Leg and Femoral Neck Length Evaluation Using an Anterior Capsule Preservation Technique in Primary Direct Anterior Approach Total Hip Arthroplasty

Background Achieving correct leg and femoral neck lengths remains a challenge during total hip arthroplasty (THA).  Several methods for intraoperative evaluation and restoration of leg length have been proposed, and each has inaccuracies and shortcomings.  Both the supine positioning of a patient on the operating table during the direct anterior approach (DAA) THA and the preservation of the anterior capsule tissue  are simple, readily available, and cost-effective strategies that can lend themselves well as potential solutions to this problem. Technique The joint replacement is performed through a longitudinal incision (capsulotomy) of the anterior hip joint capsule, and release of the capsular insertion from the femoral intertrochanteric line. As trial components of the prosthesis are placed, the position of the released distal capsule in relationship to its original insertion line is an excellent guide to leg length gained, lost, or left unchanged. Methods The radiographs of 80 consecutive primary THAs were reviewed which utilized anterior capsule preservation and direct capsular measurement as a means of assessing change in leg/femoral neck length. Preoperatively, the operative legs were 2.81 +/- 8.5 mm (SD) shorter than the nonoperative leg (range: 17.7 mm longer to 34.1 mm shorter).  Postoperatively, the operative legs were 1.05 +/- 5.64 mm (SD) longer than the nonoperative leg (range: 14.9 mm longer to 13.7 mm shorter). Conclusion The preservation and re-assessment of the native anterior hip capsule in relationship to its point of release on the femur is a simple and effective means of determining leg/femoral neck length during DAA THA

Pathogenic Huntingtin Repeat Expansions in Patients with Frontotemporal Dementia and Amyotrophic Lateral Sclerosis.

We examined the role of repeat expansions in the pathogenesis of frontotemporal dementia (FTD) and amyotrophic lateral sclerosis (ALS) by analyzing whole-genome sequence data from 2,442 FTD/ALS patients, 2,599 Lewy body dementia (LBD) patients, and 3,158 neurologically healthy subjects. Pathogenic expansions (range, 40-64 CAG repeats) in the huntingtin (HTT) gene were found in three (0.12%) patients diagnosed with pure FTD/ALS syndromes but were not present in the LBD or healthy cohorts. We replicated our findings in an independent collection of 3,674 FTD/ALS patients. Postmortem evaluations of two patients revealed the classical TDP-43 pathology of FTD/ALS, as well as huntingtin-positive, ubiquitin-positive aggregates in the frontal cortex. The neostriatal atrophy that pathologically defines Huntington's disease was absent in both cases. Our findings reveal an etiological relationship between HTT repeat expansions and FTD/ALS syndromes and indicate that genetic screening of FTD/ALS patients for HTT repeat expansions should be considered

Is Insurance Status a Predictor for the Development of Nonunion Following Scaphoid Fracture?

Introduction:  Scaphoid nonunion is a common precursor to radiocarpal arthrosis. Several factors have been associated with development of scaphoid nonunion, including delayed diagnosis, inadequate initial management, proximal location, and carpal instability. We hypothesized that insurance status would also be a risk factor for development of scaphoid nonunion. Methods:  A case-control study was performed on patients who presented to a single surgeon at a tertiary referral center during the period 2006–2015. Cases were defined as patients presenting with nonunions. Controls were defined as patients presenting with primary fractures. Insurance status was characterized as underinsured if the patient lacked any type of insurance or if the patient was on Medicaid. Case/control status was tested for association with patient and fracture characteristics, including age, sex, fracture displacement, fracture location, laterality of fracture, and insurance status. Results:  A total of 71 patients were identified. Of these, 39 (55%) were nonunions (cases) and 32 (45%) were primary fractures (controls). Cases were more likely than controls to have had displaced fractures (72% versus 41%, p  = 0.008; Table 1 ). Cases were also more likely than controls to have fractures located at the proximal aspect (18% versus 0%) and less likely than controls to have fractures located at the distal aspect (0% versus 19%; p  < 0.001). Finally, cases were more likely than controls to be underinsured (46% versus 19%, odds ratio = 3.7, 95% confidence interval = 1.3–11.0, p  = 0.015, Fig. 1 ). Conclusion:  Patients presenting with nonunions were more likely than patients presenting with primary fractures to be underinsured. This finding suggests that underinsurance is a risk factor for development of nonunion. Given that delay between fracture and intervention is a known risk factor for development of nonunion, it is likely that the association between nonunion and underinsurance is mediated through this delay. Increased attention should be turned to timely and standard-of-care management of primary fractures in those who lack adequate insurance. Fig. 1 Primary fracture(controls; N  = 32) Nonunion(cases; N  = 39) P -value Age (years ± standard deviation) 29.7 ± 19.1 25.7 ± 13.5 0.302 Sex 0.482 Male 25 (78%) 33 (85%) Female 7 (22%) 6 (15%) Fracture displacement 0.008 Nondisplaced 19 (59%) 11 (28%) Displaced 13 (41%) 28 (72%) Fracture location <0.001 Proximal pole 0 (0%) 7 (18%) Mid/waist 26 (81%) 32 (82%) Distal pole 6 (19%) 0 (0%) Laterality 0.801 Left 13 (41%) 17 (44%) Right 19 (59%) 22 (56%) Insurance status 0.015 Adequately insured 26 (81%) 21 (54%) Underinsured 6 (19%) 18 (46%

The Impact of Insurance Status on the Development of Nonunion following Scaphoid Fracture

Purpose  Certain factors have been associated with the development of scaphoid nonunion, including delayed diagnosis, smoking, inadequate initial management, proximal location, and carpal instability. We hypothesized that insurance status would also be a risk factor for the development of scaphoid nonunion. Methods  A case–control study was performed on patients who presented to a single surgeon at a tertiary referral center during 2006 to 2015. Cases were patients presenting with nonunions, controls, and patients with acute fractures. Patients were characterized as underinsured if they lacked any type of insurance or if they were on Medicaid. Results  Patients (39 nonunions [cases] and 32 primary fractures [controls]) presenting with nonunions were more likely than controls to have had displaced fractures (72 vs. 41%) and fractures located at the proximal aspect of the scaphoid (18 vs. 0%), and to be underinsured (46 vs. 19%). Conclusion  Patients presenting with nonunions were more likely to be underinsured than patients presenting with primary fractures. This finding suggests that underinsurance is a risk factor for the development of nonunion. Assuming delay between fracture and intervention is a known risk factor for the development of nonunion, and it is likely that the association between nonunion and underinsurance is mediated through this delay. Level of Evidence  Prognostic, level III, case-control study

Pathogenic Huntingtin Repeat Expansions in Patients with Frontotemporal Dementia and Amyotrophic Lateral Sclerosis

Using large-scale whole-genome sequencing, Dewan et al. identify pathogenic HTT repeat expansions in patients diagnosed with FTD/ALS neurodegenerative disorders. Autopsies confirm the TDP-43 pathology expected in FTD/ALS and show polyglutamine inclusions within the frontal cortices but no striatal degeneration. These data broaden the phenotype resulting from HTT repeat expansions