The Core Institute

Tarsometatarsal (TMT) joint arthrodesis is essential for managing surgical management of severe bunion deformities, complex midfoot trauma, and osteoarthritis. Various fixation methods and bone grafting types have been described, but the impact of the number of joints fused on union rates remains unclear. This study aimed to evaluate whether fusing multiple joints affects arthrodesis rates and to compare union outcomes among different fixation constructs and grafting techniques. We conducted a single-center retrospective cohort study of 582 TMT fusions, comparing single- vs multiple-joint fusions involving medial and central columns. The average follow-up was 15.5 months. Two fellowship-trained foot and ankle surgeons assessed radiographs and computed tomographic (CT) scans. Radiographic union was evaluated at 8 and 12 weeks as well as the specific fixation constructs and bone graft used across each joint. Single-TMT-joint surgeries had a significantly greater proportion of fusions occurring by 12 weeks than the multiple-TMT-joint surgeries, 74.9% vs 67.0%, respectively, P = .0002. Ultimate union rates were similar for single-joint fusions (80.3%) and multiple-joint fusions (82.6%. Many nonunions were asymptomatic; the combined asymptomatic nonunion and union rate was 95.4%. The revision rate for all nonunions was 25.5%. Staple fixation was associated with higher nonunion rates in the second (46.15%) and third (37.5%) TMT joints, whereas screw fixation showed the highest nonunion at the first TMT joint (54.6%). The lowest nonunion rates were observed with combined interfragmentary screw fixation and plating across all joints. Diabetic patients and current smokers experienced higher complication and nonunion rates. Although the radiographic nonunion rate (18.2%) exceeded prior reports, symptomatic nonunion was rare (4.6%). Multiple-TMT-joint surgeries required more time to confirm radiographic union than single joint surgeries. Among the modifiable factors, implant and graft choice were associated with differences in union rates.

BackgroundExternal fixators are commonly used for managing complex fractures, but they are associated with the risk of pin site infections. Pin site management following external fixator removal can be performed using either primary closure or secondary healing. The relative efficacy and safety of these approaches, particularly in terms of infection rates, remain uncertain.ObjectiveThis systematic review and meta-analysis aimed to evaluate the infection rates of pin entry sites following the removal of the temporary external fixator, comparing primary closure and secondary healing methods.MethodsWe conducted a systematic review and meta-analysis of studies comparing infection rates between primary closure and secondary healing after external fixator removal. Eligible studies included randomized controlled trials (RCTs), cohort studies, and other observational studies. Data were extracted on patient demographics, infection rates, and risk factors. The primary outcome was the rate of pin site infection, and data were synthesized using Odds Ratios (OR) with 95% confidence intervals (CI).ResultsA total of three studies (one RCT and two cohort studies) were included in the analysis, with 738 patients. Pooled analysis showed significantly lower infection rates in primary closure compared to secondary healing (OR: 0.375, 95% CI: 0.195–0.724; I² = 0.0%, P = 0.003). However, there was considerable heterogeneity among the studies, which may have contributed to the inconsistent results. Factors such as duration of external fixation, anatomical site of fixation (upper vs. lower extremity), and comorbidities may have influenced the infection rates.ConclusionThis meta-analysis demonstrated that primary closure of pin sites was associated with a lower risk of infection compared with secondary healing, based on studies with a maximum external fixation duration of 21 days. However, future well-designed, homogeneous research is needed to better understand the impact of these two wound management approaches on pin site infections.

To compare infection rates after external fixation removal, comparing pin sites that were primary closed with those left open to heal by secondary intention. Retrospective review. Multicenter study. All adult patients (18 years and older) who underwent removal of external fixator that was used for extremity fractures from 2007 to 2023 with at least 30 days follow-up. Patients were stratified into 2 cohorts: (1) external fixator pin sites primarily closed after external fixator removal and (2) pin sites left open to heal with secondary intention after external fixator removal. Patient characteristics, fracture characteristics, and details of the external fixator removal surgery were recorded. Comparison of the rate of surgical site infection (SSI) of pin site after external fixation removal were performed between the 2 groups (pin sites that were closed primarily and those left open after external fixator removal). A total of 412 patients were included, with a mean follow-up of 259 days. There were 254 patients in the closed pin site after pin removal group (mean age 53 years, range 18-95, 39% female) and 158 in the pin sites left open after pin removal group (mean age 54 years, range 18-93, 49.4% female). The median duration of external fixator in the closed group was 11 days and 19 days in the open group ( P < 0.05). Multivariate analysis demonstrated increased odds of SSI of pin site after pin removal if the pin site was left open (odds ratio = 3.2; 95% confidence interval, 1.44-7.19, P < 0.01) and with tibial plateau fractures (odds ratio = 4.45; 95% confidence interval, 1.92-10.32, P < 0.001). After external fixation removal, closure of pin sites was associated with lower risk of pin site SSI after pin removal compared with leaving them open when external fixation duration was less than 2 weeks. External fixation is a common procedure, and this study can help change practice and decrease the risk of SSI of pin site after pin removal. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The clinical discrimination of Parkinson disease (PD) from its mimics can be challenging, especially in the early stages. These mimics include atypical parkinsonian syndromes (APSs), essential tremor, drug-induced parkinsonism, and vascular parkinsonism. Moreover, differential diagnosis of PD is not exclusive; overlapping and coexisting neurodegenerative diseases are common. Most patients with suspected PD undergo standard clinical MRI (including T1- and T2-weighted sequences) as the first imaging examination, with the primary objective to exclude other diseases. Standard MRI can help detect vascular pathologic features in vascular parkinsonism or atrophy patterns in some APSs but is not sensitive for detecting PD. Dopamine transporter imaging remains the neuroimaging reference standard for specific diagnosis of PD: It can be used to detect PD and most APSs but cannot reliably be used to discriminate between them or exclude other findings, including cerebrovascular disease. Emerging MRI biomarkers of PD are nigrosome 1 (N1; the swallow tail sign at susceptibility-weighted imaging) and neuromelanin (at neuromelanin-sensitive MRI). These markers appear abnormal in PD and most APSs yet normal in essential tremor, drug-induced parkinsonism, and vascular parkinsonism. Identifying these challenging markers depends on specific technical parameters and reader experience. Although dopamine transporter imaging remains more accurate for diagnosing PD, the authors discuss how adding N1 or neuromelanin imaging to standard MRI is a practical, cost-effective, and sustainable way to help diagnose PD and PD mimics and select patients for subsequent dopamine transporter imaging.

Post-traumatic stress disorder (PTSD) stands as a pervasive psychiatric condition, exerting a profound impact on millions across the globe. Despite the availability of traditional therapeutic modalities, many individuals continue to grapple with suboptimal treatment outcomes, underscoring the urgent need for novel interventions. In recent years, stellate ganglion blocks (SGBs) have garnered attention as a promising avenue in the treatment landscape for PTSD, showcasing remarkable efficacy in ameliorating symptomatology and enhancing overall quality of life. This comprehensive review seeks to delve into the current landscape of research surrounding SGBs for PTSD, including proposed mechanisms of action, clinical efficacy across diverse patient populations, safety profile, and potential avenues for further exploration and refinement. By synthesizing the latest evidence and insights, this review aims to provide clinicians and researchers with a comprehensive understanding of the role of SGBs in PTSD management, ultimately informing clinical practice and guiding future research endeavors in this area of mental health intervention.

To identify practices for treating interprosthetic femur fracture (IFFs) and determine factors that positively impact patient outcomes. Design: Retrospective cohort study. Fifteen trauma centers in the United States. Patients aged 50 to 90 years who underwent operative fixation of an AO/OTA 32 A-B-C type IFF fracture from 2011 to 2021 were included. Patients who underwent revision arthroplasty at the time of fixation or were non-ambulatory were excluded. The primary outcome was union rate. Secondary outcomes included post-operative complications, revision surgery, mortality, and change in ambulation status. Univariate analyses using Chi-square tests, Fisher's exact tests, and analysis of variance were performed to detect associations between demographic, injury, and surgical characteristics with post-operative outcomes. One hundred thirty-nine patients were included, with 110 (79%) females and median age 78 [range, 57-90]. Distal one-third fractures were most common 68% (N=95). One hundred eighteen (85%) patients were treated with a lateral plate, 8% (N=11) were treated with nail-plate combination and 7% (N=10) were treated with dual plates. The median time to full-weight bearing (FWB) was 2.5 months. Dual plate combination was associated with the fastest time to FWB (p = 0.048) at two weeks. 61% (n=85) of patients returned to baseline ambulation status (100% [11] IMN/plate, 60% [71] lateral plate and 25% [3] dual plate) with patients treated with nail-plate had higher rates of return to baseline function (p = 0.009). The overall mortality rate was 13% and associated with greater than 1 comorbidity (p = 0.022). A spanning lateral plate was the most common fixation of IFF in our study. Patients with dual fixation were more likely to return to baseline ambulatory status, particularly those with intramedullary nail/plate combination. The mortality rate at one year was 11% and comorbidity burden was associated with higher risk of mortality. Therapeutic Level III.

A previous randomized controlled trial (RCT) evaluating operative versus nonoperative treatment of acute flail chest injuries revealed more ventilator-free days in operatively treated patients who had been ventilated at the time of randomization. It has been suggested that surgery for these injuries may also improve a patient's pain and function. Our goal was to perform a secondary analysis of the previous RCT to evaluate pain and postinjury opioid requirements in patients with operatively and nonoperatively treated unstable chest wall injuries. We analyzed data from a previous multicenter RCT that had been conducted from 2011 to 2019. Patients who had sustained acute, unstable chest wall injuries were randomized to operative or nonoperative treatment. In-hospital pain medication logs were evaluated, and daily morphine milligram equivalents (MMEs) were calculated. The patients' symptoms were also assessed, including generalized pain, chest wall pain, chest wall tightness, and shortness of breath. Additionally, patients completed the 36-Item Short Form Health Survey (SF-36), and they were followed for 1 year postinjury. In the original trial, 207 patients were analyzed: 99 patients received nonoperative treatment, and 108 received operative treatment. There were no significant differences in pain medication usage between the 2 groups at any of the examined time points (p = 0.477). There were no significant differences in generalized pain, chest wall pain, chest wall tightness, or shortness of breath at any time postinjury in the 2 groups. There were also no significant differences in the SF-36 scores. This secondary analysis of a previous RCT suggested that operative treatment of patients with flail chest injuries does not reduce in-hospital daily opioid requirements. There were also no reductions in generalized pain, chest wall pain, chest wall tightness, or shortness of breath with operative treatment. The SF-36 scores were similar for both groups. Further work is needed to identify those patients most likely to benefit from operative treatment of flail chest injuries. Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

IntroductionGLP-1 analogues can stimulate apoptosis and autophagy in endometrial cancer cell lines. We sought to assess the effect of liraglutide on endometrial cancer development and local microenvironment in the BDII/HAN rat model.Methods38 BDII/Han rats were randomised into two groups at 12 months of age - a standard group (n=17) and a liraglutide + diet restriction group (n=21). Animals were sacrificed at 15 months of age, RNAseq, whole and phospho-proteomics performed on endometrial cancers and normal endometrium. Cell state transition assessment and regulation (cSTAR), analysis of transcriptomic, proteomic and phosphor-proteomic data was used to assess the mechanism of action of liraglutide on the endometrium (Rukhlenko et al. 2022 Nature https://doi.org/10.1038/s41586-022-05194-y).ResultsLiraglutide treatment caused a 15% weight loss and reduced incidence of endometrial cancer from 53% (9/17) in the standard group to 20% (4/20) in the intervention group, all of which were poorly differentiated serous, immune excluded cancers. cSTAR analysis demonstrated that Liraglutide upregulates transcription of numerous genes, while their abundance at proteomic and phosphoproteomic levels are strongly downregulated and inhibits autophagy in normal endometrium. Liraglutide also inhibits estrogen signalling which in combination with inhibition of autophagy may support the development of serous cancers in an atrophic endometriumConclusion/ImplicationsGLP-1 analogues reduce the rate of endometrial cancer in BDII/HAN rodent models however the cancers that developed in the liraglutide group were poorly differentiated, immune excluded serous cancers. Further data is required to establish the potential role of GLP-1 induced weight loss as an adjunctive treatment in endometrial cancer.

Implant surface nanofiber (NF) coatings represent an alternative way to prevent/treat periprosthetic joint infection (PJI) via local drug release. We developed and characterized a coaxial erythromycin (EM)-doped PLGA/PCL-PVA NF coating. The purpose of this study was to determine the efficacy of EM-NF coatings (EM0, no EM, EM100 (100 mg/mL), and EM1000 (1000 mg/mL) wt/wt) in a rat PJI model. A strong bond of the EM-NF coating to the surface of titanium (Ti) pins was confirmed by in vitro mechanical testing. Micro-computed tomography (mCT) analysis showed that both EM100 and EM1000 NF effectively reduced periprosthetic osteolysis compared to EM0 at 8 and 16 weeks after implantation. Histology showed that EM100 and EM1000 coatings effectively controlled infection and enhanced periprosthetic new bone formation. The bone implant contact (BIC) of EM100 (35.08%) was higher than negative controls and EM0 (3.43% and 0%, respectively). The bone area fraction occupancy (BAFO) of EM100 (0.63 mm2) was greater than controls and EM0 (0.390 mm2 and 0.0 mm2, respectively). The BAFO of EM100 was higher than that of EM1000 (0.3 mm2). These findings may provide a basis for a new implant surface fabrication strategy aimed at reducing the risks of defective osseointegration and PJI.

Objetivo: realizar uma análise comparativa entre as características clínicas e epidemiológicas da febre maculosa em populações pediátricas e adultas, relacionando com as variáveis utilizadas no estudo, para entender as diferenças entre as faixas etárias. Métodos: Estudo epidemiológico, observacional, de delineamento transversal com dados do Sistema de Informação de Agravos de Notificação (SINAN-DATASUS) referentes a casos confirmados de febre maculosa no Brasil entre janeiro de 2007 e dezembro de 2022, incluindo indivíduos de todas as faixas etárias. AS variáveis incluídas no estudo foram idade, sexo do paciente, sinais e sintomas clínicos, reservatórios, local de provável infecção, dados clínicos e de diagnóstico. Os microdados foram extraídos diretamente do servidor do DATASUS por meio de script em linguagem R. Para as análises de associação entre as variáveis explicativas e o desfecho, foi utilizado o teste qui-quadrado de Pearson, considerando nível de significância de 0,05. Como medida de associação foi utilizada a odds ratio (OR) ajustada pelo modelo de regressão logística e respectivo intervalo de confiança a 95% (IC95%). Todas as análises foram realizadas no software R versão 4.3.2 (R Core Team, Vienna, Austria). Resultados: Foram analisados 2709 perfis de febre maculosa, em ambos os grupos, o sexo masculino foi o majoritário, 71,65% em adultos e 62,40% no grupo pediátrico. Febre foi o sintoma mais recorrente, respectivamente, 91% em adultos e 95% na população pediátrica; a hospitalização nas crianças ocorreu com maior frequência: 72,40%, enquanto nos adultos 58,51%, o contato com carrapato foi similar: 85,96 % em adulto e 79,10% no pediátrico, os adultos frequentaram com maior frequência floresta, rio ou cachoeira 80,16 % em comparação 65,11% no grupo pediátrico. Conclusão: O sexo masculino foi mais suscetível, com o ambiente doméstico sendo o local de maior contágio. Na maioria das vezes, crianças são assintomáticas, enquanto na população adulta os sintomas mais comuns incluem dor de cabeça e mialgia. O diagnóstico laboratorial geralmente é limitado, e as taxas de mortalidade são altas.