Rachel Shakked

Mesenchymal chondrosarcoma: clinicopathologic study of 20 cases.

CONTEXT Mesenchymal chondrosarcoma is a rare, high-grade malignancy of bone or soft tissue with a unique, biphasic histology and poor prognosis. Because of its rarity and variable length of disease-free survival, the natural history of the disease remains poorly understood. OBJECTIVE To present clinical, radiographic, and histopathologic features of mesenchymal chondrosarcoma from one of the largest case series collected by a single, senior-level bone pathologist. DESIGN Twenty cases were reviewed in consultations spanning 45 years. RESULTS Eighteen tumors (90%) originated in bone, and 2 tumors (10%) were of extraskeletal origin. Of the skeletal tumors, locations included craniofacial bones (n  =  9; 50%), ribs and chest wall (n  =  4; 22%), sacrum and spinal elements (n  =  3; 17%), and lower extremities (n  =  2; 11%), whereas soft tissue tumors were located about the scapula (n  =  1; 50%) and lower extremity (n  =  1; 50%). Plain radiographs demonstrated calcified, osteolytic lesions with extraosseous extension. Typical histologic features were identified consisting of small, round or spindled cells, interspersed with hyaline cartilage islands. Seventeen patients (85%) were treated surgically, and 8 patients (40%) received adjuvant treatment. Seven patients (35%) were living at last follow-up, 1.8 to 12.5 years after diagnosis, and 8 patients (40%) died between 1.2 and 21.8 years after diagnosis. CONCLUSIONS Mesenchymal chondrosarcoma presents multiple challenges. Diagnostic pitfalls include inadequate biopsy samples, which may result in sample error. Sox9 has been proposed as a unique marker for mesenchymal chondrosarcoma which may improve diagnostic specificity. Treatment and prognosis vary considerably. Patients who receive surgery and chemotherapy seem to fare better. Multicenter studies with higher sample numbers may improve our understanding of this malignancy.

Surgical treatment of talus fractures.

Talus fractures result from high-energy mechanisms and usually occur at the neck. Functional outcome after talar neck fracture worsens with increasing Hawkins grade. The mainstay of treatment for talar neck fractures is anatomic reduction and internal fixation. Prompt reduction of dislocations should be performed. Patients should be taken to the operating room as soon as stabilized. Dual incisions and a combination of minifragment plates and screws should be used. Talar body fractures have a high rate of ankle and subtalar arthritis. Lateral process fractures are frequently missed on radiographs. Complications after talus fractures include osteonecrosis, malunion, post-traumatic arthritis, and infection.

Paramecium species ingest and kill the cells of the human pathogenic fungus Cryptococcus neoformans

A fundamental question in the field of medical mycology is the origin of virulence in those fungal pathogens acquired directly from the environment. In recent years, it was proposed that the virulence of certain environmental animal-pathogenic microbes, such as Cryptococcus neoformans, originated from selection pressures caused by species-specific predation. In this study, we analyzed the interaction of C. neoformans with three Paramecium spp., all of which are ciliated mobile protists. In contrast to the interaction with amoebae, some Paramecium spp. rapidly ingested C. neoformans and killed the fungus. This study establishes yet another type of protist-fungal interaction supporting the notion that animal-pathogenic fungi in the environment are under constant selection by predation.

Operative treatment of lateral ligament instability

Purpose of reviewAnkle sprains, which account for 40% of sports injuries in the USA, can lead to chronic ankle instability. Chronic ankle instability can be classified as functional, mechanical, or a combination of both and is diagnosed using a combination of a physical exam, an MRI, and stress radiographs. This review focuses on different approaches to treatment, including non-operative and operative techniques, of chronic ankle instability, including reviewing traditional procedures as well as more novel and newer techniques.Recent findingsBased on existing literature, non-operative treatment should always precede operative treatment of chronic ankle instability. If rehabilitation fails, Brostrom-Gould type ankle stabilization has been the preferred surgical option. Recent literature suggests that arthroscopic repair might reduce recovery time and improve outcomes in certain populations; however, there are higher rates of complication following these surgeries. In more high-risk populations, some literature reports that ligament repair with peroneus brevis transfer could be a more effective treatment option.SummaryCurrently, varying surgical techniques exist for the treatment of chronic ankle instability. While the more recently reported techniques show promise, it is important to note that there is little evidence showing they are more successful than traditional techniques. It is imperative that future studies focus on outcomes and complication rates of these newer procedures.

Driving After Hallux Valgus Surgery

Background: The purpose of the study was to determine when patients can safely return to driving after first metatarsal osteotomy for hallux valgus correction. Methods: After institutional review board approval, 60 patients undergoing right first metatarsal osteotomy for hallux valgus correction surgery were recruited prospectively. Patients’ brake reaction time (BRT) was tested at 6 weeks and repeated until patients achieved a passing BRT. A control group of twenty healthy patients was used to establish as passing BRT. Patients were given a novel driver readiness survey to complete. Results: At 6 weeks, 51 of the 60 patients (85%) had BRT less than 0.85 seconds and were considered safe to drive. At 6 weeks, the passing group average was 0.64 seconds. At the 8 weeks, 59 patients (100%) of those who completed the study achieved a passing BRT. Patients that failed at 6 weeks had statistically greater visual analog scale (VAS) pain score and diminished first metatarsophalangeal (MTP) range of motion (ROM). On the novel driver readiness survey, 8 of the 9 patients (89%) who did not pass disagreed or strongly disagreed with the statement, “Based on what I think my braking reaction time is, I think that I am ready to drive.” Conclusion: Most patients may be informed that they can safely return to driving 8 weeks after right metatarsal osteotomy for hallux valgus correction. Some patients may be eligible to return to driving sooner depending on their VAS, first MTP ROM, and driver readiness survey results. Level of Evidence: Level II, comparative study

Combined Popliteal Catheter With Single-Injection vs Continuous-Infusion Saphenous Nerve Block for Foot and Ankle Surgery:

Background: The increasing scope and complexity of foot and ankle procedures performed in an outpatient setting require more intensive perioperative analgesia. Regional anesthesia (popliteal and saphenous nerve blocks) has been proven to provide satisfactory pain management, decreased postoperative opioid use, and earlier patient discharge. This can be further augmented with the placement of a continuous-flow catheter, typically inserted into the popliteal nerve region. This study investigated the use of a combined popliteal and saphenous continuous-flow catheter nerve block compared to a single popliteal catheter and single-injection saphenous nerve block in postoperative pain management after ambulatory foot and ankle surgery. Methods: A prospective study was conducted using 60 patients who underwent foot and ankle surgery performed in an outpatient setting. Demographic data, degree of medial operative involvement, American Society of Anesthesiologists physical classification system, anesthesia time, and postanesthesia care unit time were recorded. Outcome measures included pain satisfaction, numeric pain scores (NPS) at rest and with activity, and opioid intake. Patients were also classified by degree of saphenous nerve involvement in the operative procedure, by the surgeon who was blinded to the anesthesia randomization. Results: Patients in the dual-catheter group took significantly less opioid medication on the day of surgery and postoperative day 1 (POD 1) compared to the single-catheter group (P = .02). The dual-catheter group reported significantly greater satisfaction with pain at POD 1 and POD 3 and a significantly lower NPS at POD 1, 2, and 3. This trend was observed in all 3 subgroups of medial operative involvement. Conclusion: Patients in the single-catheter group reported more pain, less satisfaction with pain control, and increased opioid use on POD 1, suggesting dual-catheter use was superior to single-injection nerve blocks with regard to managing early postoperative pain in outpatient foot and ankle surgery. Level of Evidence: Level II, prospective cohort study.

Tarsal navicular stress fractures

Purpose of reviewNavicular stress fractures are common in athletes and management is debated. This article will review the evaluation and management of navicular stress fractures.Recent findingsVarious operative and non-operative adjunctive treatment modalities are reviewed including the relevance of vitamin D levels, use of shock wave therapy and bone marrow aspirate concentrate (BMAC), and administration of teriparatide. Surgical treatment may be associated with earlier return to sports.SummaryThe author’s preferred treatment algorithm with corresponding images is presented which allows for safe and rapid return to activities in the athletic patient. Future research is needed in evaluating the preventative effects of vitamin D and use of other adjunctive treatments to increase the healing rates of this fracture.

Autograft Choice in Young Female Patients: Patella Tendon versus Hamstring

Abstract With the increasing incidence of anterior cruciate ligament (ACL) reconstruction in women and younger patients, the optimal graft choice in the young female patient has become the subject of much debate. This study aimed to evaluate patient‐reported outcomes, objective knee stability, complication rates, and the incidence of failure after ACL reconstruction using bone‐patellar tendon‐bone (BPTB) autograft compared with hamstring (HS) autograft in young female patients. Female patients who underwent primary ACL reconstruction with BPTB or HS autograft between ages 15 and 25 years were identified. Medical records were reviewed for postoperative complications and subsequent procedures on the operative knee. Patients were evaluated with functional surveys, physical examination including Lachman and pivot‐shift tests, and arthrometric testing with a KT‐1000 arthrometer. There were 37 patients in the BPTB group and 28 patients in the HS group. For patients who did not undergo revision, significant differences were not found in visual analog score (p = 0.94), Lysholm score (p = 0.81), Kujala score (p = 0.85), or Tegner level (p = 0.81). No difference was detected in the rate of return to a level of activity at or above the same level prior to injury (p = 0.31). Significantly more patients in the BPTB group were graded 1a Lachman and negative pivot shift compared with the HS group (p < 0.001). There was a significant difference in mean side‐to‐side manual maximum arthrometric testing (p < 0.001). There were significantly fewer subsequent procedures and a lower rate of graft failures in the BPTB group. We detected no difference in subjective functional outcomes following ACL reconstruction. However, a higher failure rate in the HS reconstructions and greater laxity by arthrometric testing may indicate increased objective stability with the use of BPTB autograft in the young female patient population. The level of evidence for this article is (level III, retrospective cohort).

Mid-term Results of Radiographic and Functional Outcomes After Tibiotalocalcaneal Arthrodesis with Bulk Femoral Head Allograft

Introduction/Purpose: Tibiotalocalcaneal (TTC) arthrodesis with bulk femoral head allograft has previously been reported as a way to fill large osseous hindfoot deficits in order to restore limb length, but few studies have been performed evaluating outcomes and prognostic factors. The purposes of this study were to assess functional and radiographic outcomes after TTC arthrodesis with femoral head allograft and retrospectively identify prognostic factors.

A Prospective Randomized Study Evaluating the Effect of Perioperative NSAIDs on Opioid Consumption and Pain Management After Ankle Fracture Surgery

Category: Trauma Introduction/Purpose: Currently there is an epidemic in the United States regarding opioid abuse. This has resulted in strict government prescribing regulations throughout the country and increasing efforts by orthopaedic surgeons to better manage postoperative narcotic analgesia. Non-steroidal anti-inflammatory drugs (NSAIDs) can serve as a powerful adjunct in managing postoperative pain and in turn minimize the need for opioid medications. It has recently been shown that ketorolac can be used after open reduction and internal fixation (ORIF) of ankle fractures without interfering with bone healing. Therefore, we set out to evaluate whether including ketorolac in the postoperative drug regimen reduces opioid consumption and pain after ORIF of ankle fractures. Methods: 128 patients undergoing ORIF of an ankle fracture were prospectively randomized to treatment with or without ketorolac. Patients also had the option to simultaneously undergo regional anesthesia. Patients assigned to the treatment group were given 30 mg of IV ketorolac intraoperatively; prescribed 20 tablets of ketorolac 10 mg PO Q6 H and 30 tablets of Oxycodone/Acetaminophen 5/325 Q4-6 H PRN. Patients assigned to the control group were given 30 tablets of oxycodone/acetaminophen 5/325 Q4-6 H PRN only. A survey was distributed via Research Electronic Data Capture (REDCap) on postoperative days 1-7. Patients were asked to report their daily opioid consumption, pain level using the Visual Analog Scale (VAS), satisfaction with pain management, and side effects. Intention-to-treat analysis was performed. Normality of data was tested using the Shapiro-Wilk test. Differences between the control and treatment groups were tested using Mann-Whitney U or Student’s t-tests. Results: 105/128 (82%) patients with mean BMI of 29.3 completed all study requirements. 54 received ketorolac with opioid medication and 51 received opioids alone. 43 men (41%) and 62 women (59%) participated with mean age of 48 years. Patients receiving ketorolac required less oxycodone/acetaminophen (p<0.013) and reported less pain (p<0.048) during postoperative days 1 and 2 compared to control patients(Figure 1). While opioid consumption did not significantly differ after day 2, patients treated with ketorolac maintained less pain (days 1-4, p<0.028); better sleep (days 1-5, p<0.037); lower frequency of pain (days 1-3; p<0.017); and greater satisfaction with pain management (days 1-3, p<0.047). Hypersensitivity was significantly less on day 1 (p=0.036) and paresthesias on day 3 (p=0.011). Surprisingly, there was no difference in nausea/constipation between groups (p>0.139). Conclusion: The addition of ketorolac to the postoperative drug regimen significantly reduced pain, while decreasing the use of opioid medication following ORIF of ankle fractures early in the postoperative period. Better pain management during postoperative days 1 and 2 is particularly important because patients on average consume the most opioids during this time. With the assurance that ketorolac does not interfere with bone healing, this NSAID is a valuable tool for helping patients manage postoperative pain with less narcotic analgesia.