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Treatment of end-stage ankle conditions is a complex challenge in foot and ankle surgery. The talus is prone to issues such as osteoarthritis (OA) and avascular necrosis (AVN). Patient-specific total ankle and total talus replacement (TATTR) procedures have emerged as potential solutions, but the decision to include subtalar arthrodesis in these surgeries is multifaceted. In this study, we aimed to understand the relationship between past surgeon decisions for fusion with TATTR and three-dimensional joint health assessments using preoperative CT data. Twenty-seven TATTR with subtalar fusion and 19 TATTR without subtalar fusion were analyzed. Each patient underwent a bilateral computed tomography scan, which was segmented prior to surgery. Distance mapping of various subtalar regions was performed, and average distance was reported. For better analysis, the sinus tarsi was divided into four sectors and the calcaneus posterior facet into nine sectors. Statistical analysis involved calculating the difference in means between the fused and unfused cases. The fusion group exhibited significant joint space narrowing in the posterolateral aspect of the sinus tarsi (p = 0.021). Conversely, on the posterior facet of the subtalar joint, the fusion group showed significant joint space widening in both the anteromedial (p = 0.025) and middle/medial (p = 0.032) sections. Surgeons' decision to perform subtalar arthrodesis in TATTR procedures often aligns with clinical signs of sinus tarsi impingement, as evidenced by significant changes in joint space measurements. While joint health assessments play a pivotal role, other factors, such as surgeon preference and patient-specific considerations, also influence decision-making. [ABSTRACT FROM AUTHOR]

Globally, suicide is a leading cause of death among adolescents, with the highest burden of suicide occurring in Africa. Despite this, little is known about the epidemiology of suicide among adolescents in West Africa. In this study, we explore suicidality among West African adolescents. Using pooled data from the Global School-Based Student Health Survey in four West African countries (Ghana, Benin, Liberia, and Sierra Leone), we investigated the prevalence of suicidal ideation and suicide attempt and examined associations with 15 covariates using univariate and multivariable logistic regression. Overall, 18.6% of adolescents in the pooled sample (N = 9,726) had considered suicide, while 24.7% reported attempting suicide. Significant correlates of suicide attempt included older age (16+ years; odds ratio [OR]: 1.70, confidence interval [CI]: 1.09–2.63), difficulty sleeping due to worry (OR: 1.27, CI: 1.04–1.56), loneliness (OR: 1.65, CI: 1.39–1.96), truancy (OR: 1.38. CI: 1.05–1.82), being a target of bullying (OR: 1.53, CI: 1.26–1.85), getting physically attacked (OR: 1.73, CI: 1.42–2.11), physical fighting (OR: 1.47, CI: 1.21–1.79), current cigarette use (OR: 2.71, CI: 1.88–3.89), and initiation of drug use (OR: 2.19, CI: 1.71–2.81). Conversely, having close friends was associated with lower odds of suicide attempt (OR: 0.67, CI: 0.48–0.93). Several covariates were also significantly associated with suicidal ideation. Suicidal ideation and attempts are highly prevalent among school-going adolescents in these West African countries. Multiple modifiable risk and protective factors were identified. Programs, interventions, and policies aimed at addressing these factors may play a significant role in preventing suicides in these countries. [ABSTRACT FROM AUTHOR]

Previous studies have reported excellent results with tapered, titanium, porous plasma-sprayed components in patients undergoing uncemented primary total hip arthroplasty (THA). The purpose of this study was to examine survival and clinical results at a minimum 25-year follow-up. We reviewed all patients who underwent primary THA at our center through 1995 with a specific femoral component that was essentially unchanged since its 1984 introduction, except porous coating was continued circumferentially in 1987, a hydroxyapatite-coated option was offered in 1988, and an offset option was added in 1999. There were 332 patients (396 THA) who had a minimum 25-year follow-up (range, 25 to 37). Mean age at surgery was 48 years (range, 21 to 70 years). Mean follow-up in nonfailed patients was 29 years (range, 25 to 37 years). There were 31 femoral revisions (7.8%): 9 infections, 3 failures of ingrowth, 5 aseptic loosening, 8 osteolysis well-fixed, 2 periprosthetic fractures, 2 polyethylene wear with trochanteric avulsion, 1 component breakage, and 1 malalignment well-fixed. Kaplan-Meier survival with the endpoint of all-cause stem revision was 94.8% (95% confidence interval: ±0.9%) at 37 years, and with the endpoint of aseptic loosening/failure of ingrowth was 98.7% (95% confidence interval: ±0.5) at 37 years. Harris hip scores improved significantly from 43 preoperatively to 76 most recently. This tapered, titanium, porous plasma spray-coated femoral component continues to demonstrate high long-term survival with a low rate of femoral component revision for any reason or aseptic loosening/failure of ingrowth. [ABSTRACT FROM AUTHOR]

Custom acetabular components are an increasingly utilized reconstructive option in total hip arthroplasty for catastrophic bone loss and acetabular failure. The purpose of this study was to determine the survivorship of such components for reconstruction due to catastrophic bone loss at a minimum 5-year follow-up. From August 2003 to July 2016, 64 patients (66 hips) underwent acetabular reconstruction with custom triflange components. All hips were classified as Paprosky 3B or 3C. Harris hip scores were analyzed. Overall survivorship was determined by survival analysis. Seventeen patients (18 hips) died prior to returning for 5-year follow-up. One presumed living patient was lost to contact, yielding a cohort of 46 patients (47 hips) who had minimum 5-year follow-up. The mean age was 65 years (range, 46 to 85), mean body mass index was 29.4 (range, 18 to 45), and 72% were women. Mean follow-up was 8 years (range, 5 to 16). There were 3 revisions of the triflange device (6.4%) due to infection. Survivorship to end point of triflange removal for any reason was 94.1% (95% confidence interval: ±3.4%) at a mean of 16 years. In the overall series (n = 66), there were 9 (13.6%) additional reoperations as follows: 5 incision and debridements, one open reduction internal fixation, two stem revisions for periprosthetic femoral fracture, and one head revision. Harris hip scores improved significantly from a mean of 41 points preoperatively to 64 points postoperatively. Custom acetabular triflange components represent a highly effective tool in a surgeon's armamentarium. These devices are extremely helpful in managing catastrophic bone loss and have a good mean 16-year survival. [ABSTRACT FROM AUTHOR]

Precise indications for medial unicondylar knee arthroplasty (UKA) continue to be defined. It is unclear if patients who have proximal tibia vara should be considered candidates for UKA. The purpose of this study was to evaluate the impact of proximal tibial varus alignment on outcomes after UKA. A retrospective review identified 2,416 patients (3,029 knees) who underwent mobile-bearing medial UKA with 2-year minimum follow-up or revision. Preoperative radiographs were evaluated, and medial proximal tibial angle (mPTA) was measured. Patients were grouped into two groups as follows: mPTA <80 degrees and mPTA ≥80 degrees. Analyses were performed on the impact of mPTA on clinical outcomes, all-cause revisions, and tibial failures. At a mean follow-up of 5 years (range, 0.5 years to 12.8 years), there was not a statistically significant difference in clinical outcomes nor increased risk for all-cause revision or tibial failure in patients who had an mPTA <80°. Mean mPTA in patients who had tibial failures was 82.5° and not significantly different than those who did not have a tibial failure (82.9°) (P =.289). Tibial failure rate in knees with an mPTA <80° was 2.2% and not significantly different than knees with an mPTA ≥80° at 1.4% (P =.211). The all-cause revision rate in knees with an mPTA <80° was 5.8% and was not significantly different than knees with an mPTA ≥80° at 4.9% (P =.492). Patients who have tibia vara are not at increased risk for tibial related or all-cause failure in medial UKA. This data may allow surgeons to increase their indications for medial UKA. [ABSTRACT FROM AUTHOR]

Total ankle arthroplasty (TAA) is an increasingly utilized treatment for ankle arthritis, and opioids are commonly used as part of perioperative pain control. However, many states have enacted opioid-limiting legislation to reduce perioperative opioid prescribing. The aim of this study was to evaluate the impact of time and state legislation on perioperative opioid prescribing in TAA. This study is a retrospective, observational review of 90-day perioperative opioid prescribing in 1,829 patients undergoing TAA throughout the United States using a large insurance database. Initial and cumulative volumes and rates of opioid prescription filling were recorded along with baseline patient and operative characteristics. Dates of state legislation enactment were also recorded. Student t-tests, analysis of variance, and multivariable linear and logistic regression were utilized to analyze the impact of time and state legislation on opioid prescription filling. In the 90-day perioperative time period, initial and cumulative opioid prescription filling in oxycodone 5-mg equivalents has decreased significantly from 2010 (63.8 initial and 163.3 cumulative) to 2019 (41.1 initial and 67.2 cumulative). States with opioid-limiting legislation saw larger and more significant reductions in initial and cumulative opioid prescription filling preact to postact (63.3-50.6 with legislation vs 61.4-51.9 without legislation initial and 146.4-93.3 with legislation vs 125.1-108.6 without legislation cumulative). This study demonstrates that foot and ankle surgeons in states with opioid-limiting legislation have responded by significantly reducing 90-day perioperative opioid prescribing in TAA. These results encourage states without legislation to enact opioid-specific laws to reduce opioid prescribing. [ABSTRACT FROM AUTHOR]

Mangrove habitats support taxonomically diverse benthic communities, yet their effects on microphytobenthos remain understudied. This study investigated the benthic diatom community structure of 17 microtidal mangrove estuaries situated along the east coast of South Africa. High sediment organic content (≤ 18.1 %) and clay fraction (≤ 17.5 %) measured in the Avicennia marina and Rhizophora mucronata habitats favoured diverse communities (H′ > 3) and the presence of unique benthic diatom species such as Gyrosigma balticum. The habitat complexity and stabilisation provided by the mangrove forests served as microrefugia for colonisation of benthic diatoms. Taxa displayed a broad range of nutrient tolerance, with some nutrient tolerant species (e.g., Halamphora acutiuscula, Navicula clausii , Navicula gregaria, and Navicula radiosa) dominating the communities in the Mbashe and Mnyameni estuaries. The presence of these nutrient tolerant taxa in relatively pristine systems serves as an early warning for possible anthropogenic nutrient enrichment. • Low-nutrient conditions supported a diverse benthic diatom community. • Benthic diatom diversity was higher (H′ >3) in the mangrove habitats. • The finer cohesive mangrove sediments favoured the proliferation of select taxa. • Lower diversity (H′ < 2) due to higher flow were unique to the control habitat. • Some nutrient tolerant taxa were recorded in select estuaries. [ABSTRACT FROM AUTHOR]

Background: Survivorship of total hip arthroplasty (THA) in younger patients is concerning given the inverse relationship between age and lifetime risk for revision. The purpose of this study is to determine if risk of revision has improved for patients aged 55 years or younger who undergo primary THA using modern polyethylene liners.Methods: A retrospective review identified 2,461 consented patients (2,814 hips) with minimum 2-year follow-up who underwent primary THA at our institution between September 2007 and August 2014 using components from a single manufacturer (Zimmer Biomet), all with vitamin E-infused highly crosslinked polyethylene acetabular inserts. There were 561 patients (643 THA; 23%) aged 55 or younger and 1,900 (2,171 THA; 77%) older than 55.Results: Mean follow-up was 5.0 years for both groups. There were more male patients in the younger (55%) than older (41%) group. Body mass index (BMI) was higher in younger patients independent of gender. Improvement in Harris hip score (HHS) was similar between groups. Kaplan-Meier survival to endpoint of all cause revision was similar between groups at 12 years (P = .8808) with 97.5% (95% CI: ±0.7%) for younger versus 97.1% (95% CI: ±0.6%) for older patients. Most frequent reason for revision overall was periprosthetic femoral fracture (21; 0.75%); univariate analysis revealed risk factors were female gender (P = .28) and age ≥65 years (P = .012).Conclusion: Use of modern polyethylene, such as vitamin E-stabilized highly cross-linked, liners during THA may improve survivorship in younger patients undergoing THA. Younger patients undergoing primary THA with highly cross-linked polyethylene liners had no increased rate of revision at mid-term follow-up. [ABSTRACT FROM AUTHOR]

Background: Use of metal-on-metal (MoM) articulations in total hip arthroplasty (THA) has sharply declined due to high failure rates from metal-related complications. Although certain MoM designs have demonstrated only 46% survival, not all MoM designs have performed the same. The purpose of this study is to evaluate mid-term to long-term survival of a specific MoM implant with a modular titanium taper adapter.Methods: A retrospective review was performed on all patients who underwent primary THA at our center with the M2a-Magnum system (Zimmer Biomet, Warsaw, IN). Of 829 patients (956 hips) identified, 754 patients (869 hips) met inclusion criteria of signed research consent, minimum 2-year follow-up, and/or any revision surgery.Results: Mean follow-up was 11.0 years (range 2-16; ±3.5). Mean cup angle of inclination was 42.8° (range 24°-70°, ±6.3°), with 88.0% reconstructed within the 40° ± 10° safe zone. There were 64 revisions (7.36%): 7 (0.81%) septic and 57 (6.56%) aseptic. Of those, 32 (3.68%) were adverse reactions to metal debris. Kaplan-Meier survival free of revision for all causes was 88.6% at 16 years (95% confidence interval 86.8-90.4). Univariate analysis of risk factors for all-cause, aseptic, and adverse reaction to metal debris revision found no relationship with female gender, age ≥65 years, body mass index >30 kg/m2, higher activity level, or inclination angle outlier.Conclusion: The results of this study demonstrate a more favorable mid-term to long-term survivorship with this specific MoM implant compared to other designs. Although our institution no longer performs MoM THA, further investigation into differences in MoM implant designs is warranted. [ABSTRACT FROM AUTHOR]

Objective: Human and in vivo animal research implicates inflammation following articular fracture as contributing to post-traumatic arthritis. However, relevant immune cell subsets present following injury are currently undefined. Immunophenotyping human and murine synovial fluid may help to identify immune cell populations that play key roles in the response to articular fracture.Methods: Immunophenotyping by polychromatic flow cytometry was performed on human and mouse synovial fluid following articular fracture. Specimens were collected in patients with closed ankle fracture at the time of surgical fixation and from C57BL/6 mice with closed articular knee fracture. Immune cells were collected from injured and uninjured joints in mice via a novel cell isolation method. Whole blood samples were also collected. Immunohistochemistry (IHC) was performed on mouse synovial tissue to assess for macrophages and T cells.Results: Following intra-articular fracture, the prominent human synovial fluid immune cell subset was CD3+ T cells, containing both CD4+ and CD8+ T cells. In mice, infiltration of CD45+ immune cells in synovial fluid of the fractured limb was dominated by CD19+ B cells and CD3+ T cells at 7 days after intra-articular fracture. We also detected adaptive immune cells, including macrophages, NK cells, dendritic cells and monocytes. Macrophage and T cell findings were supported by IHC of murine synovial tissue.Conclusions: Determining specific cell populations that mediate the immune response is essential to elucidating the chain of events initiated after injury and may be an important step in identifying potential immune signatures predictive of PTA susceptibility or potential therapeutic targets. [ABSTRACT FROM AUTHOR]

Osteochondral lesions of the talus (OLTs) are difficult to treat. Despite a multitude of interventions, there are no generally-agreed-upon guidelines regarding treatment. The objective of this study was to conduct a systematic review of clinical outcomes after fresh osteochondral allografts transplantation of the talus. PubMed, the Cochrane Central Register of Controlled Trials, EMBASE, and Medline were searched using PRISMA guidelines. Studies that evaluated outcomes after fresh osteochondral allograft transplantation for OLTs were included. Clinical outcomes, according to standardized scoring systems, such as the American Orthopaedics Foot & Ankle Society (AOFAS) Ankle/Hindfoot Scale and the Visual Analog Scale (VAS) were compared across studies. The literature search yielded 12 eligible studies with a mean Coleman Methodology Score of 68.1 (57-79). A total of 191 patients were included with an average age of 37.5 (17-74) years and average follow-up of 56.8 (6-240) months. The AOFAS Ankle/Hindfoot score was obtained pre- and postoperatively in 6 of the studies and had significant improvements in each (p <.05). Similarly, the VAS pain score was evaluated in 5 studies and showed significant decreases from pre- to postoperatively (p <.05). While there were no reported short-term complications, 21.6% of patients required minor subsequent procedures, most commonly arthroscopic debridement and hardware removal. The aggregate graft survival rate was 86.6%. Based on these findings, osteochondral allograft transplantation for OLTs results in positive outcomes with high rates of graft survival and patient satisfaction at intermediate follow-up. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study is to evaluate early postoperative surgical and medical complications in patients undergoing staged bilateral total knee arthroplasty (TKA) and determine if the interval to the second stage influences the risk of complications.Methods: A retrospective review was performed from 2016 through 2018 of all staged bilateral primary TKA procedures, yielding a cohort of 1005 patients (2010 TKAs). Four groups were created based on the timing of the second stage: 3 to 6 weeks, 7 to 12 weeks, 13 to 24 weeks, and >24 weeks. Clinical data compared between groups included demographics, knee range of motion, University of California, Los Angeles (UCLA) activity score, Knee Society pain score, Knee Society clinical score, and Knee Society functional score. Postoperative complications within 90 days were evaluated, with complications after the second knee being the primary outcome.Results: The mean follow-up after second stage was 10.7 months (range, 3 to 37 months). No significant differences were found between groups in the range of motion, Knee Society pain, Knee Society clinical score, Knee Society functional score, or University of California Los Angeles activity score in either the first or second knee. After the first knee surgery, medical complications were highest in the >24-week group. After the second knee, there were no significant difference in manipulation (P = .9), wound complications (P = .7), venous thromboembolism (P = .8), or other medical complications (P = 1) based on the interval duration.Conclusion: The interval between staged TKA did not affect early medical or surgical complications after the second stage. Early clinical and function results were not different based on timing of the second surgery. [ABSTRACT FROM AUTHOR]

The 3D custom total talus replacement is a novel treatment for avascular necrosis of the talus. However, patients who require a total talus replacement often have concomitant degenerative changes to the tibiotalar, subtalar, or talonavicular joints. The combined 3D custom total ankle-total talus replacement (TATTR) is used for patients with an unreconstructable talus and adjacent tibial plafond involvement. The goal of performing a TATTR is to provide pain relief, retain motion at the tibiotalar joint, maintain or improve the patient's functional status, and minimize limb shortening. TATTR is made possible by 3D printing. The advent of 3D printing has allowed for the accurate recreation of the native talar anatomy with a talar dome that can be matched to a total ankle replacement polyethylene bearing. In this article, we will discuss a case of talar avascular necrosis treated with a combined TATTR and review the current literature for TATTR. [ABSTRACT FROM AUTHOR]

Successful tibiotalocalcaneal (TTC) arthrodesis can be difficult to achieve in patients with bulk bone defects even with the use of femoral head allograft. Retrograde intramedullary nail placement through custom 3-dimensional (3D) spherical implants is an innovative option for these patients. The purpose of this study was to compare fusion rates, graft resorption, and complication rates between patients undergoing TTC fusion with 3D sphere implants versus femoral head allografts. Patients who underwent TTC arthrodesis with an intramedullary nail along with a 3D spherical implant (n = 8) or femoral head allograft (n = 7) were included in this study. The rate of successful fusion of the tibia, calcaneus, and talar neck to the 3D sphere or femoral head allograft was compared between the groups. The rate of total fused articulations was significantly higher in the 3D sphere group (92%) than the femoral head allograft group (62%; p =.018). The number of patients achieving successful fusion of all 3 articulations was higher in the 3D sphere group (75%) than the femoral head allograft group (42.9%, p =.22). The rate of graft resorption was significantly higher in the femoral head allograft group (57.1%) than the 3D sphere group (0%, p =.016). There were no significant differences between the groups in terms of complications. These data demonstrate that the use of a custom 3D printed sphere implant is safe in patients with severe bone loss undergoing TTC arthrodesis with a retrograde intramedullary nail and may result in improved rates of successful arthrodesis. [ABSTRACT FROM AUTHOR]

Background: As total knee arthroplasty (TKA) continues moving to the outpatient arena, the demand for revision surgery will subsequently increase which draws into question the feasibility for some revision scenarios as an outpatient. The purpose of this study is to report on the safety of outpatient revision knee arthroplasty.Methods: From June 2013 through December 2018, 102 patients (106 knees) underwent revision knee arthroplasty at a free-standing ambulatory surgery center. Mean patient age was 58.0 years, and 43% of patients were male. Procedures included the following: 45 cases of unicompartmental arthroplasty to TKA, 54 TKA revisions, and 52 cases involved a full exchange of components.Results: Ninety-three patients (88%) were discharged the same day without incident, none required transfer to acute facility, and 13 required overnight stay with 4 of these for convenience and 9 for medical reasons. There were no major complications within the first 48 hours postoperative. One patient required readmission for treatment of ileus 11 days postoperative. There were no other readmissions, no subsequent surgeries, and no deaths within 90 days. One or more major comorbidities were present in 66 patients.Conclusion: Outpatient revision knee arthroplasty was found to be safe in carefully selected patients and case scenarios. Presence of medical comorbidities was not associated with risk of complications. The paradigm changes of patient education, medical optimization, and a multimodal program to mitigate the risk of blood loss and reduce need for narcotics facilitates performing some revision arthroplasties safely in an outpatient setting. [ABSTRACT FROM AUTHOR]

Background: At the turn of the 21st century, there was a re-emergence of metal-on-metal (MoM) articulation with 35% of all total hip arthroplasty implants having MoM articulation. Approximately 10 years after its peak use, MoM articulation began to decrease dramatically as revisions became more apparent because of adverse reaction to metal debris. Today, there are surveillance guidelines and reconstructive clinical pearls a surgeon should recognize.Methods: This article gives a literature-based overview of clinical pearls and discusses how to avoid pitfalls when performing revision of a metal-on-metal total hip arthroplasty.Results: Patients with MoM can be risk-stratified based on symptom, implant, and testing variables. Those patients who are symptomatic and/or develop adverse reaction to metal debris with local tissue destruction will require a revision. The revision of MoM can be challenging due to bone and soft tissue destruction. Constraint may be needed in cases of abductor deficiency.Conclusion: Although MoM implants for THA have declined significantly, surgeons are still faced with the revision burden from a decade of high use. Risk stratification tools are available to aid in revision decision making, and the surgeon should be prepared to address the challenges these revisions present. [ABSTRACT FROM AUTHOR]

Osteochondral lesions of the talus (OLTs) are difficult to treat. Arthroscopic microfracture augmented with micronized cartilage (BioCartilage; Arthrex, Naples, FL) and platelet-rich plasma is emerging as a treatment for moderate-sized, well-contained full-thickness OLTs. This treatment may provide superior histologic results and is less technically demanding and yields less morbidity than an open osteochondral allograft or autograft transfer. This technique guide presents the senior author's preferred strategy for treatment of a moderate-sized OLT with arthroscopic microfracture and placement of micronized cartilage and platelet-rich plasma. [ABSTRACT FROM AUTHOR]

Background: Ventilator tidal volumes of >8 mL/kg of predicted body weight (PBW) may increase the risk of lung injury. We sought to evaluate the impact of a quality improvement intervention among intubated Emergency Department (ED) patients to protocolize the prescription of low tidal volume ventilation.Methods: In this before-and-after study, the average tidal volume delivered to ED patients receiving volume assist-control ventilation was compared before (2007-2014) and after (2015-2016) implementation of a ventilator initiation protocol (the quality improvement intervention). The intervention emphasized 1) measurement of the patient's height to calculate PBW and therefore tailor the tidal volume to estimated lung size (<8 mL/kg PBW), and 2) focused education and reference materials for ED physicians and respiratory therapists.Results: Among ventilated ED patients meeting inclusion criteria in the before (N = 2185) and after (N = 774) cohorts, the mean (±SD) tidal volume decreased from 9.0 ± 1.4 mL/kg to 7.2 ± 0.9 mL/kg PBW following the intervention (absolute difference 1.8 mL/kg, 95% confidence interval 1.7 to 1.9 mL/kg, p < 0.001). The proportion of patients receiving low tidal volume ventilation increased after the intervention (72%), as compared to before (23%). Low tidal volume ventilation continued to be utilized at 24 h after ICU admission in patients who remained intubated in the cohort following the intervention (mean tidal volume 7.3 mL/kg PBW).Conclusions: Pairing a ventilator initiation protocol with focused education and resources for emergency physicians and respiratory therapists was associated with a significant reduction in tidal volume delivered to ED patients. [ABSTRACT FROM AUTHOR]

Post-traumatic elbow contracture remains a common and challenging complication with often unsatisfactory outcomes. Although the etiology is unknown, elevated or abnormal post-fracture synovial fluid cytokine levels may result in the migration of fibroblasts to the capsule and contribute to capsular pathology. Thus, the purpose of this study was to characterize the cytokine composition in the synovial fluid fracture hematoma of patients with intra-articular elbow fractures. The elbow synovial fluid fracture hematoma of 11 patients with intra-articular elbow fractures was analyzed for CTXII (C-terminal telopeptides of type II collagen [a cartilage breakdown product]) as well as 15 cytokines and matrix metalloproteinases (MMPs) including interferon γ, interleukin (IL) 1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor α, MMP-1, MMP-2, MMP-3, MMP-9, and MMP-10. The uninjured, contralateral elbow served as a matched control. Mean concentrations of each factor were compared between the fluid from fractured elbows and the fluid from control elbows. The levels of 14 of 15 measured cytokines and MMPs—interferon γ, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-13, tumor necrosis factor α, MMP-1, MMP-3, MMP-9, and MMP-10—were significantly higher in the fractured elbows. In addition, post hoc power analysis revealed that 10 of 14 significant differences were detected with greater than 90% power. The mean concentration of CTXII was not significantly different between groups. These results demonstrate a proinflammatory environment after fracture that may be the catalyst to the development of post-traumatic elbow joint contracture. The cytokines with elevated levels were similar, although not identical, to the cytokines with elevated levels in studies of other weight-bearing joints, indicating the elbow responds uniquely to trauma. [ABSTRACT FROM AUTHOR]

Background: Recurrent instability after total hip arthroplasty is a difficult complication. In certain cases, a constrained acetabular device is needed to address these issues. The purpose of this study is to report the midterm outcomes and survivorship of a single novel constrained liner device.Methods: A retrospective review as performed on all procedures (except first stage exchange for infection) in which a Freedom Constrained (Zimmer Biomet, Warsaw, IN) liner was used between December 2003 and November 2016. Patients with 2-year minimum follow-up or failure were included, yielding a cohort of 177 patients. Procedures were 130 aseptic revisions, 40 reimplantations following infection eradication, and 7 complex primaries. The constrained mechanism was implanted in 46 hips (26%) to treat active instability and 131 hips (74%) for increased risk of instability and intraoperative instability. Patients had on average 3.4 previous surgeries.Results: With an average 7.1-year follow-up, 11 hips dislocated (6.2%), and 13 hips (7.3%) were revised for acetabular aseptic loosening, resulting in an overall constrained aseptic or mechanical failure rate of 13.6%. Nineteen hips (10.7%) failed from infection with 58% of these having had a previous infection. Patients with active instability had significantly higher failure for dislocation than patients who were at risk (15.2% vs 3%, P = .01). All-cause survival rate at 7 years was 74.8%, aseptic survival was 83.6%, and survival for instability was 91.8%.Conclusion: Revision for instability remains challenging as many patients have had numerous previous surgeries and at-risk anatomy. Constrained inserts are one option to manage instability, but a high rate of recurrence can still occur. [ABSTRACT FROM AUTHOR]

Background: The impact of a patient's activity level following total knee arthroplasty (TKA) remains controversial, with some surgeons concerned about increased polyethylene wear, aseptic loosening, and revisions. The purpose of this study is to report on implant survivorship and outcomes of high activity patients compared to low activity patients after TKA.Methods: A retrospective review identified 1611 patients (2038 knees) that underwent TKA with 5-year minimum follow-up. Patients were divided in 2 groups based on their University of California Los Angeles (UCLA) activity level: low activity (LA) (UCLA ≤5) and high activity (HA) (UCLA ≥6). Outcomes included range of motion, Knee Society scores, complications, and reoperations. Parametric survival analysis was performed to evaluate the significance of activity level on survivorship while controlling for age, gender, preoperative pain, Knee Society clinical scores, Knee Society functional scores, and body mass index (BMI).Results: Mean follow-up was 11.4 years (range 5.1-15.9). The LA group had significantly more female patients, were older, had higher BMI, and had lower functional scores preoperatively (all with P < .001). The HA group had significantly higher improvements in Knee Society scores (P < .001) and pain postoperatively (P < .001). Revisions were performed in 4% of the LA group and 1.7% knees of the HA group (P = .003). After controlling for age, gender, preoperative pain, Knee Society clinical scores, Knee Society functional scores, and BMI, a higher postoperative activity level remained a significant factor for improved survivorship with an odds ratio of 2.4 (95% confidence interval 1.2-4.7, P = .011). The all-cause 12-year survivorship was 98% for the HA group and 95.3% for the LA group (P = .003). The aseptic 12-year survivorship was 98.4% for the HA group and 96.3% for the LA group (P = .02).Conclusion: Highly active patients had increased survivorship at 5-year minimum follow-up compared to lower activity patients after TKA. Patient activity level after TKA may not need to be limited with modern implants. [ABSTRACT FROM AUTHOR]

Background: Management of an infected total hip arthroplasty (THA) is challenging. The eradication of infection as well as complications of component removal must all be considered. This study is an update on previous reports of treating periprosthetic infection of the hip with a partial 2-stage exchange with retention of the femoral component.Methods: A retrospective review of our practice's arthroplasty registry from 2000 to 2018 revealed 41 hips with 2-year minimum follow-up that were treated with a 2-stage partial exchange for an infected THA. All first-stage procedures allowed an articulating construct with 1 of 3 variations: cemented constrained liner (13 hips), StageOne Hip Cement Spacer Mold (14 hips), or an antibiotic polymethylmethacrylate head molded from a bulb syringe (14 hips). Of 41 cases, 34 were culture positive, with 3 cases having methicillin-resistant Staphylococcus.Results: Mean follow-up was 5.5 years (range, 1.5-18.5 years). The second-stage reimplantation was accomplished in 39 of the 41 hips (95%) at a mean interval of 9.2 weeks (range, 5-9 weeks). Two patients underwent repeat radical debridement with removal of all components before reimplantation for persistent clinical evidence of infection. Thirty-three of the 41 hips (81%) were infection free at most recent follow-up. The mean postoperative Harris hip score at most recent evaluation was 63.6 (range, 24-100).Conclusion: Eradication of periprosthetic joint infections, while minimizing patient morbidity, continues to be a challenge. Partial 2-stage exchange may be considered in cases where removal of a well-fixed femoral component may result in significant bony destruction. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study is to report the long-term outcomes and survivorship of a high flexion knee system.Methods: We identified 1312 patients (1664 knees) who underwent primary total knee arthroplasty with the Vanguard Complete Knee System with 10-year minimum follow-up. Preoperative and postoperative range of motion, Knee Society scores, complications, and reoperations were evaluated.Results: At an average of 11.9 years of follow-up, 88 knees were revised (5.3%). The deep infection rate was 1.4%. There was an average range of motion improvement of 3.9°, pain level decreased by 35.8, Knee Society clinical scores improved by 48, and Knee Society functional scores improved by 15.1 (all P < .001). Survival was 96.4% at 10 years for aseptic causes and 95.5% for all causes.Conclusion: At a 10-year minimum follow-up, this high flexion knee system demonstrates excellent survivorship. [ABSTRACT FROM AUTHOR]

Background: Metal-on-metal (MoM) revisions have shown high rates of complications from aseptic loosening, deep infection, and dislocation. The purpose of this study is to report on outcomes and complications of a large consecutive series of patients who were revised for failed MoM total hip arthroplasty (THA).Methods: We evaluated 188 patients (203 hips) who underwent revisions of failed MoM THA. Mean age at the revision was 60 years old. Gender was female in 112 hips (55%) and male in 91 hips (45%). Mean interval to failure after primary THA was 4.9 years (range, 0-18 years). The acetabular component was revised in 183 cases (92%). Clinical outcomes assessed included pain score and Harris hip score.Results: Mean follow-up from revision was 4.2 years. Harris hip score improved from 53.6 pre-revision to 73.5 at most recent follow-up (P < .001). Pain level significantly improved from 17.2 pre-revision to 32.8 post-revision (P < .001). Reoperations occurred in 28 (14%) hips. Re-revision was required in 16 hips (7.9%). The most common reasons for re-revision were aseptic loosening (5), dislocation (3), infection (2), and iliopsoas tendonitis (2). Re-revision was significantly higher in cases of pseudotumor. There was no difference in survival with ultraporous cups. Three hips required re-revision to custom triflange components. All-cause survival was 90.5% at 4.2 years. Metal ion levels significantly declined after revision.Conclusion: Revisions of failed MoM THA showed improvements in clinical outcomes, but present significant surgical challenges and complications especially in cases with soft tissue damage and pseudotumor. [ABSTRACT FROM AUTHOR]

Background: Patients are often cautioned against a high level of activity after knee arthroplasty. The purpose of this study was to report on implant survivorship and outcomes of high-activity patients compared with low-activity patients after unicondylar knee arthroplasty (UKA).Methods: We identified 487 patients (576 knees) who underwent UKA with the Oxford mobile bearing knee (Zimmer Biomet, Warsaw, IN) with a 5-year minimum follow-up. Patients were divided into 2 groups: low activity (LA) (University of California Los Angeles ≤6) and high activity (HA) (University of California Los Angeles ≥7). Preoperative and postoperative range of motion, Knee Society scores, complications, and reoperations were evaluated.Results: Mean follow-up was 9 years (range, 4 to 13.1). The HA group had significantly more male patients, were younger, and had higher knee society clinical scores and knee society functional scores preoperatively. The HA group had significantly higher improvements in Knee Society scores and pain postoperatively. Revisions were performed in 8.4% of the LA group and 6.2% of the HA group (P = .43). At our mean of 9-year follow-up, there was 94.0% survival for the HA group and 92.1% for the LA group (P = .6085).Conclusions: Highly active patients had no increased risk of revision after UKA with the Oxford mobile bearing knee at 5-year minimum follow-up. [ABSTRACT FROM AUTHOR]

When community engaged service learning (CESL) is integrated as a component of nursing education, student learning outcomes are improved. Utilizing this pedagogical strategy in undergraduate pathophysiology and pharmacology courses comes with a unique set of challenges and barriers. However, integrating this high impact, evidence-informed approach offers an opportunity for students to advance knowledge of course concepts while meeting the needs of underserved community groups. Forty-two sophomore level nursing students enrolled in pathophysiology and pharmacology completed semester long projects in the community. Student reflective responses were collected, analyzed for content, and revealed themes of perceived community connection, empathy, and empowerment to become community engaged leaders. • CESL is one high impact approach that, when used intentionally, can serve as a mechanism to solidify patho/pharm content. • PP r Projects focused primarily on chronic disease, medications used to treat these conditions, and health promotion activities. • Students recognized the importance of connecting with community members which is foundational to empathy. • Engaging with the community to determine priorities is one way to ensure that the projects were valued by community members. • Students needed to be well-versed on the knowledge they were presenting/discussing with community members. [ABSTRACT FROM AUTHOR]

Background: Persistent pain after medial unicompartmental knee arthroplasty (UKA) is a prevailing reason for revision to total knee arthroplasty (TKA). Many of these pathologies can be addressed arthroscopically. The purpose of this study is to examine the outcomes of patients who undergo an arthroscopy for any reason after medial UKA.Methods: A query of our practice registry revealed 58 patients who had undergone medial UKA between October 2003 and June 2015 with subsequent arthroscopy. Mean interval from medial UKA to arthroscopy was 22 months (range 1-101 months). Indications for arthroscopy were acute anterior cruciate ligament tear (1), arthrofibrosis (7), synovitis (12), recurrent hemarthrosis (2), lateral compartment degeneration including isolated lateral meniscus tears (11), and loose cement fragments (25).Results: Mean follow-up after arthroscopy was 49 months (range 1-143 months). Twelve patients have been revised from UKA to TKA. Relative risk of revision after arthroscopy for lateral compartment degeneration was 4.27 (6 of 11; 55%; P = .002) and for retrieval of loose cement fragments was 0.05 (0 of 25; 0%; P = .03). Relative risk for revision after arthroscopy for anterior cruciate ligament tear, arthrofibrosis, synovitis, or recurrent hemarthrosis did not meet clinical significance secondary to the low number of patients in these categories.Conclusion: The results of this study suggest that arthroscopic retrieval of cement fragments does not compromise UKA longevity. However, arthroscopy for lateral compartment degradation after UKA, while not the cause of revision, appears to be an ineffective treatment and predicts a high risk of revision to TKA regardless of its relative radiographic insignificance. [ABSTRACT FROM AUTHOR]

Background: Despite improvements in polyethylene bearing surface properties, only 1 previous study has examined the results of larger thickness bearings. The purpose of this study was to determine whether polyethylene thickness influenced patient outcomes and implant survival following modular total knee arthroplasty.Methods: A retrospective review was performed of patients undergoing primary total knee arthroplasty from 2003 to 2014 in a single practice database. Patients were separated into "thin" and "thick" polyethylene groups based on manufacturer polyethylene bearing sizes of 14 mm or less compared to those greater than 14 mm, respectively. Patient clinical outcomes, need for revision surgery, and overall implant survival rates were evaluated.Results: A total of 6698 primary knee arthroplasties were included, and a thin bearing was used in 96.5% of these cases. Preoperatively, patients with a thick bearing had significantly lower Knee Society clinical scores (P < .01), a trend toward lower functional scores (P = .06), and more significant coronal plane deformity. Postoperatively, patients with thick bearings exhibited better Knee Society clinical and pain scores as well as similar functional scores and University of California at Los Angeles activity scores. The overall reoperation rate and 10-year survivorship free of revision were similar between thick and thin bearings (1.7% vs 2.3%; 98.2% vs 96.1%). Patients with thin bearings were twice as likely to require a manipulation under anesthesia postoperatively (P = .02), while there were no failures in the thick bearing group due to aseptic loosening or instability.Conclusion: Patients with thick polyethylene bearings performed similarly or better in multiple clinical outcomes and survivorship compared to those with thin bearings. [ABSTRACT FROM AUTHOR]

Background & Aims Variants at the ABCB4 or MDR2 locus, which encodes a biliary transport protein, are associated with a spectrum of cholestatic liver diseases. Exacerbation of liver disease has been linked to increased hepatic levels of interleukin (IL) 17, yet the mechanisms of this increase are not understood. We studied mice with disruption of Mdr2 to determine how defects in liver and alteration in the microbiota contribute to production of IL17 by intrahepatic γδ T cells. Methods We performed studies with Mdr2 -/- and littermate FVB/NJ (control) mice. IL17 was measured in serum samples by an enzyme-linked immunosorbent assay. Mice were injected with neutralizing antibodies against the γδ T-cell receptor (TCR; anti-γδ TCR) or mouse IL17A (anti-IL17A). Livers were collected and bacteria were identified in homogenates by culture procedures; TCRγδ + cells were isolated by flow cytometry. Fecal samples were collected from mice and analyzed by 16S ribosomal DNA sequencing. Cells were stimulated with antibodies or bacteria, and cytokine production was measured. We obtained tissues from 10 patients undergoing liver transplantation for primary sclerosing cholangitis or chronic hepatitis C virus infection. Tissues were analyzed for cytokine production by γδ TCR + cells. Results Mdr2 –/– mice had collagen deposition around hepatic bile ducts and periportal–bridging fibrosis with influx of inflammatory cells and increased serum levels of IL17 compared with control mice. Administration of anti-IL17A reduced hepatic fibrosis. Livers from Mdr2 –/– mice had increased numbers of IL17A + γδTCR + cells—particularly of IL17A + Vγ6Jγ1 γδ TCR + cells. Fecal samples from Mdr2 –/– mice were enriched in Lactobacillus , and liver tissues were enriched in Lactobacillus gasseri compared with control mice. Mdr2 –/– mice also had increased intestinal permeability. The γδ TCR + cells isolated from Mdr2 -/- livers produced IL17 in response to heat-killed L gasseri . Intraperitoneal injection of control mice with L gasseri led to increased serum levels of IL17 and liver infiltration by inflammatory cells; injection of these mice with anti-γδ TCR reduced serum level of IL17. Intravenous injections of Mdr2 -/- mice with anti-γδ TCR reduced fibrosis; liver levels of IL17, and inflammatory cells; and serum levels of IL17. γδTCR + cells isolated from livers of patients with primary sclerosing cholangitis, but not hepatitis C virus infection, produced IL17. Conclusions In Mdr2 -/- mice, we found development of liver fibrosis and inflammation to require hepatic activation of γδ TCR + cells and production of IL17 mediated by exposure to L gasseri . This pathway appears to contribute to development of cholestatic liver disease in patients. [ABSTRACT FROM AUTHOR]

Background Plasma amino acid measurements have been extensively investigated in individuals with autism spectrum disorder (ASD). Results thus far have been inconclusive as studies generally disagree on which amino acids are different in individuals with ASD versus their typically developing (TD) peers, due in part to methodological limitations of several studies. Method This paper investigates plasma amino acids in children and adults with ASD using data from Arizona State University’s Comprehensive Nutritional and Dietary Intervention Study. Measurements from 64 individuals with ASD and 49 TD controls were analyzed using univariate and multivariate statistical techniques. Results Univariate analysis indicated increased median levels of glutamate (+21%, p  = 0.014) and serine (+8%, p  = 0.043), and increased mean levels of hydroxyproline (+17%, p  = 0.018) for the ASD cohort, although these differences were insignificant after correcting for multiple comparisons. A multivariate approach was used to classify study participants into ASD/TD cohorts using Fisher discriminant analysis (FDA) and its nonlinear extension, kernel Fisher discriminant analysis (KFDA). Model fitting with FDA using all available measurements produced Type I and Type II errors of 27.0% and 27.8%, respectively. KFDA was most effective when using hydroxyproline, leucine, and threonine as inputs; however, leave-one-out cross-validation with this nonlinear model only resulted in 70.3% sensitivity and 77.6% specificity. Conclusions The finding of elevated glutamate in ASD is in agreement with several other studies. Overall, however, these results suggest that plasma amino acid measurements are of limited use for purposes of ASD classification, which may explain some of the inconsistencies in results presented in the literature. [ABSTRACT FROM AUTHOR]

Hydrological regimes are key in shaping the structure of phytoplankton communities in estuaries. Because anthropogenic disturbances often alter the quantity and quality of riverine inputs, this research focused on investigating phytoplankton dynamics in the St. Lucia Estuary, since being reconnected to the Mfolozi River. Due to the closed mouth state of the estuary, the input from the river resulted in oligohaline (≥5) conditions and the characteristic reverse salinity gradient to persist throughout the study (i.e. one year). Model results indicated that phytoplankton communities were structured by rainfall, light transmittance and depth, while shifts between dominant groups were driven by salinity and flow season. The persistence of chlorophytes and euglenophytes as the co-dominant functional group indicates the freshening and nutrient-enriched nature of the river. This study provides the first detailed account documenting the response of the phytoplankton community to recent restoration efforts in the St Lucia Estuary, a Ramsar Site. [ABSTRACT FROM AUTHOR]

A focused diagnosis of ecosystem health in two South African estuaries (Kromme and Gamtoos) was conducted. Four pollution indices were used, i.e., geoaccumulation (Igeo), ecological risk (RI), contamination factor (CF) and pollution load index (PLI), to assess toxicity levels of metal contaminants in relation to background values. The Igeo results (11.1 %) can be classified as contaminated, with Cd, the only element with high values in both estuaries. Likely sources (herbicides, pesticides) of Cd are used in the agricultural dominated catchments. There was a high concentration of Mn (13.4 ± 2.51 and 12.3 ± 1.13 μg·g−1) and Fe (1289 ± 243 and 1291 ± 130 μg·g−1) at site 4 for Gamtoos and Kromme estuary respectively compared to the other metal elements. Although results indicate low metal contamination, with increasing global anthropogenic pressure, continuous monitoring should be prioritised to assist in managing estuarine systems that support a wide range of socio-economic and ecosystem services. • Geoaccumulation, ecological risk, contamination factor and pollution load indices were used to assess estuarine health. • Pollution indices results indicated low metal contamination. • Cd was the only element with high values showing contamination from the catchment. [ABSTRACT FROM AUTHOR]

Rapid urbanisation and industrialisation have placed increased pressure on the ecosystem health of urban estuaries. Sustainable drainage systems (SuDS) are globally accepted practices for managing the water quality of stormwater and effluent discharged into urban systems. The Swartkops Estuary in South Africa is a heavily urbanized estuary that has a long history of pollution, specifically trace metal contamination, originating from industrial sources and urban wastewater. Using a novel SuDS treatment train, the physical characteristics (total suspended solids), macronutrients (orthophosphates, nitrate, ammonium), trace metals (As, Cd, Hg, Fe, Pb, Cu), and E. coli concentrations were measured monthly for one year, both before and after the treatment train. The treatment train consisted of five interconnected 500 L plastic tanks for sedimentation, filtration (sand and stone), biodegradation and floating wetlands. Results indicate that the SuDS treatment train provided an efficient method in reducing the pollution load to this urban estuary, by reducing macronutrient concentrations by 76 %, trace elements concentrations by 74 % and faecal bacteria counts (E. coli) by 80 %. [Display omitted] • Novel SuDs treatment train removed pollution to an urban estuary. • Measurements before and after the treatment train showed pollution reduction. • Macronutrients (76 %), trace elements (76 %), and faecal bacteria (80 %) were removed. • SuDS can provide cleaner discharges from stormwater canals. • Nature-inspired stormwater treatment technologies are recommended for catchments. [ABSTRACT FROM AUTHOR]

Rapid urbanisation and industrialisation have placed increased pressure on the ecosystem health of urban estuaries. Sustainable drainage systems (SuDS) are globally accepted practices for managing the water quality of stormwater and effluent discharged into urban systems. The Swartkops Estuary in South Africa is a heavily urbanized estuary that has a long history of pollution, specifically trace metal contamination, originating from industrial sources and urban wastewater. Using a novel SuDS treatment train, the physical characteristics (total suspended solids), macronutrients (orthophosphates, nitrate, ammonium), trace metals (As, Cd, Hg, Fe, Pb, Cu), and E. coli concentrations were measured monthly for one year, both before and after the treatment train. The treatment train consisted of five interconnected 500 L plastic tanks for sedimentation, filtration (sand and stone), biodegradation and floating wetlands. Results indicate that the SuDS treatment train provided an efficient method in reducing the pollution load to this urban estuary, by reducing macronutrient concentrations by 76 %, trace elements concentrations by 74 % and faecal bacteria counts (E. coli) by 80 %. [Display omitted] • Novel SuDs treatment train removed pollution to an urban estuary. • Measurements before and after the treatment train showed pollution reduction. • Macronutrients (76 %), trace elements (76 %), and faecal bacteria (80 %) were removed. • SuDS can provide cleaner discharges from stormwater canals. • Nature-inspired stormwater treatment technologies are recommended for catchments. [ABSTRACT FROM AUTHOR]

• In proximal suspensory desmitis and superficial digital flexor tendinitis, the lameness scores decreased between the first and third treatments. • Proximal suspensory desmitis and superficial digital flexor tendinitis ultrasound results did not differ between the first and third treatments. • The number of electrohydraulic shock wave therapy treatments had no effect on the positive outcome. • Time was the only factor associated with favorable outcomes. Superficial digital flexor tendinitis (SDFT) and proximal suspensory desmitis (PSD) are common causes of lameness in horses. Current treatment options include rest, controlled exercise, administration of anti-inflammatories, intralesional injections, surgery, and electrohydraulic shock wave therapy (ESWT). ESWT is safe, noninvasive, and is used to treat a variety of musculoskeletal abnormalities. Medical records between 2010 and 2021 were reviewed. Horses were separated into two categories: (group 1: ≥ 3 ESWT treatments; group 2: < 3 ESWT treatments). Our objective was to examine the effect of the number of ESWT treatments in the management of SDFT and PSD injuries and to compare short- and long-term outcomes for the two groups. For group 1, lameness scores between the first and third treatments were significantly reduced in both PSD (P <.0001) and SDFT (P =.016) horses. However, neither the PSD (P =.062) nor SDFT's (P =.125) ultrasound findings were significantly different at the end of the third treatment. Horses with PSD showed a significant improvement in forelimb lameness between the first and third treatments compared to hindlimb (P =.033). In the multivariable ordered logistic regression model, only time (months of follow-up) was significantly associated with a positive outcome (P =.001) and there was no difference in short and long-term outcome between groups 1 and 2. Also, chronicity of injury was negatively associated with improvement of lameness (P =.028). [ABSTRACT FROM AUTHOR]

Background: Revision total knee arthroplasty (TKA) poses unique challenges compared with primary TKA such as bone loss, deformity, and ligament instability. Modular component options allow flexibility to deal with these complexities. The purpose of this study was to evaluate midterm outcomes for revision TKA using a modular revision knee system with complete interchangeability and multiple options for augmentation, offset, constraint, and stem extensions.Methods: A query of our practice registry revealed 257 consented patients (274 knees and 278 TKA) with minimum 2-year follow-up who underwent aseptic revision TKA with a modular system (Vanguard Super Stabilized Knee; Zimmer Biomet, Warsaw, IN) between 2005 and 2013. Four patients were rerevised to a second Vanguard Super Stabilized Knee within the study period. Mean age was 68 years, and mean number of previous surgeries was 2 (1-14).Results: At mean follow-up of 6.0 years (range, 2-11 years), there have been 25 aseptic revisions involving one or more components (9.0%): 15 aseptic loosening with concomitant instability in 2, 8 others with instability, 1 with hypersensitivity, and 1 revised elsewhere for unknown cause. Ten knees were revised for infection. Range of motion improved from 100° preoperatively to 105° most recently. Knee Society clinical scores improved from 45 to 79, and function scores from 46 to 56. Radiographic evaluation revealed satisfactory position, fixation, and alignment in 97% and abnormal findings in 7 knees: 4 limited to the patella, 1 tibial radiolucency, 1 femoral and tibial radiolucency, and 1 tibial subsidence.Conclusion: The results of this modular TKA revision system at 6 years mean follow-up are promising for use in complex scenarios, with a low frequency of aseptic rerevision, good knee stability, and substantial improvements in range of motion and clinical and functional outcomes. [ABSTRACT FROM AUTHOR]

This study compared the spatio-temporal dynamics in two agriculturally-influenced South African estuaries - Gamtoos and Sundays - to investigate how contrasting hydrological alterations influence physical, chemical and biological responses. With the Gamtoos Estuary experiencing regular high flow conditions, a key difference between the two systems is the propensity for natural flushing events to occur; a mechanism largely eliminated from the highly-regulated Sundays Catchment. Phytoplankton blooms (> 20 Chl- a μg l − 1 ) were persistent and seasonal in the Sundays, inducing summer bottom-water hypoxia (< 2 mg l − 1 ), whilst those in the Gamtoos were episodic and flow-dependent. Of concern in the Sundays Estuary, was the magnitude (> 550 μg l − 1 ) and recurrent nature of two harmful algal bloom (HAB) species. This study provides the first account of HAB persistence and seasonal hypoxia in a South African estuary, demonstrating the possible consequences of shifting an ecosystem into a new stable state. [ABSTRACT FROM AUTHOR]

Wetland plants are naturally exposed to high metal concentrations, and often have mechanisms to prevent metal toxicity. This study compared metal concentrations in seagrass (Zostera capensis) and salt marsh (Spartina maritima, Salicornia tegetaria) — to determine their niche as metal sinks. Samples were collected in each season over a year at five sites in the estuary and analysed using a Total X-Ray Fluorescence (TXRF) spectrometer. Spartina maritima and S. tegetaria accumulated in their roots, and displayed little translocation to leaves (BCF = 1–14; TF [leaf/root] < 1). Contrastingly, Z. capensis showed high uptake to its leaves (TF [leaf/root] = 1–8; Mn, Zn, Cr, Pb, Ni, Cu). Spartina maritima and S. tegetaria were identified as good phytostabilisers (BCF > 1, TF [leaf/root] < 1). Compartmentalization was unique to each species, and considering their ecosystem service importance, more plant species should be analysed to estimate their ecological value for management purposes. [Display omitted] • Urbanised and industrialised estuaries face heavy metal pollution. • Seagrass has potential as bioindicator and accumulator of metals. • Salt marsh species are good phytostabilisers of metals. • Compartmentalisation used as a metal tolerance mechanism. [ABSTRACT FROM AUTHOR]

Background: Modular femoral components emerged because of the advantages of recreating limb length, offset, and native femoral version in total hip arthroplasty. Despite its potential benefits, the increase in modularity at the head-neck junction can lead to corrosion and subsequently failure of the implant.Methods: We present 3 case examples of patients who underwent revision surgery secondary to corrosion of their modular femoral components.Results: Issues addressed include understanding corrosion at the head-neck junction, presentations of adverse local tissue reactions, efficacy of metal ion testing and metal artifact reduction sequence magnetic resonance imaging, and approaches to revision surgery for failed modular neck stems.Conclusions: When revision surgery is indicated for failed modular neck stems, we recommend a thoughtful approach with contemporary extraction techniques and options to enhance stability. Furthermore, long-term follow-up is needed to define the growing effect of modularity in total hip arthroplasty. [ABSTRACT FROM AUTHOR]

Background The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk-adjustment model for patients who require hepatic resection does not include metrics of underlying chronic liver disease. The applicability of the current risk adjustment model is under debate. This study aims to assess the impact of chronic liver disease on the ACS NSQIP estimates of postoperative morbidity and mortality. Study design This retrospective cohort study included all cases of hepatic resection at our quaternary referral institution between 2006 and 2013. Metrics of chronic liver disease were abstracted and linked with the ACS NSQIP risk-adjustment model estimated probabilities of morbidity and mortality for each case. Sequential general linear models were used to estimate differences in ACS NSQIP probabilities of morbidity and mortality associated with measures of underlying chronic liver disease. Results A total of 522 hepatic resections were performed during the study period. The patient cohort included 91 patients with fibrosis (17%) and 38 patients with cirrhosis (7%). The mean ACS NSQIP estimated probability of morbidity was 0.24 ± 0.11 and probability of mortality was 0.02 ± 0.02. Fibrosis was associated with increased probability of morbidity (0.26 ± 0.11; P = .019); cirrhosis was also associated with increased probability of morbidity (0.27 ± 0.10; P = .059). Parenchymal liver disease was not associated with increased probability of mortality (all P ≥ .62). Increased probabilities of mortality were associated with diagnosis and extent of resection (both P < .001). Conclusions In patients selected for hepatectomy, metrics of chronic liver disease were associated with differences in ACS NSQIP estimated probability of morbidity. Incorporation of metrics of chronic liver disease into the ACS NSQIP targeted hepatectomy modules should improve estimates of risk after hepatic resection. [ABSTRACT FROM AUTHOR]

This study assessed the tissue distribution, dietary intake, and potential health risks of eight OPPs in Pomadasys commersonnii (Spotted grunter) and Mugil cephalus (Flathead mullet) from the Sundays and Swartkops estuaries in South Africa. The highest concentration in fish tissues was found in muscles of M. cephalus (178 ± 80.4 ng/g ww) and P. commersonnii (591 ± 280 ng/g ww) from Sundays Estuary. The ∑ 6 OPPs concentration in muscles from both fish species was higher in muscles than in the gills with fenitrothion dominating the distribution profile. Results from the path analysis indicate that lipid, weights, and length of the fish species do not influence the concentration of OPPs in the studied fish species. The calculated hazard ratios, which represent the non-carcinogenic risks, were less than one for all OPPs, indicating that the concentration of OPPs detected in fish muscles had negligible consequences on human health. [Display omitted] • Six OPPs were detected in tissues of both fish species. • Higher OPPs levels were found in muscles compared to gills. • Fenitrothion was the dominant pesticides. • Paths analysis showed fish physical parameters do not influence ∑ 6 OPPs occurrence. • No non-cancer risk was associated with the consumption of both fish species. [ABSTRACT FROM AUTHOR]

Objectives: To describe the percentage of pediatric outpatient pharmacy prescriptions with inappropriate prescribing identified by a pharmacist that resulted in a change to the prescription. Secondary objectives include describing types of inappropriate prescribing errors, prevalence of Institute of Safe Medication Practices high-alert medications, patient demographics, prescriber origin, and prescription origin.Methods: This retrospective outpatient prescription record review was approved by an institutional review board and performed at an outpatient pharmacy located in an academic teaching hospital. The study reviewed pediatric outpatient prescriptions for a 6-month period. Prescriptions with prescribing errors were identified from pediatric prescriptions sent to the problem queue and documented with appropriate pharmacist notes.Results: This study demonstrated the impact of a dose checking procedure and pharmacist interventions on pediatric prescriptions. Initial results show that 3% of all pediatric prescriptions required a pharmacist intervention. Of these prescriptions, 50% resulted in a change to the original prescription.Conclusion: Weight-based dose checking in a pediatric outpatient pharmacy proactively prevents potential adverse events among the pediatric population. Despite this study's limitations, we believe that a pediatric dose checking procedure in community pharmacies will reduce adverse events. Further study is warranted in this field. [ABSTRACT FROM AUTHOR]

The femoral component and proprietary instrumentation of a mobile-bearing unicompartmental knee arthroplasty (UKA) was redesigned with an additional peg for enhanced fixation, 15° of extra femoral surface for contact in deep flexion, more rounded profile, better fit into the milled surface, and redesigned intramedullary based instrumentation. To assess the benefit of these changes, we compared postoperative radiographs of 219 single-peg and 186 twin-peg UKAs done in 2008–2011. All surviving knees demonstrated satisfactory position and alignment with no radiolucencies observed. Radiographic analysis showed improved and consistent component positioning with the twin-peg design implanted with updated instrumentation compared with the single-peg. The radiographic benefits of improved implant positioning using the twin-peg component and updated instrumentation are clear and carry tremendous potential. More robust follow-up is imperative. [ABSTRACT FROM AUTHOR]

Dual mobility liners represent an alternative to large heads to prevent dislocation. We used dual mobility in primary total hip arthroplasty in 2 patients (3 hips) with cerebral palsy; there were no dislocations or revisions at a mean follow-up of 2.3 years. In 22 patients (22 hips) revised to dual mobility, the most prevalent indication was adverse reaction to metal debris. There were 3 re-revisions at 1.8 years: 1 recurrent dislocation precipitated by traumatic injury, 1 deep infection and 1 unexplained pain. For abductor deficiency, a constrained liner may be indicated. [ABSTRACT FROM AUTHOR]

The seasonal variation, spatial distribution, and ecological risks of thirteen organophosphate pesticides (OPPs) were studied in the Sundays and Swartkops estuaries in South Africa. Ten pesticides were detected in surface water samples from both estuaries, while all OPPs were detected in sediments. The highest concentration of OPPs (18.8 μg pyrazophos L−1) was detected in surface water samples from Swartkops Estuary, while 48.7 μg phosalone kg−1 dw was the highest in sediments collected from Sundays Estuary. There was no clear seasonal pattern in OPPs occurrence in surface water from both systems. However, their occurrence in sediments was in the following order: winter > autumn > summer > spring, perhaps indicating major pesticide input in the winter seasons. Results from ecological risk assessment showed that pyraclofos and chlorpyrifos (CHL) in surface water from both systems are respectively likely to cause high acute and chronic toxicity to fish (risk quotient – RQ > 1). For sediments of both estuaries, the highest acute and chronic RQs for fish were calculated for isazophos and CHL respectively. The majority of the detected OPPs in sediments posed potential high risks to Daphnia magna from both systems. These results suggest that these aquatic organisms (fish, and Daphnia), if present in the studied estuaries, can develop certain forms of abnormalities due to OPP exposure. To this end, proper measures should be taken to reduce OPP input into the estuarine systems. [Display omitted] • At least one of the 13 OPPs was detected in sample matrices from both estuaries. • Pyrazophos recorded the highest concentration of OPPs in water. • Phosalone recorded the highest concentration of OPPs in sediments. • Winter season recorded the highest ∑ 13 OPPs concentration in sediments. • Most pesticides in sediments pose high acute and chronic ecotoxicological risks. [ABSTRACT FROM AUTHOR]

Background Cholangiocarcinoma (CCA) is a malignancy with a poor 5-year survival rate (5%-10%). ERCP-directed radiofrequency ablation (RFA) or photodynamic therapy (PDT) can be performed as palliative therapy for unresectable CCA. ERCP with PDT is associated with improved survival compared with stent placement alone. However, ERCP-directed RFA has not been directly compared with PDT in patients with CCA. Objective To compare overall survival in patients with unresectable CCA who underwent palliative ERCP-directed RFA versus PDT. Design Retrospective cohort study. Setting Tertiary-care academic medical center. Patients Forty-eight patients with unresectable CCA who underwent ERCP-directed ablative therapy for palliation of unresectable CCA. Interventions ERCP-directed RFA or PDT. Main Outcome Measurements Overall survival by Kaplan-Meier analysis after initial treatment with either RFA or PDT. Results Patients who underwent RFA (n = 16) demonstrated an overall survival similar to that of those who underwent PDT (n = 32), with a median survival of 9.6 versus 7.5 months, respectively ( P = .799). Patient age ( P = .45), sex ( P = .52), and lead time ( P = .59) from presentation to initial RFA or PDT had no significant association with survival. The presence of distant metastasis was inversely associated with survival (hazard ratio 3.55; 95% confidence interval, 1.29-9.77; P = .014). Patients who underwent RFA (compared with PDT) had a lower mean number of plastic stents placed per month (0.45 vs 1.10, P = .001) but also had more episodes of stent occlusion (0.06 vs 0.02, P = .008) and cholangitis (0.13 vs 0.05, P = .008) per month. Limitations Retrospective, single-center design. Conclusions Survival after ERCP-directed RFA and PDT was not statistically different in patients with unresectable CCA. A randomized, controlled trial is warranted to validate these preliminary results. [ABSTRACT FROM AUTHOR]

This study investigated the nutrient removal efficiency of a constructed wetland (CW) piloted to treat urban runoff before entering an estuary. Physico-chemical, dissolved inorganic nutrient (DIN and DIP), and stormwater inflow volume data were measured. The CW removal efficiency of DIN was negligible (5% uptake), while it acted as a consistent source of DIP (68% efflux) to the receiving estuarine waters. There was low water residency within the small CW (0.8 ha) that has been compounded by a 10-fold increase in flow volume since 2016. The surface area of the CW would need to be increased to 46 ha to cope with current daily inputs (ca. 6300 m3 d−1). The lack of maintenance (e.g., macrophyte harvesting, sediment desludging) has reduced nutrient uptake and increased autochthonous inputs. The conversion of an abandoned saltpan into an extension of the CW has been considered to manage the high flow volume and remove nutrients. • Nutrient uptake in the small study CW is limited by excessive stormwater volumes. • The lack of primary producer diversity reduces nutrient removal efficiency. • Routine maintenance is required to prevent saturation of nutrient uptake processes. • Flooding of an abandoned saltpan to expand the current CW is a remediation option. [ABSTRACT FROM AUTHOR]

Objective: The authors hypothesized that the measurement of strain by speckle tracking with transesophageal echocardiography (TEE) is feasible and comparable to transthoracic echocardiography (TTE). Design: A prospective observational comparative study. Setting: A university hospital. Participants: Adult patients undergoing elective cardiac surgery. Interventions: Structured intraoperative TTE and TEE examination. Measurements and Main Results: Images were obtained after the induction of anesthesia from 25 patients to enable speckle tracking of the left ventricle in comparable short- and long-axis (SAX and LAX) views using TTE and TEE. Left ventricular strain was measured offline using both modalities and correlation assessed using the Pearson test with assessment of bias using the Bland-Altman method. Significantly more segments were tracked by TEE than TTE in LAX views but not SAX views. Correlation was moderate between TTE and TEE (r = 0.5-0.6) for longitudinal strain in the LAX views, whereas it was poor for regional radial strain (r = 0.07). Correlation for global circumferential strain was higher for the apical SAX views (r = 0.7) than the basal or mid- SAX views. Speckle tracking by TEE showed excellent reproducibility with small bias. Conclusions: Strain measured by speckle tracking in TEE correlated moderately with TTE for global strain and poorly for regional strain. This may be explained by differences in scanning frequency and other imaging factors. Nevertheless, because of the high degree of reproducibility, it may be a useful tool to quantify intraoperative changes in ventricular function with TEE. However, equivalence between TTE and TEE cannot be assumed, and limits of comparability should be recognized. [ABSTRACT FROM AUTHOR]

Abstract: Metal-on-metal (MoM) articulations offers low wear, larger head size, and increased stability. Reports of early failure are troubling and include failure of ingrowth and metal articulation problems such as metallosis, hypersensitivity, pseudotumor, and unexplained pain. This study investigates the survivorship of modern MoM articulations by gender. We reviewed 1589 primary MoM THA in 1363 patients, with minimum 2-year follow-up for 1212 hips. Follow-up averaged 60 months. There were 643 female patients and 719 male patients. The incidence of cup revision was significantly higher in women than in men (8.2% vs 2.7%; P = .0000), as was incidence of aseptic loosening (4.3% vs 1.1%; P = .0006), and failure for metal-bearing complications (2.2% vs 0.6%; P = .0126). There appear to be gender factors influencing the success of MoM THA, which may include hormonal, anatomic, or functional differences. [Copyright &y& Elsevier]