Extremity ultrasound can be performed quickly and accurately by nonphysician personnel with excellent accuracy. Pulmonary ultrasound appears promising; blinded verification of the utility of ultrasound in patients with extremity injury should be performed to determine whether extremity and respiratory evaluation should be added to the FAST examination (the FASTER examination) and to verify the technique in remote locations such as military and aerospace applications.
Recognition of biased immunoglobulin variable (IgV) gene usage in B-cell chronic lymphocytic leukemia (B-CLL) may yield insight into leukemogenesis and may help to refine prognostic categories. We explored Ig variable heavy (V H ) and light (V L ) chain gene usage in highly stable and indolent B-CLL (n ¼ 25) who never required treatment over 10 or more years. We observed an unexpectedly high usage of mutated V H 3-72 (6/25; 24.0%), a gene that was otherwise rare in B-CLL (7/805; 0.87%; Po0.01), including mutated cases (6/432; 1.39%; Po0.01) and was exceptional among indolent (1/230, 0.435%; Po0.01), and aggressive B-cell lymphomas (0/105; Po0.01). Three of six V H 3-72 B-CLL cases utilized the same V L V j 4-1 gene. Two V H 3-72 B-CLL cases had highly homologous V H complementarity determining regions 3 (CDR3s), encoding Cys-XXXX-Cys domains, and utilized V j 4-1 genes with homologous IgV L CDR3s. An identical threonine to isoleucine change at codon 84 of V H 3-72 framework region 3 (FR3) recurred in four cases of highly stable V H 3-72 B-CLL. This mutation is expected to cause a conformational change of FR3 proximal to CDR3 that might critically affect high-affinity antigen binding. B-cell receptors encoded by V H 3-72 may identify a specific B-CLL group and be implicated in leukemogenesis through an antigen-driven expansion of B cells.
There is growing evidence that anatomic placement of the femoral tunnel in anterior cruciate ligament reconstruction confers biomechanical advantages over the traditional tunnel position. The anteromedial portal technique for anatomic anterior cruciate ligament reconstruction has many well-described technical challenges. This article describes the translateral all-inside technique, which produces anatomic femoral tunnel placement using direct measurement of the medial wall of the lateral femoral condyle and outside-in drilling. All work is carried out through the lateral portal with all viewing through the medial portal. Thus there is no need for an accessory medial portal or hyperflexion of the knee during femoral socket preparation. A single quadrupled hamstring graft is used with cortical fixation at both the femoral and tibial tunnels.T ranstibial drilling remains the most popular method for creating the femoral tunnel in anterior cruciate ligament (ACL) reconstruction. With this technique, femoral socket placement is dictated by the tibial tunnel, which invariably results in a relatively vertical position of the graft. Although this technique has had good early clinical outcomes, the procedure has been shown to be nonanatomic.
Anatomic placement of the femoral tunnel in anterior cruciate ligament (ACL) reconstruction confers biomechanical advantages over the traditional tunnel position. The anteromedial portal technique for anatomic ACL reconstruction has many well-described technical challenges. This paper describes the TransLateral technique. The technique produces anatomic femoral tunnel placement using direct measurement of the medial wall of the lateral femoral condyle and out to in drilling. All work is carried out through the lateral portal with all viewing via the medial portal. There is no need for an accessory medial portal or hyperflexion of the knee. Level of evidence Expert opinion, Level V.
Objective Pyrocardan trapeziometacarpal interposition implant is a free intra-articular spacer composed of pyrocarbon. This biconcave resurfacing implant, both ligament and bone-stock sparing, is indicated for use in early-to-moderate stage trapeziometacarpal osteoarthritis. It was hypothesized that the postoperative outcome measures of the Pyrocardan implant would be comparable to those seen with ligament reconstruction and tendon interposition (LRTI) surgeries and those reported by the designer of the implant, Phillipe Bellemère, but that strength would be greater than for LRTI. Methods In this prospective case series, 40 Pyrocardan implants were performed in 37 patients. Average age was 58 years (range: 46–71). Patients were assessed preoperatively, 3 months, 6 months, 1 year, 2 years, and beyond (long term) wherever possible. Results There have been no major complications or revision surgeries for the series. Average follow-up was 29 months (range: 12 months–7 years). Twenty-eight joints were assessed at over 2 years post index surgery. Outcome measure scores improved from preoperative assessment to the most recent follow-up equal or greater than 2 years. Average grip strength at 2 years was 30 kg, as compared with 19.6 kg in an age-matched cohort who underwent trapeziectomy and 25 kg in Bellemère's original series of Pyrocardan implants. Conclusions Pyrocardan interposition arthroplasty appears to be a safe, effective treatment for trapeziometacarpal arthritis. Patient-reported clinical outcomes were at least equivalent to LRTI and are comparable to Bellemère's original series. Grip and pinch strength appear to be better than LRTI. Level of Evidence This is a Level III, prospective observational cohort study.
Arthritis of the wrist is a painful disabling condition that has various causes and presentations. The traditional treatment has been a total wrist fusion at a price of the elimination of movement. However, forms of treatment which allow the preservation of movement are now preferred. Modern arthroplasties of the wrist are still not sufficiently robust to meet the demands of many patients, nor do they restore normal kinematics of the wrist. A preferable compromise may be selective excision and partial fusion of the wrist using knowledge of the aetiology and pattern of degenerative change to identify which joints can be sacrificed and which can be preserved. This article provides an overview of the treatment options available for patients with arthritis of the wrist and an algorithm for selecting an appropriate surgical strategy.
Cadaveric and clinical biomechanical studies show improved kinematic restoration using double-bundle anterior cruciate ligament (ACL) reconstruction techniques. These have been criticized in the past for being technically challenging. We present a novel 3-socket approach for anatomic "all-inside" double-bundle reconstruction using a single hamstring tendon fashioned to create a trifurcate graft: the TriLink technique. The semitendinosus alone is harvested, quadrupled, and attached to 3 suspensory fixation devices in a Y-shaped configuration, creating a 4-stranded tibial limb and 2 double-stranded femoral limbs. A medial viewing/lateral working arthroscopic approach is adopted using specifically designed instrumentation. Anatomic placement of the 2 femoral tunnels is performed by a validated direct measurement technique. A single mid-bundle position is used on the tibia. Both femoral and tibial sockets are created in a retrograde manner using outside-to-in drilling. This is a simplified operative technique for anatomic double-bundle ACL reconstruction that maximizes bone preservation. The TriLink construct replicates the 2 bundles of the ACL, conferring native functional anisometry and improving femoral footprint coverage while avoiding the complexities and pitfalls of doubleetibial tunnel techniques. Preservation of the gracilis reduces the morbidity of hamstring harvest and allows greater flexibility in graft choice in cases requiring multiligament reconstruction.
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