Isolated Traumatic Subscapularis Tear in a 12-Year-Old Male Gymnast: A Case Report

Isolated avulsion fractures of the lesser tuberosity are rarely encountered in younger and older populations. However, because the tendon of the subscapularis insertion is stronger in skeletally immature individuals, isolated tears to the tendon occur more commonly in adults than children and adolescents. Most studies have been limited to case reports that mainly describe traumatic subscapularis tears in adolescent athlete-patients. We present a 12-year-old male gymnast who reported to our clinic with pain and weakness in the right shoulder at 2 months after the initial injury. We performed open repair with suture anchor fixation for treatment of an isolated subscapularis tear. At 6 months postoperatively, the child felt no pain, regained full range of shoulder motion and strength, and returned to highly competitive physical activity. Isolation of the subscapularis insertion during physical examination can be essential to initial diagnosis, allowing for successful and early operative treatment

Sciatic Nerve Palsy After Operative Treatment of Subtrochanteric Femur Fracture Resulting from Postoperative Hematoma: A Case Report

Treatment of subtrochanteric femur fractures can be difficult owing to high risk of complications. No cases of sciatic nerve palsy after hematoma following open reduction and intramedullary nailing of a subtrochanteric femur fracture have been reported. We describe a 28-yearold man who presented with a subtrochanteric fracture in the left femur after a motor-vehicle collision, in whom open reduction and intramedullary nailing led to an immediate postoperative hematoma and sciatic nerve palsy. Prompt diagnosis and early wound exploration resulted in complete resolution of the palsy at 1 month postoperatively. Our findings reinforce the importance of prompt diagnosis and treatment in limiting long-term complications for patients who develop postoperative sciatic nerve palsy associated with hematoma after undergoing operative treatment of subtrochanteric femur fractures

Bone Marrow Stromal Cells: Characterization and Clinical Application

The bone marrow stroma consists of a heterogeneous population of cells that provide the structural and physiological support for hematopoietic cells. Additionally, the bone marrow stroma contains cells with a stem-cell-like character that allows them to differentiate into bone, cartilage, adipocytes, and hematopoietic supporting tissues. Several experimental approaches have been used to characterize the development and functional nature of these cells in vivo and their differentiating potential in vitro. In vivo, presumptive osteogenic precursors have been identified by morphologic and immunohistochemical methods. In culture, the stromal cells can be separated from hematopoietic cells by their differential adhesion to tissue culture plastic and their prolonged proliferative potential. In cultures generated from single-cell suspensions of marrow, bone marrow stromal cells grow in colonies, each derived from a single precursor cell termed the colony-forming unit-fibroblast. Culture methods have been developed to expand marrow stromal cells derived from human, mouse, and other species. Under appropriate conditions, these cells are capable of forming new bone after in vivo transplantation. Various methods of cultivation and transplantation conditions have been studied and found to have substantial influence on the transplantation outcome The finding that bone marrow stromal cells can be manipulated in vitro and subsequently form bone in vivo provides a powerful new model system for studying the basic biology of bone and for generating models for therapeutic strategies aimed at regenerating skeletal elements.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68070/2/10.1177_10454411990100020401.pd

Comparison of Narcotic Prescribing Habits Between Trainee and Attending Orthopaedic Surgeons

Background: Orthopaedic surgeons are among the highest prescribing physicians of narcotics to opioidnaïve patients. Despite the current opioid epidemic, few studies have specifically quantified the appropriate amount of opioids necessary for postoperative pain control. We hypothesized a significant variability in the quantity of postoperative opioids prescribed among trainee (ie, residents and fellows) and attending surgeons at a single institution. Methods: Postoperative narcotic prescribing habits were assessed using an anonymous survey. Ultimately, 28 trainee physicians and 17 attending physicians responded to the survey (86.5%). The survey recorded the amount of 5-mg oxycodone tablets that were commonly prescribed to manage pain after various typical orthopaedic procedures (eg, total knee arthroplasty). Non-narcotic analgesic use was also measured. Mean, standard deviation, and variance values were calculated, with significance set at α = 0.05. Results: After the following procedures, the respondents reported prescribing the following quantities of 5-mg oxycodone tablets: total knee arthroplasty, 56 (SD, 16); total hip arthroplasty, 53 (SD, 13); anterior cruciate ligament reconstruction, 38 (SD, 16); partial meniscectomy, 23 (SD, 14); arthroscopic rotator cuff repair, 39 (SD, 16); carpal tunnel release, 10 (SD, 10); A1 pulley release for treating trigger finger, 9 (SD, 9); open reduction and internal fixation (ORIF) for treating distal radius fractures, 32 (SD, 16); and ORIF for treating ankle fractures, 39 (SD, 15). Statistically significant variation existed between trainee and attending physicians for total hip arthroplasty and A1 pulley release. There was no difference for acetaminophen or nonsteroidal anti-inflammatory drugs, with about 70% of patients receiving at least one of these adjuncts. Conclusions: Variability exists in postoperative opioid prescribing habits between trainee and attending physicians at the academic training institution we accessed. In light of the ongoing opioid epidemic, institutions may benefit from standardized postoperative pain protocols

Multimodal Analgesia in Orthopaedic Surgery and Presentation of a Comprehensive Postoperative Pain Protocol: A Review

Rising opioid use in the United States has now been termed an epidemic. Opioid use is associated with considerable morbidity, mortality, and cost to the healthcare system. Orthopaedic surgeons play a key role in the opioid epidemic by prescribing postoperative narcotics. Although our understanding of the quantity of narcotics to prescribe postoperatively for analgesia is progressing, there is still a paucity of data focused on routine postoperative pain protocols. The purpose of this article is to review the current options for both opioid and non-opioid analgesia and put forth a multisubspecialty orthopaedic protocol of postoperative pain. On the basis of study findings and the individual experiences of surgeons within our orthopaedic department, our comprehensive pain protocol includes the following considerations: use of non-steroidal antiinflammatory drugs on an individual basis, limited use of benzodiazepines, use of diazepam in only pediatric patients undergoing major procedures, lower doses of gabapentin after hip and knee arthroplasty, higher doses of gabapentin after spine procedures, general use of oxycodone owing to its accessibility, use of isolated opioids rather than combined forms, and close collaboration with anesthesiologists for determining use of peripheral nerve block. Our resultant comprehensive pain protocol can provide orthopaedic surgeons with a framework to build upon, which will benefit greatly from future studies that examine narcotic use with specific procedures

RNase1 as a potential mediator of remote ischaemic preconditioning for cardioprotection

© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. OBJECTIVES: Remote ischaemic preconditioning (RIPC) is a non-invasive and virtually cost-free strategy for protecting the heart against acute ischaemia-reperfusion injury (IRI). We have recently shown that the inhibition of extracellular RNA (eRNA) using non-toxic RNase1 protected the heart against acute IRI, reduced myocardial infarct (MI) size and preserved left ventricular systolic function in rodent animal MI models. Based on this previous work in animals, the role of the eRNA/RNase1 system in cardiac RIPC in humans should be defined. METHODS: Fourteen patients underwent cardiac surgery without RIPC; from each patient, six separate 5 ml blood specimens from radial artery and two blood specimens from coronary sinus at different time points during heart surgery were taken. Six healthy donors received RIPC (4 × 5 min upper limb ischaemia); blood parameters were quantified before and after RIPC. Twelve patients underwent cardiac surgery of which 6 received RIPC, whereas the remaining 6 were exposed to sham procedure. Circulating eRNA was quantified in plasma from arterial and coronary sinus blood obtained from patients undergoing cardiac by standard procedures. Tumour necrosis factor-α (TNF-α) production by heart tissue was assessed by enzyme-linked immuno-sorbent assay; RNase activity was quantified by an enzymatic assay. RESULTS: Before surgery, eRNA levels were similar in both groups (14 ± 6 vs 13 ± 5 ng/ml; P = 0.9967). In patients without RIPC, arterial eRNA levels rose during surgery (87 ± 12 ng/ml) and peaked after (127 ± 11 ng/ml) aortic declamping; accordingly, eRNA levels in coronary sinus blood were significantly higher (206 ± 32 ng/ml; P = 0.0129) than that in radial artery. Moreover, significant elevation of TNF-α (36 ± 6 ng/ml; P = 0.0059) particularly in coronary sinus blood after opening of the aortic clamping was observed. Interestingly, applying a RIPC protocol significantly increased levels of plasma endogenous vascular RNase1 by >7-fold, and the levels of arterial (31 ± 7 ng/ml; P = 0.0024) and coronary sinus (37 ± 9 ng/ml; P < 0.0001) circulating eRNA, as well as circulating TNF-α (20 ± 4 ng/ml; P = 0.0050) levels were significantly reduced. CONCLUSIONS: Upon RIPC, the level of cardioprotective RNase1 increased, while the concentration of damaging eRNA and TNF-α decreased. The present findings imply a significant contribution of the RIPC-dependent (endothelial) RNase1 for improving the outcome of cardiac surgery. However, the exact mechanism of RNase1-induced cardioprotection still remains to be explored

Thrombospondin 2 expression is correlated with inhibition of angiogenesis and metastasis of colon cancer

Two subtypes of thrombospondin (TSP-1 and TSP-2) have inhibitory roles in angiogenesis in vitro, although the biological significance of these TSP isoforms has not been determined in vivo. We examined TSP-1 and TSP-2 gene expression by reverse transcription polymerase chain reaction (RT-PCR) analysis in 61 colon cancers. Thirty-eight of these 61 colon cancers were positive for TSP-2 expression and showed hepatic metastasis at a significantly lower incidence than those without TSP-2 expression (P = 0.02). TSP-2 expression was significantly associated with M0 stage in these colon cancers (P = 0.03), whereas TSP-1 expression showed no apparent correlation with these factors. The colon cancer patients with TSP-2 expression showed a significantly low frequency of liver metastasis correlated with the cell-associated isoform of vascular endothelial growth factor (VEGF-189) (P = 0.0006). Vascularity was estimated by CD34 staining, and TSP-2(–)/VEGF-189(+) colon cancers showed significantly increased vessel counts and density in the stroma (P < 0.0001). TSP-2(–)/VEGF-189(+) colon cancer patients also showed significantly poorer prognosis compared with those with TSP-2(+) / VEGF-189(–) (P = 0.0014). These results suggest that colon cancer metastasis is critically determined by angiogenesis resulting from the balance between the angioinhibitory factor TSP-2 and angiogenic factor VEGF-189. © 1999 Cancer Research Campaig