a non-physeal-sparing arthroscopic approach for symptomatic FAI with open physes and a minimum 1-year follow-up. Specific plain radiographic and computed tomography parameters were determined, and preoperative and postoperative outcomes were prospectively evaluated with modified Harris Hip Score (mHHS), 12-Item Veterans-Rand, and pain on a visual analog scale., Results: Thirty-seven hips (28 patients; 75% male) with a mean age of 15.9 years (range, 12.8-18.3 years) had imaging studies consistent with open femoral neck and iliac crest physes. The ischial tuberosity and greater trochanteric physes were open in 95% and 54% of the hips, respectively. All patients participated in organized athletics, and 50% were in multiple sports year-round. Mean follow-up was 39.8 months post-arthroscopic FAI correction. There was a mean 27.7-point improvement in the mHHS (P < .001), a 4.8-point decrease in the visual analog scale for pain (P < .001), and a 15.2-point improvement in the 12-Item Veterans-Rand physical component (P < .001). Ninety-three percent of patients returned to their preinjury level of sports participation without limitations. Thirty (81.1%) patients demonstrated improvements in mHHS greater than the minimally clinically important difference (of mHHS 8 points). Two patients could not reach minimally clinically important difference because of a preoperative mHHS of > 92. There were no postoperative physeal growth arrests, growth disturbances, physeal instability, or avascular necrosis., Conclusions: A non-physeal-sparing arthroscopic approach for FAI in adolescents with open physes is safe and effective with no evidence of clinically relevant complication of growth arrest-related deformity or physeal instability in patients with a minimum of 1 year (mean, 39.8 months) of follow-up after surgery. Young, highly athletic adolescent patients with larger FAI deformities demonstrated greater outcomes improvement after arthroscopy., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

The objective of this study was to evaluate the frequency of different extended-spectrum β-lactamases (ESBL) as well as to associate these ESBL with antimicrobial (ATM) resistance in Escherichia coli and Klebsiella spp. isolates from outpatients and inpatients with urinary tract infections. The study included 435 consecutive nonduplicate clinical isolates, including 362 E. coli isolates, 62 Klebsiella pneumoniae isolates, and 11 K. oxytoca isolates. Isolates were obtained from patients who were treated in a University Hospital between August 2012 and July 2013. Three multiplex PCR were performed to identify the ESBL groups. A total of 48 (11%) ESBL-producing isolates were found. The risk for the ESBL presence was significantly higher in males (26.4%) than females (8%), from hospital-acquired infections (29.1%) than community-acquired infections (7.0%) and in Klebsiella spp. (27.4%) than in E. coli (7.7%). ESBL-producing isolates presented a significantly higher percentage of resistance in 21 of the 23 ATMs analyzed. The CTX-M-1 group was the most predominant ESBL identified. The bla CTX-M-1-group gene was found in 56% of the total ESBL producers from community and in 42.4% from hospital origins; it was followed in frequency by the bla CTX-M-8/25-group , also found in both environments. Klebsiella spp. presented the largest variety of β-lactamase enzyme combinations and a higher level of resistance to cefotaxime. These findings contribute to better knowledge of the epidemiology of ESBL enzymes and are alarming for the reduced therapeutic options available for the risk groups identified in the studied populations.

A library of peptides and glycopeptides containing (4R)-hydroxy-L-proline (Hyp) residues were designed with a view to providing stable polyproline II (PPII) helical molecules with antifreeze activity. A library of dodecapeptides containing contiguous Hyp residues or an Ala-Hyp-Ala tripeptide repeat sequence were synthesized with and without α-O-linked N-acetylgalactosamine and α-O-linked galactose-β-(1→3)-N-acetylgalactosamine appended to the peptide backbone. All (glyco)peptides possessed PPII helical secondary structure with some showing significant thermal stability. The majority of the (glyco)peptides did not exhibit thermal hysteresis (TH) activity and were not capable of modifying the morphology of ice crystals. However, an unglycosylated Ala-Hyp-Ala repeat peptide did show significant TH and ice crystal re-shaping activity suggesting that it was capable of binding to the surface of ice. All (glyco)peptides synthesized displayed some ice recrystallization inhibition (IRI) activity with unglycosylated peptides containing the Ala-Hyp-Ala motif exhibiting the most potent inhibitory activity. Interestingly, although glycosylation is critical to the activity of native antifreeze glycoproteins (AFGPs) that possess an Ala-Thr-Ala tripeptide repeat, this same structural modification is detrimental to the antifreeze activity of the Ala-Hyp-Ala repeat peptides studied here., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Sporotrichosis occurs after fungal implantation of Sporothrix spp. in the skin, and is the main subcutaneous mycosis in Latin America. Here we describe three atypical cases of the disease. The first case report an extra-cutaneous occurrence of the disease with joint infection; the second one describes a patient with bilateral lymphocutaneous form of sporotrichosis; and the third shows a zoonotic cutaneous case with the development of an erythema nodosum as a hypersensitivity reaction. These cases show the disease importance on the region and the necessity of fungal culture to the diagnosis confirmation.

A novel post-translational modification of threonine, β-N-acetylglucosaminyl-phosphate, was recently discovered on assembly protein AP180, a protein which plays a crucial role in clathrin coated vesicle formation in synaptic vesicle endocytosis (SVE). Herein, we report studies aimed at probing the effect of this modification on binding to proteins in rat brain lysate using pull down experiments with peptide fragments of AP180.

Objectives: Failure to thrive (FTT) is a serious condition of childhood, with failure to grow as expected for age and gender. Numerous potential etiologies have been suggested, including occult obstructive sleep disturbance (OSD). We determined the prevalence of OSD in an FTT population, examined correlation to tonsil size, and assessed correlation with a parental questionnaire regarding symptoms., Patients and Methods: A cross-sectional prevalence study was conducted. Thirty-six FTT children in Boston Medical Center's FTT Clinic aged 12 to 60 months were evaluated by formal polysomnography, parental questionnaire, and physical examination. The prevalence and nature of sleep disorders in this population are compared with published age-appropriate norms., Results: The prevalence of OSD in an FTT population in these 36 children is 5.5%. This is compared with the prevalence in the general pediatric population, which is between 0.7 and 4.3%., Conclusions: The prevalence of OSD in FTT tends toward higher than published values for the general pediatric population but does not reach statistical significance. Tonsillectomy and adenoidectomy have been suggested in the literature to be of benefit to improve the growth of children with FTT. Sleep disturbance has been suggested as the underlying pathology. However, using current guidelines, we could not identify an increased prevalence of sleep disturbance in children with FTT. Nonetheless, a continued high level of clinical suspicion is necessary in appropriate diagnosis and treatment of OSD, found in some children with FTT. That growth in children with FTT often improves following management of sleep disturbance (eg, tonsillectomy) is not explained by a significantly higher incidence of OSD in this population.

Idiopathic pulmonary fibrosis (IPF) is a progressive, scarring lung disease characterized by fibroblast accumulation and deposition of collagen. Factors that promote growth and/or survival of fibroblasts are potential therapeutic targets. Methionine aminopeptidase 2 (MetAP2), a member of the aminopeptidase family of proteases, has been implicated in cell proliferation in a variety of cell types, but its expression and function in the lung is not known. By immunohistochemistry, MetAP2 was expressed in many cell types, including fibroblasts, in IPF lungs. Fumagillin, an irreversible inhibitor of the enzymatic activity of MetAP2, attenuated collagen deposition in the bleomycin model of acute lung injury in mice. Treatment with fumagillin caused a selective reduction in the numbers of bromodeoxyuridine (BrdU)-positive myofibroblasts, but not type II alveolar epithelial cells, macrophages, or B- and T-lymphocytes in the lungs of bleomycin-treated mice. Incubation of primary rat lung fibroblasts with either fumagillin or with short interfering RNA that targeted MetAP2 led to reduced proliferation, as assessed by incorporation of BrdU. The profibrotic growth factor, platelet-derived growth factor, increased expression of MetAP2 in rat lung fibroblasts. We propose that MetAP2 plays a role in the proliferation of fibroblasts and myofibroblasts in fibrotic lung diseases and may serve as a novel pharmacologic target in IPF.

Objective: The Wisconsin Collaborative Diabetes Quality Improvement Project was initiated in 1999 by the Wisconsin Department of Health and Family Services, Diabetes Prevention and Control Program to monitor quality of diabetes care among the state's health plans., Study Design: Prospective observational., Methods: Annual invitations were mailed to all Wisconsin managed care plans to participate in the project. Collaborators submitted Comprehensive Diabetes Care Health Plan Employer Data and Information Set (HEDIS) measures, as well as other selected HEDIS measures. Data were summarized and reported anonymously back to the collaborators at quarterly forums and in annual reports., Results: Five of the 6 Comprehensive Diabetes Care HEDIS measures have improved significantly in Wisconsin since 1999. Despite this improvement, measure variation across health plans remains high. Collaborators have continued to share resources and best practices at quarterly forums and through statewide initiatives., Conclusions: This project is an example of an ongoing statewide collaborative quality improvement effort among otherwise competing health plans. Collaboration at regular forums, sharing of HEDIS data to assess quality of diabetes care in health plans, and sharing of resources and best practices may have contributed to improvements in the quality of diabetes care in Wisconsin.

This paper investigates new methods for measuring forces and tactile sense as a contribution towards relaying the sense of touch to the surgeon. The approach used is to determine a distribution of contact force using a small number of sensory outputs to detect the bending of a surface of known behaviour. Software algorithms have been produced to interpret the contacting force from sensory data, and have achieved a bandwidth of 30 Hz and an accuracy of 2 per cent. The sensor construction is of sufficiently low cost to produce a disposable unit and uses materials that are compatible with the invasive working environment.