Repair of Proximal Hamstring Tears: A Surgical Technique

Proximal hamstring tears are among the most common sports-related injuries. These injuries often occur as strains or partial tears at the proximal muscle belly or the musculotendinous junction, with avulsion injuries of the proximal attachment occurring less frequently. Regardless of the mechanism, they produce functional impairment and negatively affect an athlete's performance. Various classifications for these injuries are reported in the literature. Early surgical treatment is recommended for patients with either a 2-tendon tear/avulsion with more than 2 cm retraction or those with complete 3-tendon tears. Surgery can be performed in the chronic phase but it is technically demanding because of scar formation and tendon retraction. This Technical Note describes a biomechanically validated surgical technique for repair of the proximal hamstring tears.

Classification and Analysis of Attritional Glenoid Bone Loss in Recurrent Anterior Shoulder Instability

BACKGROUND

Recognition and proper treatment of glenoid bone loss (GBL) are important for successful management of anterior shoulder instability. Although GBL has been described as the amount of bony loss from the front of the glenoid, there is also a fragment of bone that is usually displaced and often undergoes attrition. Thus, due to attritional bone loss (ABL) of the fragment, insufficient bone is left to fully reconstruct the glenoid.

PURPOSE

To (1) evaluate ABL of the glenoid fragment in recurrent anterior shoulder instability and (2) correlate ABL with clinical history, fragment size, and radiographic findings.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

GBL was evaluated on 3-dimensional computed tomography (3D CT) en-face view and was measured as percentage loss. The bone fragment size was measured, and attrition of the fragment was determined by evaluation of the amount remaining relative to the initial defect; patients were stratified into minimal (<34%), moderate (34% to <67%), and severe (≥67%) attritional loss groups. Clinical history and demographics were correlated to ABL, and GBL and ABL were compared.

RESULTS

The overall median percentage GBL was 15.3% (interquartile range [IQR], 9.9%-20.0%), with a mean (±SD) percentage GBL of 16.5% ± 9.0%. Study participants had a corresponding median percentage ABL of 75.8% (IQR, 53.8%-95.7%) and a mean percentage ABL of 72.0% ± 24.4%. A total of 61.2% of patients (n = 85) exhibited severe ABL, while 30.2% had moderate ABL and 8.6% had minimal ABL. The total time of instability was significantly associated with percentage of attritional bone loss ( P < .05). In addition, the time of instability was greatest in patients in the third tertile of ABL (≥87.5%; P = .08). A significant difference was found in total time of instability among patients in the highest tertile of ABL (38.6 months) versus both the middle (26.7 months) and lowest (32.8 months) tertiles ( P < .05).

CONCLUSION

The study results indicate that in the majority of patients with recurrent anterior instability, GBL presents with extensive attrition of the bone fragment independent of initial glenoid bone loss; therefore, surgeons should be cognizant that the remaining bone fragment is unable to reconstitute glenoid bone stock. In addition, the results showed more attritional bone loss in patients with a longer duration of instability symptoms, indicating a role for incorporating symptom duration in determining proper management.

The Epidemiology of Ankle Injuries Identified at the National Football League Combine, 2009-2015

Background:

American football is a leading cause of sports-related injuries, with the knee, ankle, and shoulder most commonly involved.

Purpose/Hypothesis:

The purpose of this study was to describe the epidemiology, characteristics, and imaging findings of ankle injuries in football players at the National Football League (NFL) Combine and determine the relationship to player position. We hypothesized that there would be a high relative incidence of ankle injuries in these players compared with other sports and that there would be a direct correlation between the incidence of ankle injuries and player position.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A retrospective chart review of data collected from NFL Combine participants between 2009 and 2015 was performed. Patient demographics, history, physical examination results, and imaging findings were reviewed.

Results:

Of 2285 players, 1216 (53.2%) had a history of ankle injuries; of these, 987 (81.2%) had unilateral injuries, while 229 (18.8%) had bilateral injuries (total of 1445 ankles injured). This included 1242 ankle sprains (86.0% of ankle injuries): 417 (33.6% of sprains) high and 930 (74.9%) low. The most common soft tissue injuries were to the anterior talofibular ligament (n = 158, 12.7% of sprains) and syndesmosis (n = 137, 11.0%). Of all players at the NFL Combine with radiographs, 131 (10.9%) had evidence of an ankle fracture, all of which had healed. Magnetic resonance imaging (MRI) identified 66 players (28.9% of players at the combine who underwent MRI) with articular cartilage injuries: 62 involving the talus and 16 involving the tibia. Furthermore, 85 players (37.3% of players with MRI) with tendon injuries were identified: 26 Achilles, 55 peroneal, 3 flexor hallucis longus, and 19 posterior tibial. A total of 611 players (50.6% of players with radiographs) had signs of arthrosis on radiography. Running backs (61.9%), offensive linemen (60.3%), and tight ends (59.4%) had the highest rates of ankle injuries by position, while kickers/punters (23.3%) and long snappers (37.5%) had the lowest.

Conclusion:

Prior ankle injuries were present in more than 50% of elite college football players attending the NFL Combine. The rate of these ankle injuries varied by player position: offensive linemen, running backs, and tight ends had the highest overall rates, while special teams players had the lowest. Additional prospective work is needed to determine the impact of prior injuries on future playing career.

Meniscectomy and Resultant Articular Cartilage Lesions of the Knee Among Prospective National Football League Players: An Imaging and Performance Analysis

BACKGROUND

The effect of prior meniscectomy and the resulting reduction in meniscal tissue on a potential National Football League (NFL) player's articular cartilage status and performance remain poorly elucidated. Purpose/Hypothesis: (1) To determine the epidemiology, imaging characteristics, and associated articular cartilage pathology of the knee among players with a previous meniscectomy who were participating in the NFL Combine and (2) to evaluate the effect of these injuries on performance as compared with matched controls. The hypothesis was that players with less meniscal tissue would have worse cartilage status and inferior performance metrics in their first 2 NFL seasons.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All athletes with a history of a meniscectomy and magnetic resonance imaging scan of the knee who participated in the NFL Combine (2009-2015) were identified. Medical records and imaging were analyzed, and surgical history, games missed in college, position played, and draft position were documented. The conditions of the meniscus and cartilage were graded with modified ISAKOS scores (International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine) and ICRS scores (International Cartilage Repair Society), respectively. Players with a previous meniscectomy of at least 10% of total medial or lateral meniscal volume excised (ISAKOS meniscus grade ≤8) and matched controls without a significant pre-Combine injury were similarly evaluated and compared by position of play through analysis of draft position, number of games played and started, and how many eligible plays they participated in (snap percentage) within the first 2 NFL seasons.

RESULTS

Of the 2285 players who participated in the NFL Combine (2009-2015), 287 players (322 knees) had a prior meniscectomy (206 lateral, 81 medial). Among these players, 247 (85%) had a total of 249 chondral lesions, most commonly on the lateral femoral condyle (111 lesions, 45%). There was a significant inverse correlation found between the ISAKOS medial and lateral meniscus grade and the corresponding compartment chondral lesion grade ( P = .001). A poorer meniscus score was also associated with worse chondral pathology, especially in the lateral compartment. After controlling for position of play, the injury-free control group had a significantly greater number of total games played and games started and higher snap percentage versus those with a prior meniscectomy of at least 10% volume (ISAKOS meniscus grade ≤8). Players with severe chondral lesions (ICRS grade 4) in the medial and lateral compartments had significantly worse performance metrics when compared with matched controls.

CONCLUSION

Previous meniscectomy of at least 10% of total medial or lateral meniscus volume in prospective NFL players was significantly correlated with larger and more severe chondral lesions. Chondral and meniscal defects of the knee were found to result in a significant decrease in objective performance measures during a player's initial NFL career versus matched controls. Given these findings, players with a prior meniscectomy with evidence of chondral damage should be evaluated carefully for their overall functional levels; however, additional work is needed to fully clarify the effect of prior knee meniscal surgery on overall NFL performance.

Surgical Release of the Pectoralis Minor Tendon for Scapular Dyskinesia and Shoulder Pain

BACKGROUND

Pectoralis minor (PM) tightness has been linked to pain and dysfunction of the shoulder joint secondary to anterior tilt and internal rotation of the scapula, thus causing secondary impingement of the subacromial space.

PURPOSE

To describe outcomes pertaining to nonoperative and operative treatment via surgical release of the PM tendon for pathologic PM tightness in an active population.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over a 3-year period, a total of 46 patients were enrolled (mean age, 25.5 years; range, 18-33 years). Inclusion criteria consisted of symptomatic shoulder pain, limited range of overhead motion, inability to participate in overhead lifting activities, and examination findings consistent with scapular dysfunction secondary to a tight PM with tenderness to palpation of the PM tendon. All patients underwent a lengthy physical therapy and stretching program (mean, 11.4 months; range, 3-23 months), which was followed by serial examinations for resolution of symptoms and scapular tilt. Of the 46 patients, 6 (13%) were unable to adequately stretch the PM and underwent isolated mini-open PM release. Outcomes were assessed with scapula protraction measurements and pain scales as well as American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) scores.

RESULTS

Forty of the 46 patients (87%) resolved the tight PM and scapular-mediated symptoms with a dedicated therapy program (pre- and posttreatment mean outcome scores: 58 and 91 [ASES], 50 and 90 [SANE], 4.9 and 0.8 [VAS]; P < .01 for all), but 6 patients were considered nonresponders (mean score, 48 [ASES], 40 [SANE], 5.9 [VAS]) and elected to have surgical PM release, with improved scores in all domains (mean score, 89 [ASES], 90.4 [SANE], 0.9 [VAS]; P < .01) at final follow-up of 26 months (range, 25-30 months). Additionally, protraction of the scapula improved from 1.2 to 0.3 cm in a mean midline measurement from the chest wall preoperatively to postoperatively ( P < .01), similar to results in nonoperative responders. No surgical complications were reported, and all patients returned to full activities.

CONCLUSION

In most patients, PM tightness can be successfully treated with a nonoperative focused PM stretching program. However, in refractory and pathologically tight PM cases, this series demonstrates predictable return to function with notable improvement in shoulder symptoms after surgical release of the PM. Additional research is necessary to evaluate the long-term efficacy of isolated PM treatment.

Changes in the rectal mucosa induced by hypertonic enemas

The aspect of the rectal mucosa after administration of hypertonic enemas is occasionally confused with the macroscopic appearance of quiescent ulcerative colitis. Criteria for a diagnosis of enema reaction were derived from a retrospective series and tested prospectively on 11 healthy volunteers. Photographs and biopsies were obtained before and after administration of a sodium phosphate hypertonic enema. Three observers evaluated blindly the "before" and "after" macroscopic and microscopic pictures, graded the features, and made an overall diagnosis. In random studies, two observers mistakenly classified a macroscopic picture, but all correct histologic diagnoses of "before" and "after" biopsies. In decreasing order of discriminating power, the following features of an enema reaction were found to be useful: separation and mucous depletion of the glands (no observer variation), increase in mucosal fragility in 91 per cent of cases (82--100 per cent), edema of the lamina propria in 88 per cent (73--100 per cent), straightening of the basal membrane in 82 per cent (73--91 per cent) and an increase in extruded mucus in 70 per cent (18--100 per cent). In 39 per cent of cases (36--45 per cent), erythrocytes appeared focally in the lamina propria. The effects of hypertonic enemas can be recognized on biopsy.

Traditional Versus Congruent Arc Latarjet Technique: Effect on Surface Area for Union and Bone Width Surrounding Screws

PURPOSE

To compare the surface area available for bony contact and the width of bone on each side of the Latarjet fixation screws in the traditional Latarjet technique versus the congruent arc modification of the Latarjet technique.

METHODS

Computed tomographic scans of 24 shoulders in patients with glenohumeral instability who underwent multiplanar reconstruction measurements with multiple dimensions of the coracoid. The surface area of the coracoid available for bony contact with the anterior glenoid and width of bone on each side of a 3.5-mm screw was compared for the traditional Latarjet technique versus the congruent arc modification.

RESULTS

The surface area available for bony contact to the anterior glenoid was 5.65 ± 1.08 cm² using the traditional Latarjet technique compared with 3.64 ± 0.93 cm² using the congruent arc modification of the Latarjet technique (P < .001). The mean width of bone on each side of a 3.5-mm screw was 7.1 ± 1.0 mm using the traditional Latarjet technique compared with 4.1 ± 1.0 mm using the congruent arc modification (P < .001).

CONCLUSIONS

The traditional Latarjet technique has greater bony contact with the glenoid and greater bone width on each side of the screws compared with the congruent arc modification of the Latarjet technique. This potentially allows for a larger surface for healing in the traditional Latarjet technique. Moreover, because of smaller width of the bone around the screw, the congruent arc modification is potentially less tolerant of screw-positioning error compared with the traditional Latarjet technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Crohn's disease of the vulva

Three patients with Crohn's disease primarily involving the large intestine had unusual abscesses of the vulvar area. At biopsy, the abscesses had classic features of the primary disease and were clearly separated from the intestinal tract. There was no fistula in the anal canal, and the perineum between the vulvar abscess and the anus was normal. One of the patients also had an early lesion of Crohn's disease in the sigmoid. The lesion appeared as a small erythematous spot without ulceration. Biopsy revealed a typical granuloma under an intact mucosa. It is concluded that Crohn's disease is not confined to the gastrointestinal tract, and that early lesions of the disease within the gastrointestinal tract are submucosal rather than mucosal.

Latarjet Technique for Treatment of Anterior Shoulder Instability With Glenoid Bone Loss

Anterior glenohumeral instability is a common clinical entity, particularly among young athletic patient populations. Nonoperative management and arthroscopic treatment of glenohumeral instability have been associated with high rates of recurrence, particularly in the setting of glenohumeral osseous defects. Coracoid transfer, particularly the Latarjet procedure, has become the treatment of choice for recurrent anterior glenohumeral instability in the setting of osseous deficiencies greater than 20% to 30% of the glenoid surface area and may also be considered for the primary treatment of recurrent instability in the high-risk contact athlete, even in the setting of limited osseous deficiency. The following Technical Note provides a diagnostic approach for suspected glenohumeral instability, as well as a detailed description of the congruent-arc Latarjet procedure, performed with a deltoid split, with its postoperative management.

Pectoralis Major Repair: A Biomechanical Analysis of Modern Repair Configurations Versus Traditional Repair Configuration

BACKGROUND

Pectoralis major (PM) ruptures are increasingly common, and a variety of surgical techniques have been described. However, tested techniques have demonstrated diminished strength with inadequate restoration of the footprint and suture failure at relatively low loads. Purpose/Hypothesis: The purpose was to biomechanically compare PM transosseous suture repair (current gold standard) to modern PM repair techniques that use larger caliber sutures, suture tape, and unicortical button fixation (UBF). The null hypothesis was that there would be no mechanical difference between repair techniques and no difference in the amount of footprint restoration.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-four fresh-frozen cadaveric shoulders controlled for age and bone mineral density were randomized equally to 4 groups: (1) UBF, suture tape; (2) UBF, No. 5 suture, suture tape; (3) bone trough with No. 2 suture; and (4) native PM tendon group; all groups were tested to failure. The specimens were tested under cycling loads (10 N to 125 N) with a final load-to-failure test at 1 mm/s. Failure modes were classified by location and cause of rupture based on optical markers, while tendon footprint length was measured to determine amount of footprint restoration.

RESULTS

For fixation strength, the mean peak load was significantly greater in the native tendon (1816 ± 706 N) versus UBF/No. 5 suture/suture tape (794 ± 168 N), UBF/suture tape (502 ± 201 N), and bone trough (492 ± 151 N) ( P < .001 for all). UBF/No. 5 suture/suture tape featured the lowest displacement superiorly (1.09 ± 0.47 mm) and inferiorly (1.14 ± 0.39 mm) with a significant difference compared with bone trough. With regard to tendon footprint reapproximation, cortical button fixation best approximated native tendon footprint length versus bone trough.

CONCLUSION

Based on peak failure load, the UBF/No. 5 suture/suture tape construct demonstrated 61% greater construct strength than a traditional bone trough technique. Moreover, displacement after cyclic loading was by far smallest in the UBF/No. 5 suture/suture tape construct. Therefore, repair constructs with larger caliber suture and suture tape provide a measurable improvement in construct strength versus traditional PM repair techniques in a biomechanical model and may be advantageous for repair.

CLINICAL RELEVANCE

Cortical button fixation with larger caliber suture and suture tape allows for a significantly better PM repair than more traditional techniques at the time of surgery, which may ultimately result in improved clinical outcomes if implemented in surgical practice.

Gene transfer of NMDAR1 subunit sequences to the rat CNS using herpes simplex virus vectors interfered with habituation

1. The aim is to study some roles of the hippocampal NMDA receptor, by modifying the expression of the essential NR1 subunit, with temporal and spatial restrictions in the central nervous system (CNS) of the rat. 2. Due to their neurotropism and the size of inserts they can accomodate, herpes simplex virus type-1 (HSV-1) derived amplicon vectors were used to transfer sequences, either in sense (+) or antisense (-) orientations, of the NR1 subunit gene, or of the green fluorescent protein (GFP) gene, into the CNS. 3. Vector expression in cell lines was followed by GFP autofluorescence, immunofluorescence and western blot. 4. The vectors were inoculated into the dorsal hippocampus of adult male Wistar rats, which were evaluated for habituation to an open field, and then, for expression of the transgenes, by autofluorescence and western blot; the expression mainly happened in pyramidal cells of CA1. 5. The animals injected with vectors carrying the NR1(+) transgene showed habituation to the new environment, as also happened with rats injected with vectors carrying only the GFP transgene. 6. In contrast, animals injected with vectors carrying NR1(-) sequence, did not show habituation. This might be retrograde amnesia or disability to record the trace, suggesting that the NR1 subunit in the dorsal hippocampus, is involved in habituation to a new environment. 7. HSV-1 derived amplicon vectors appear to be useful tools to modify endogenous gene expression, at a defined period, in restricted regions of the CNS.

AFLP assessment of genetic variability in cassava accessions (Manihot esculenta) resistant and susceptible to the cassava bacterial blight (CBB)

Cassava bacterial blight (CBB) is caused by Xanthomonas axonopodis pv. manihotis (Xam). Resistance is found in Manihot esculenta and, in addition, has been introgressed from a wild relative, M. glaziovii. The resistance is thought to be polygenic and additively inherited. Ninety-three varieties of M. esculenta (Crantz) were assessed by AFLPs for genetic diversity and for resistance to CBB. AFLP analysis was performed using two primer combinations and a 79.2% level of polymorphism was found. The phenogram obtained showed between 74% and 96% genetic similarity among all cassava accessions analysed. The analysis permitted the unique identification of each individual. Two Xam strains were used for resistance screening. Variation in the reaction of cassava varieties to Xam strains was observed for all plant accessions. The correlation of resistance to both strains, had a coefficient of 0.53, suggesting the independence of resistance to each strain. Multiple correspondence analysis showed a random distribution of the resistance/susceptibility response with respect to overall genetic diversity as measured by AFLP analysis. A total heterozygosity index was calculated to determine the diversity within clusters as well as among them. Our results demonstrate that resistance to CBB is broadly distributed in cassava germplasm and that AFLP analysis is an effective and efficient means of providing quantitative estimates of genetic similarities among cassava accessions.

Prospective Evaluation of Surgical Treatment of Humeral Avulsions of the Glenohumeral Ligament

BACKGROUND

Humeral avulsion of the glenohumeral ligament (HAGL) is an infrequent but significant contributor to shoulder dysfunction, instability, and functional loss.

PURPOSE

To prospectively identify patients with HAGL lesions and then conduct retrospective evaluation of the clinical history, examination findings, and surgical outcomes of these patients.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Over a 6-year period (2006-2011), patients with shoulder dysfunction and a HAGL lesion that was confirmed via magnetic resonance arthrogram (MRA) were prospectively evaluated with a minimum 2-year follow-up. Patient demographics, presentation, examination, and surgical findings were documented. Outcomes of return to activity as well as Western Ontario Shoulder Instability Index (WOSI) and Single Assessment Numeric Evaluation (SANE) scores were recorded at final follow-up. Anterior HAGL (aHAGL) lesions were repaired with a partial subscapularis tenotomy approach, while reverse (rHAGL) lesions were repaired arthroscopically.

RESULTS

Of 28 patients, 27 (96%) completed the study requirements at a mean of 36.2 months (range, 24-68 months). The sample contained 12 females (44%) and 15 males (56%), who had a mean age of 24.9 years (range, 18-34 years). The chief complaint reported was pain in 23 patients (85%), while only 4 (15%) patients complained primarily of recurrent instability symptoms. Fourteen patients (52%) had aHAGL lesions, 10 patients (37%) had rHAGL lesions, and 3 patients (11%) had combined aHAGL and rHAGL lesions. Ten patients (37%) had concomitant HAGL lesions and labral tears, whereas 17 patients (63%) had isolated HAGL lesion without labral tear. The 17 patients (63%) with aHAGL lesions or combined lesions underwent a partial subscapularis tenotomy approach, while the remaining 10 patients (37%) with rHAGL lesions underwent arthroscopic surgical repair. After surgery, WOSI outcomes improved from 54% to 88% and SANE outcomes improved from 50% to 91% ( P < .01 for both), with no reports in recurrence of instability symptoms at final follow-up.

CONCLUSION

This study demonstrated that patients with symptomatic HAGL lesions predominantly report shoulder pain and dysfunction, with few chief complaints of recurrent instability complaints. After surgery, patients showed predictable return to full activity, improvement in objective and patient-reported outcomes, and satisfaction with treatment outcome.

Epidemiology and Outcomes of Lisfranc Injuries Identified at the National Football League Scouting Combine

BACKGROUND

Lisfranc injuries are challenging to treat and may have a detrimental effect on athletic performance.

PURPOSE

(1) Determine the epidemiological characteristics of Lisfranc injuries at the annual National Football League (NFL) Scouting Combine, (2) define player positions at risk for these injuries, and (3) evaluate the impact that these injuries and radiographic findings have on NFL draft position and performance.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All players who sustained a Lisfranc injury prior to Combine evaluation between 2009 and 2015 were evaluated. The epidemiological characteristics, player positions affected, treatment methods, and number of missed collegiate games were recorded. Radiographic outcomes were analyzed via Combine radiograph findings, while NFL performance outcomes were assessed for all Lisfranc injuries (2009-2013) compared with matched controls in the first 2 years of play.

RESULTS

A total of 41 of 2162 (1.8%) Combine participants were identified with Lisfranc injuries, of whom 26 of 41 (63.4%) were managed operatively. Players who underwent surgery were more likely to go undrafted compared with players managed nonoperatively (38.5% vs 13.3%, operative vs nonoperative management, respectively; P = .04) and featured a worse NFL draft pick position (155.6 vs 109; P = .03). Lisfranc-injured players when compared with controls were noted to have worse outcomes in terms of NFL draft position (142 vs 111.3, Lisfranc-injured players vs controls, respectively; P = .04), NFL career length 2 years or longer (62.5% vs 69.6%; P = .23), and number of games played (16.9 vs 23.3; P = .001) and started (6.8 vs 10.5; P = .08) within the first 2 years of their NFL career. Radiographs demonstrated that 17 of 41 (41.5%) athletes had residual Lisfranc joint displacement greater than 2 mm compared with the contralateral foot. Lisfranc-injured athletes with greater than 2 mm residual displacement, when compared with matched controls, had worse draft position (156.9 vs 111.2 for Lisfranc-injured players vs controls, respectively; P = .009) and fewer games played (14.4 vs 23.3; P = .001) and started (3.1 vs 10.5; P = .03). Moreover, athletes with greater than 2 mm residual displacement featured worse outcomes across all assessed NFL variables versus athletes with residual displacement of 2 mm or less.

CONCLUSION

Lisfranc injuries identified at the NFL Combine have an adverse effect on an NFL athlete's draft status, draft position, and overall play during initial NFL seasons. In particular, residual displacement of the Lisfranc joint has a detrimental effect on the first 2 seasons of NFL play and may lead to long-lasting negative effects on the athlete's career.

Preliminary evaluation of a full-time falling monitor for the elderly

The article presents the early outcomes of the evaluation of an intelligent accelerometer unit (IAU) utilized for detecting the falling events of elderly people . The overall design of the monitor where the IAU is integrated is briefly exposed. The outcomes of a laboratory study carried out over 8 volunteers show that the device is able to distinguish true falling events from normal activities like fast walking or going up/downstairs. The influences of the subject and the environment have been taken into account profiting from the processing capacity of the monitor distributed architecture.

Radiographic Analysis of the Hill-Sachs Lesion in Anteroinferior Shoulder Instability After First-Time Dislocations

PURPOSE

To identify the relation between the Hill-Sachs (H-S) angle and arm position at the time of the initial dislocation, and to see if this correlates with the glenoid track.

METHODS

A total of 102 patients (89 male patients, 87.2%), with a mean age of 32 years (range, 17 to 38 years), were divided into 2 groups, abduction (ABD) and adduction (ADD), dependent on the position of the arm at the time of the instability event. All patients were evaluated with bilateral computed tomography scans (3-dimensional) to define the H-S position on the glenoid track and to measure the H-S angle. One-way analysis of variance was used to compare the H-S angle between the 2 groups.

RESULTS

Dislocation occurred in ABD in 45 patients (44.1%) and in ADD in 57 (55.9%). The H-S angle was 32.4° ± 4.7° in the ABD group versus 16.1° ± 2.9° in the ADD group. All patients' injuries were "on-track" glenoid injuries in both groups.

CONCLUSIONS

This study identified a difference in the H-S angle relative to arm position at the time of initial dislocation. Patients whose injury occurred in the ABD position showed a higher H-S angle, leading to an increased risk of engagement, because the long axis of the H-S lesion is parallel to the glenoid in a position of function. Thus arm position at the time of the initial instability event may be a risk factor for engagement and higher risk of recurrence. LEVEL OF

EVIDENCE

Level IV, prognostic case series.

Biological characterization of Trypanosoma cruzi stocks from Chilean insect vectors

Fifty-seven Trypanosoma cruzi stocks isolated from Triatoma infestans and Triatoma spinolai of the five different geographic endemic areas of Chile were studied by schizodeme and molecular karyotype analysis. Four different genotypes are found in the sylvatic T. spinolai vector and five in the T. infestans domiciliary vector. Of these genotypes, two common genotypes overlap on both transmission cycles exclusively in the extreme northern endemic areas of Chile. Metacyclic trypomastigotes obtained in vitro or cell-derived trypomastigotes proved to be infective in gamma-irradiated Balb/c mice for the study of the immune response and biological behavior. Of a total of 57 T. cruzi stocks obtained, 19 of them, representing all the different genotypes found in Chile, were tested on a murine experimental model and then fully studied. Female compared with male animals demonstrated greater resistance to Chagas disease with all the T. cruzi stocks tested. The immune response was assessed by lytic antibodies that were studied by the in vitro antibody-dependent complement-mediated lytic assay with the use of bloodstream trypomastigotes as target cells. In one unique parasite genotype the elicited lytic antibodies reacted in a genotype-specific manner, in contrast with lytic antibodies generated by other T. cruzi genotypes. Parasitemias were high, moderate, and low, with mortality ranges of 6-50%, 0-45%, and 0-10%, respectively. No association was found between specific infective genotypes and virulence or mortality. Independently of the T. cruzi strain studied, each population displayed a characteristic parasitemia curve and prepatent period. A considerable number of the parasite stocks proved to be mixed populations, according to molecular karyotype patterns obtained before and after differentiation and amplification of the parasites. This fact created difficulty in assessing the identity of the genotype really infective to mice.

Paraglacial gravitational deformations in the SW Alps: a review of field investigations, 10Be cosmogenic dating and physical modelling

Catastrophic deep-seated landslides (DSL) are generally considered to be the result of large slope deformations also known as deep-seated gravitational slope deformation (DSGSD). This paper aims to build a synthesis of multiple studies made in the Tinée Valley (southern French Alps) to assess the geometrical, kinematical, mechanical and chronological relationships between these two gravitational processes.

At the scale of the valley, data issued from geological, geomorphological and 10Be dating indicate a clear geometrical link between DSGSD and DSL occurring at the base of the slope and suggest that gravitational slope evolution began after the glacial retreat (13 ka BP). This is supported by the example of the well-documented La Clapière slope. A continuous evolution process is characterized geometrically and temporally from geomorphic observations and analogue modelling. Coupling structural, geomorphological, physical and chronological studies allowed us to propose a four-dimensional (4D) deformation model mechanically correlated with progressive failure concept. The validity and variability of this reference site are discussed at the valley scale (taking Isola and Le Pra slope deformation as examples).

It allows a rough estimation of the state of slope deformation at the valley scale to be constructed and the slope evolution with time to be considered. This 4D model could then be considered as a reference for other deep-seated gravitational slope deformations in comparable Alpine valleys.

Biological characterization of Trypanosoma cruzi zymodemes: in vitro differentiation of epimastigotes and infectivity of culture metacyclic trypomastigotes to mice

Thirty-one Trypanosoma cruzi isolates from Chile, Peru, and Bolivia were studied in their capacity to differentiate in vitro from epimastigotes to metacyclic trypomastigotes on TAU-3AAG medium. Zymodeme 1 parasites displayed the best level of differentiation, which ranges from 60 to 90% depending on the isolate. Zymodeme 2 parasites exhibited highly heterogenous differentiation rates. This differentiation method permits the obtention of large amounts of metacyclic trypomastigotes from zymodeme 1 parasites. Metacyclic trypomastigotes obtained in vitro were infective to nude Balb/c hybrid mice. Zymodeme 1 parasites produced high parasitemias in this murine model; in contrast, zymodeme 2 parasites displayed lower parasitemias. Of a total of 27 T. cruzi isolates, 20 proved to be infective to mice, 12 gave enough parasites for further studies, and 8 of these were used for biological characterization. Results are compared with the infective clone Dm28 and Tulahuén strains maintained since 1954 in mice.

Laparoscopic management of Spigelian hernia

Spigelian hernia (SH) is an uncommon abdominal wall hernia. Its clinical symptoms are not characteristic, and the preoperative diagnosis is often difficult because SH can simulate the symptoms of more classical lower quadrant abdominal diseases. We report a case of SH in an 80-year-old woman that was complicated by incarceration and diagnosed by physical examination and ultrasound. At the time of presentation, she had an abdominal mass that was soft and occasionally painful, and aggravated by movements that increase intraabdominal pressure. Laparoscopic examination of the abdominal cavity identified the incarcerate jejunum ansae. The defect was a large opening in the peritoneum along the lateral margin of the rectus abdominis muscle. After dissection of the intestinal adhesions, a prosthetic polypropylene mesh was introduced and fixed with staples into the lateral abdominal wall. There were no postoperative complications. We conclude that the laparoscopic approach is a feasible alternative to the conventional open technique that is easy, safe, and allows excellent operative visualization.

5Hz Repetitive transcranial magnetic stimulation to left prefrontal cortex for major depression

BACKGROUND

Repetitive transcranial magnetic stimulation (rTMS) to left prefrontal cortex at 10Hz is the most commonly utilized protocol for major depressive disorder (MDD). Published data suggests that left sided 5Hz rTMS may be efficacious and well tolerated.

OBJECTIVE

We analyzed outcomes in a naturalistic cohort of MDD patients who could not tolerate 10Hz rTMS and were routinely switched to 5Hz. We hypothesized that the efficacy of 5Hz rTMS would be equivalent to 10Hz.

METHODS

Records were reviewed for patients (n=98) who received 15 or more acute rTMS treatments. The sample was split based upon the frequency (10 or 5Hz) at which the majority of treatments were delivered. The Inventory of Depressive Symptoms (IDS-SR) and 9-Item Patient Health Questionnaire (PHQ-9) were used to evaluate outcomes.

RESULTS

Baseline IDS-SR was higher in the 5Hz (n=27) than in the 10Hz (n=71) group (p<.05), as was frequency of comorbid anxiety (p=.002). Depression outcomes did not differ between groups, and there were no differences in response or remission rates (all p>.1). Statistical power was sufficient to detect small group differences (d=.26).

LIMITATIONS

Open-label data in a naturalistic setting.

CONCLUSION

Outcomes associated with 5Hz rTMS did not differ from 10Hz, despite higher baseline depressive symptom severity and anxiety in 5Hz patients. 5Hz stimulation may be an alternative treatment option for patients unable to tolerate 10Hz rTMS.