Partial Injury Research Articles

Management of Neuropathic Pain Using Natural Products in Different Animal Models: A Review

The focus of this review is on how natural products and their bioactive ingredients can treat neuropathic pain disorders by acting as neuroprotective agents. which includes information about neuropathic pain and their types, namely central neuropathy and peripheral neuropathy with their mechanistic involvement of various pathways may contribute to the development of neuropathic pain. It also includes information about treatment modalities for peripheral neuropathy i.e., first-line therapy includes, tricyclic antidepressant, antiepileptic, anticonvulsants and serotonin- noradrenaline reuptake inhibitors (SNRIs) and second-line therapy (opioids, topical capsaicin, lidocaine patch). Several alternative remedies exist, includes non-pharmacological treatments that play a key part in the reduction of neuropathic pain. Bioactive ingredients, provide great efficacy with minimal side effects correlated with synthetic compounds. The main focus is on animal models utilised for the evaluation of neuropathic pain, Which include several animal models such as, Streptozotocin Induced diabetic neuropathy in rats and mice is a widely used animal model for assessment of neuropathic pain. Other animal models include, Alloxan-Induced Diabetic Neuropathy, the Spinal Cord Injury (SCI) model, the Chronic Construction Injury model (CCI), the Partial sciatic Nerve Injury model (PNI), Anticancer agents induced neuropathy (vincristine and paclitaxel and Oxaliplatin-induced Neuropathic pain and spinal nerve ligation (SNL) model of neuropathic pain.

The Effect of Platelet Rich Plasma versus MSCs Derived Exosomes on the Healing of Burn Injury in Albino Rat: Histological Study

Abstract Background The clinical treatment of skin loss due to severe and massive burns or wounds continues to be a major problem in surgical procedures. Although different kinds of dressings and therapies have been developed, but most of them are expensive. Therefore, new strategies are needed to promote and help in wound healing and repair. Recent studies have demonstrated that exosomes help tissue repair because of high stability, non immune rejection and easy control of dosage and concentration. Platelet-rich plasma (PRP) is an autologous concentration of platelets in concentrated plasma. It has been used to promote soft and hard tissue healing. Aim to compare the effect of MSCs derived exosomes versus PRP on the promotion of healing of experimentally induced second degree partial thickness burn injury in adult male albino rats. Methods The thirty-two adult male albino rats were divided randomly into 4 groups. Group I (control). Group II (burn injury group) that will be left for spontaneous healing. Group III (burn injury treated with PRP intradermal injection). Group IV (burn injury treated with intradermal MSCs derived exosome). All the animals were sacrificed at 7th day (subgroup a) and 21th day (subgroup b). The skin biopsies will be taken and processed for light microscope examination. Results H&E stained section of untreated burn (subgroup IIa) showed coagulative necrosis in epidermis and papillary layer of the dermis. Sign of epithelial migration from the edge of the wound appeared. In Subgroup IIb the surface of the wound was covered by an eschar that converted partial thickness into complete thickness. This resulted in formation of granulation tissue in the dermis. In Subgroup IIIa showed the formation of thin layer of epidermis containing undifferentiated keratinocytes. The underlying dermis contained collagen fibers and beginning of new hair follicles formation. Some specimens in Subgroup IIIb revealed thin epidermis with incomplete differentiation of keratinocytes. Numerous hair follicles were detected in the dermis. However some specimens showed thickened epidermis with presence of rete ridges. The dermis showed few irregularly distributed collagen fibers in granulation tissue with absence of skin appendages. In exosome treated group (subgroup IVa) showed thin epidermis with well differentiated keratinocytes. The dermis contained collagen fibers with absence of skin appendages. Subgroup IVb was more or less similar to the control group. Conclusion The current study revealed that burn treated exosomes group was better than PRP treated group. In addition PRP treated group revealed hyperplastic changes in epidermis with delay in remodeling phase of burn healing.

Ultrasound-guided percutaneous opening of the A1 pulley with surgical knife on anterograde versus retrograde approach: A comparative cadaver study (40 fingers)

ObjectiveTrigger finger is one of the most common pathologies of the finger flexor mechanism. Previous studies have shown the value of ultrasound-guided percutaneous tenolysis. The aim of this study was to compare the efficacy and safety of anterograde versus retrograde percutaneous ultrasound-guided tenolysis. Materials and methodsThis was a comparative cadaver study performed between December 2021 and April 2022 in France, with 40 fresh cadaver fingers. Thumbs were excluded. A single surgeon performed 20 ultrasound-guided anterograde releases and 20 ultrasound-guided retrograde releases, using a second-generation minimally invasive surgical knife, and a multipurpose linear ultrasound transducer. The primary endpoint was the success of ultrasound-guided release, defined as complete opening of the A1 pulley along its entire length. ResultsThe success rate was 90% in the retrograde group and 95% in the anterograde group (non-significant difference: p = 0.56). There was no significant difference in superficial flexor tendon slip injuries or partial A2 pulley injuries. There were no neurovascular pedicle lesions. ConclusionThe choice of anterograde or retrograde ultrasound-guided tenolysis should be left to the surgeon's discretion.

The need for hemispheric separation in pairwise structural disconnection studies.

The development of new approaches indirectly measuring the structural disconnectome has recently led to an increase in studies investigating pairwise structural disconnections following brain damage. Previous studies jointly analyzed patients with left hemispheric and patients with right hemispheric lesions when investigating a behavior of interest. An alternative approach would be to perform analyses separated by hemisphere, which has been applied in only a minority of studies to date. The present simulation study investigated whether joint or separate analyses (or both equally) are appropriate to reveal the ground truth disconnections. In fact, both approaches resulted in very different patterns of disconnection. In contrast to analyses separated by hemisphere, joint analyses introduced a bias to the disadvantage of intra-hemispheric disconnections. Intra-hemispheric disconnections were statistically underpowered in the joint analysis and thus surpassed the significance threshold with more difficulty compared to inter-hemispheric disconnections. This statistical imbalance was also shown by a greater number of significant inter-hemispheric than significant intra-hemispheric disconnections. This bias from joint analyses is based on mechanisms similar to those underlying the "partial injury problem." We therefore conclude that pairwise structural disconnections in patients with unilateral left hemispheric and with unilateral right hemispheric lesions exhibiting a specific behavior (or disorder) of interest should be studied separately by hemisphere rather than in a joint analysis.

Investigating Risk Factors and Magnetic Resonance Imaging (MRI)-Based Grading of Subchondral Incomplete Fracture (SIF) of Medial Femoral Condyle.

Subchondral insufficiency fractures (SIF) of the knee joint are prevalent in osteoporosis patients over the age of 55. Early diagnosis of SIF fracture of the medial femoral condyle is crucial for delaying disease progression, early therapy, and potential disease reversal. Magnetic resonance imaging (MRI) is useful in detecting SIF, which is often undetectable on initial radiographs. This study aimed at developing a grading system for subchondral insufficiency fractures (SIF) based on MRI to predict outcomes and evaluate risk factors. In this study, MRI was used to examine SIF risk variables in the medial condyle of the femur to help clinicians diagnose, treat, and delay the condition. A total of 386 patients with SIF from 2019 to 2021 were retrospectively analyzed and divided into 106 patients in the disease group and 280 patients in the control group according to whether they had SIF. The lesion site, meniscus, ligament, and other parameters were evaluated and compared. At the same time, a grading system was introduced to stratify and statistically analyze the size of the lesion area, the degree of bone marrow edema (BME), meniscus tears, and other parameters in the patients. Most SIF were low-grade (LG) fractures, and the predictors of LG and high-grade (HG) fractures included heel tear (P =0.031), degree of medial malleolus degeneration (P < 0.001), advanced age (P < 0.001), and lesion size (P < 0.001). The prognostic factors that showed significant differences between the two groups included age (P =0.027), gender (P =0.005), side (P =0.005), medial tibial plateau injury (P < 0.0001), femoral medullary bone marrow edema (P < 0.0001), medial tibial plateau bone marrow edema (P < 0.0001), meniscus body partial injury (P =0.016), heel tear (P =0.001), anterior cruciate ligament injury (P =0.002), and medial collateral ligament injury (P < 0.0001). This current study proposed an MRI-based grading system for inferior condylar fractures of the femur, in which HG inferior condylar fractures are associated with severe medial malleolus degeneration, advanced age, lesion size (correlation), and meniscus heel tears.

Reorganization of corticospinal projections after prominent recovery of finger dexterity from partial spinal cord injury in macaque monkeys.

We investigated morphological changes in the corticospinal tract (CST) to understand the mechanism underlying recovery of hand function after lesion of the CST at the C4/C5 border in 7 macaque monkeys. All monkeys exhibited prominent recovery of precision grip success ratio within a few months. The trajectories and terminals of CST from the contralesional (n = 4) and ipsilesional (n = 3) hand area of primary motor cortex (M1) were investigated at 5-29 months after the injury using an anterograde neural tracer, biotinylated dextran amine (BDA). Reorganization of the CST was assessed by counting the number of BDA-labeled axons and bouton-like swellings in the gray and white matters. Rostral to the lesion (at C3), the number of axon collaterals of the descending axons from both contralesional and ipsilesional M1 entering the ipsilesional and contralesional gray matter, respectively, were increased. Caudal to the lesion (at C8), axons originating from the contralesional M1, descending in the preserved gray matter around the lesion, and terminating in ipsilesional laminae VI/VII and IX were observed. In addition, axons and terminals from the ipsilesional M1 increased in the ipsilesional laminae IX after recrossing the midline, which were not observed in intact monkeys. Conversely, axons originating from the ipsilesional M1 and directed toward the contralesional laminae VII decreased. These results suggest that multiple reorganizations of the corticospinal projections to spinal segments both rostral and caudal to the lesion originating from bilateral M1 underlie a prominent recovery in long-term after spinal cord injury.SIGNIFICANCE STATEMENTPrevious studies have shown that dexterous finger movements recover prominently after lesion of the corticospinal tract (CST) at the mid-cervical segments through rehabilitative training in macaque monkeys. Here, we show reorganization of the CST including sprouting of axons originating from the contralesional and ipsilesional motor cortex in the gray matter both caudal and rostral to the lesion, including a re-direction of the CST to hand motoneurons in the monkeys 5-29 months after the lesion. Thus, multiple mechanisms of reorganization of CST axons underlie the recovery of impaired cortico-motoneuronal pathways for the long-term recovery of finger dexterity.

Cervical spinal hemisection effects on spinal tissue oxygenation and long-term facilitation of phrenic, renal and splanchnic sympathetic nerve activity

HypothesesModerate acute intermittent hypoxia (mAIH) elicits plasticity in both respiratory (phrenic long-term facilitation; pLTF) and sympathetic nerve activity (sympLTF) in rats. Although mAIH produces pLTF in normal rats, inconsistent results are reported after cervical spinal cord injury (cSCI), possibly due to greater spinal tissue hypoxia below the injury site. There are no reports concerning cSCI effects on sympLTF. Since mAIH is being explored as a therapeutic modality to restore respiratory and non-respiratory movements in humans with chronic SCI, both effects are important. To understand cSCI effects on mAIH-induced pLTF and sympLTF, partial or complete C2 spinal hemisections (C2Hx) were performed and, 2 weeks later, we assessed: 1) ipsilateral cervical spinal tissue oxygen tension; 2) ipsilateral & contralateral pLTF; and 3) ipsilateral sympLTF in splanchnic and renal sympathetic nerves. MethodsMale Sprague-Dawley rats were studied intact, or after partial (single slice) or complete C2Hx (slice with ∼1 mm aspiration). Two weeks post-C2Hx, rats were anesthetized and prepared for recordings of bilateral phrenic nerve activity and spinal tissue oxygen pressure (PtO2). Splanchnic and renal sympathetic nerve activity was recorded in intact and complete C2Hx rats. ResultsSpinal PtO2 near phrenic motor neurons was decreased after C2Hx, an effect most prominent with complete vs. partial injuries; baseline PtO2 was positively correlated with mean arterial pressure. Complete C2Hx impaired ipsilateral but not contralateral pLTF; with partial C2Hx, ipsilateral pLTF was unaffected. In intact rats, mAIH elicited splanchnic and renal sympLTF. Complete C2Hx had minimal impact on baseline ipsilateral splanchnic or renal sympathetic nerve activity and renal, but not splanchnic, sympLTF remained intact. ConclusionGreater tissue hypoxia likely impairs pLTF and splanchnic sympLTF post-C2Hx, although renal sympLTF remains intact. Increased sympathetic nerve activity post-mAIH may have therapeutic benefits in individuals living with chronic SCI since anticipated elevations in systemic blood pressure may mitigate hypotension characteristic of people living with SCI.

Systematic review on the use of platelet-rich fibrin as a treatment for rotator cuff injuries

This article discusses the use of platelet-rich fibrin as an alternative for the treatment of rotator cuff injuries. Recent studies show that the use of these products reduces lesion recurrence and improves clinical outcomes. The purpose of this study was to perform a systematic review of the use of platelet-rich fibrin in the treatment of partial and complete rotator cuff injuries. From an initial search of 703 articles on electronic platforms, seven articles were selected for full reading and inclusion. Simple arthroscopy was the most common type of surgical intervention used. The sample sizes of the studies ranged from a minimum of 20 to a maximum of 88 patients. The results indicate that the use of platelet-rich fibrin is effective in rotator cuff repair, with better clinical outcomes and lower recurrence rates when compared to traditional methods. Various methods, such as prospective randomized controlled trials, double-blind studies and clinical trials, have been used and have reported positive effects on rotator cuff healing.

Loads on the Knee Joint Ligaments during Stair Climbing

Background. Stair climbing is often performed by people in daily life and requires considerable energy and muscle effort. This task has been widely described in the literature, but the role of the knee joint ligaments has not been sufficiently investigated. This could be relevant for planning ligament reconstruction surgery, for providing suggestions to subjects with partial ligament injuries, and for identifying compensatory strategies for reducing ligament loads. Methods. A dynamic musculoskeletal model was used to analyse the relationship between ligament loads and muscle forces during stair climbing. Results. The most loaded ligaments were the posterior cruciate ligament and the deep fibres of the medial collateral ligament, particularly during the mid-swing phase, where the knee was maximally flexed and the hamstring muscles contracted. The anterior cruciate ligament was recruited during the stance phase to compensate for the anteriorly-directed force applied to the tibia by the vasti muscles; the collateral ligaments stabilized the knee joint during the swing phase. The tibiofemoral contact force, resulting from all external and internal forces applied to the knee, was in good agreement with data provided in the literature. Conclusions. This study represents a forward step in the knowledge of ligament loads during stair climbing, which could be useful for providing informed recommendations to subjects with ligament injuries.

Renal vascular responses to angiotensin II infusion in two kidneys-one clip hypertensive rats under partial ischemia/reperfusion with and without ischemia preconditioning: the roles of AT1R blockade and co-blockades of AT1R and MasR.

The renin-angiotensin system activation, partial ischemia/reperfusion (IR) injury, and hypertension contribute to the development of acute kidney injury. The study aims to look at the vascular responses of angiotensin II (Ang II) during Ang II type 1 receptor (AT1R) blockade (losartan) or co-blockades of AT1R and Mas receptor (A779) in two kidneys one clip (2K1C) hypertensive rats which subjected to partial IR injury with and without ischemia preconditioning (IPC). Thirty-three 2K1C male Wistar rats with systolic blood pressure ≥ 150 mmHg were divided into three groups of sham, IR, and IPC + IR divided into two sub-groups receiving losartan or losartan + A779. The IR group had 45 min partial kidney ischemia, while the IPC + IR group had two 5 min cycles of partial ischemia followed by 10 min of reperfusion and then 45 min of partial kidney ischemia followed by reperfusion. The sham group was subjected to similar surgical procedures except for IR or IPC. Ang II increased mean arterial pressure in all the groups, but there were no significant differences between the sub-groups. A significant difference was observed in the renal blood flow response to Ang II between two sub-groups of sham and IR groups treated with AT1R blockade alone or co-blockades of AT1R + A779. These findings demonstrated the significance of AT1R and Mas receptor following partial renal IR in the renal blood flow responses to Ang II in 2K1C hypertensive rats.

Achilles Tendon Injuries in the Pediatric Population.

Achilles tendon injuries are common in adults, and there is extensive literature describing the injury characteristics and treatment of these adult injuries. However, Achilles injuries are rare in the pediatric population and as a result, there is limited research reported on this age group. We therefore sought to characterize the injury presentation, treatment and outcomes for pediatric patients with partial and complete Achilles injuries. A retrospective chart review was conducted of patients aged 0-18 treated for Achilles tendon injuries at 2 geographically distinct tertiary institutions between 2008 and 2021. Data collected included demographics, injury characteristics, and treatment course. Injury types were separated into 2 cohorts: traumatic Achilles injuries and ruptures due to muscular contraction. Traumatic injuries were further delineated into 2 injury mechanisms: open injuries related to penetrating trauma and closed injuries related to blunt trauma. Standard descriptive analyses were utilized to summarize findings. Thirty-nine patients (43.6% female, median age 15 years) were identified, 29 (74.4%) of whom had complete tears. Twenty-five patients (64.1%) presented with traumatic injuries; among these, 48.0% (n=12/25) were ≤12 years. All patients ≤12 years sustained a traumatic injury. The most common traumatic mechanism was an open laceration due to penetrating trauma (68.0%), followed by closed ruptures associated with blunt trauma (32.0%). Fourteen patients (35.9%) presented with closed ruptures due to muscular contraction. Four patients (10.2%) had a prior history of clubfoot treated with Achilles tenotomy. Thirty-five patients (89.7%) were surgically treated with an open repair. The median immobilization period across all patients was 11 weeks (interquartile range: 10-12), starting most commonly with a posterior splint (46.2%) and concluding with a CAM boot (94.9%). Of patients with full follow-up data (n=22/39), all resumed normal activities, with a median clearance time of 6 months (interquartile range: 5-7.9). We found that older adolescents (≥14y) were more likely to rupture their Achilles tendon through a forceful muscular contraction, whereas younger patients (≤12y) were more likely to injure their Achilles via a traumatic mechanism. Most patients were treated operatively and returned to sports at a median time of 6 months. A further prospective study is warranted to better characterize treatment protocols and patient outcomes in this population. Level-IV.

45 A Three Year Analysis of a Multi-tiered Orthotic Protocol

Abstract Introduction A variety of factors affect the fit of custom orthoses in those with burn injuries. A resting hand orthosis (RHO) is a common device within burn care, yet fabrication and fitting of this custom orthosis requires precision and expert assessment. However, burn therapists have varying degrees of education and credentials and previously we had noted preventable complications. Our center implemented a multi-tiered protocol focused on custom RHOs and found a marked decrease in complications immediately following implementation. The purpose of this QI project was to evaluate whether these improvements had been sustained over the following three-year period. Methods This was a retrospective chart review. Per protocol an RHO could be fabricated by a single certified hand therapist (CHT) or co-fabricated by two (non-CHT) therapists. Incidence of orthosis complications, defined as erythema and/or an orthotic induced partial-thickness injury to the volar second metacarpal head (index finger) was the primary outcome measure. Other data collected were average time to fabricate &amp; modify devices and average refabrication(s) required between CHT vs non-CHT devices. Patients with missing data points was excluded. Results Eighty-five patient hands were examined from 2019-2022. Prior to implementation, total erythema occurrences were reported in 23.4% of orthoses (n=18) and total orthotic induced partial thickness injury occurred in 11.7% (n=9) of cases. Post protocol implementation erythema occurred in 5% of cases (n=5), and partial thickness injury in 0% of cases (n=0). This represents a decrease of 95% and 100%, respectively. On average CHTs fabricated RHOs in 59 minutes vs 48 minutes for non CHTs. CHTs had a complication rate of 0.0% vs 10.98% for non-CHTs. Potential complication was also limited to 0.0% for CHTS and 27% of non-CHTs. Modification rates were limited to 18.75% for CHTS vs 47.56% of non-CHTs. Conclusions Data from this QI project showed a clinically significant decrease in erythema and decrease in breakdown and number of modifications needed from utilization of either a CHT or two therapists when managing hand orthoses. Since instituting our protocol focusing on RHOs, our center has decreased complications and potential complications to improve patient outcomes. Although, most therapists receive standard education, it can be inferred that CHTs may approach orthotic fabrication through a different lens. The required studying and education required to maintain an advanced practice certification may benefit burn therapy departments. Therapists without this specialty certification can enhance skill and outcomes via co-fabrication and assessment. Applicability of Research to Practice Orthotic induced erythema may be decreased by utilizing CHTs or two non-CHTs to manage RHOs. This protocol can be expanded to include other orthoses or with other advanced certifications.

509 Relationship of Full Thickness Burn And Volume of Initial Fluid Resuscitation After Major Burn Injury

Abstract Introduction Full thickness burn injury affects the host response to burn injury differently that partial thickness burn injury. Current guidelines for initial resuscitation calculate fluid infusion based on Total Body Surface Area (TBSA) affected and patient’s weight. The widely used formula does not offer guidance based on the depth of the injury. We present an investigation into relationship of full thickness burn injury on fluid resuscitation. This study was approved by our Institutional Review Board. Methods We performed a retrospective review of patients’ charts who were admitted after major burn injury of greater than 20% TBSA to a busy regional burn center. We included patients over age of 14 years admitted from year 2014-2019. We excluded patients who did not have complete resuscitation data, allowing 99 patients for analysis. We performed t test to uncover relationship of age, gender, body weight, TBSA and percent of full thickness burn with fluid received during initial resuscitation with significance set at p &amp;lt; 0.05. Results The volume of fluids given during initial resuscitation was significantly affected by gender and full thickness burn injury. Fluids requirement for females was 4.6ml/kg/TBSA vs males was 3.3ml/kg/TBSA (p value 0.04). Fluid requirement for full thickness burn was 8.4ml/kg/TBSA vs 3.7ml/kg/TBSA for all patients (p=0.0004). Initial fluid resuscitation fluids did not have significant relationship with age, body weight or overall TBSA. Conclusions This study demonstrates that full thickness burn injury has a significant impact on initial fluid resuscitation. Further research is needed to elicit the mechanism to explain the higher fluid requirement for full thickness burn injury. Applicability of Research to Practice Our study brings attention to the effect of depth of burn injury on the actual volume of fluids needed during initial resuscitation of burn injury. This study will alert the clinician to take into account both the surface area as well as depth of the burn injury while embarking on fluid resuscitation after a major burn injury.

577 Impact of the Bismuth Tribromophenate Stick-down Method on Pediatric Burns

Abstract Introduction Burn injuries are a leading cause of morbidity and mortality in the pediatric population. Patients require frequent dressing changes to minimize infection risk and promote wound healing via re-epithelialization. Bismuth Tribromophenate, an affordable petrolatum-based dressing, has been shown to have rapid re-epithelization of skin grafts and low infection rates in clean wound environments. A stick-down (SD) protocol has been developed to minimize the frequency of dressing changes. This SD protocol involves daily assessment and changing of the dressing until it begins to adhere to the underlying wound bed, where the dressing is then left in place as a protective layer as re-epithelialization occurs. The objective of this study is to characterize baseline features and compare outcomes associated with the SD dressing compared to non-stick-down (NSD) Bismuth Tribromophenate dressing. Methods Patients under 18 years treated at our institution for partial thickness burn injuries were retrospectively identified using our medical records. Demographic data, injury characteristics, dressing type, length of hospitalization, and outpatient outcomes were collected from these records. Statistical analysis between dressing types was achieved using Fisher’s exact test and Mann-Whitney U test, with statistical significance defined as p &amp;lt; 0.05. Results A total of 106 individuals receiving Bismuth Tribromophenate were identified. 36 patients received the Bismuth Tribromophenate SD dressing and 70 patients received NSD dressing. SD patients had a higher hospital admission rate compared to NSD patients (52.8% versus 33.3%, p = 0.088), though not statistically significant. 47.3% of admitted SD patients were admitted for burn severity compared to 25% in NSD patients. SD patients also had higher PICU admission rates compared to NSD patients (36.8% versus 4.8%, p = 0.017). SD patients also required initial debridement sedation more often (63.6% versus 36.7%, p = 0.017). SD and NSD patients had re-epithelialization rates of 66.7% and 65.6% (p = 1), respectively. Median time to re-epithelialization was 13 (10.8-17.2) days in SD patients compared to 12 (10-20) days in NSD patients (p = 1). Conclusions SD-receiving patients were more likely to be admitted to the hospital and admitted for burn severity. In contrast, patients receiving NSD were less likely to be admitted, but more commonly admitted for pain. SD-receiving patients were also more likely to be admitted to the PICU and require sedation for debridement. Despite this difference in baseline characteristics, re-epithelialization rates and time to re-epithelialization between SD and NSD patients were not statistically distinct, with comparable rates and days to healing. Applicability of Research to Practice Identifying cost-effective, efficacious, and convenient dressing protocols for the treatment of pediatric burns.

Ultrasonographic detection of cranial cruciate ligament pathology in canine stifles without cranio-caudal instability

Objective Explore the value of musculoskeletal ultrasound in detecting cruciate ligament pathology Background Partial tears of the cranial cruciate ligament (CCL) can be difficult to diagnose due to the lack of instability present on orthopedic examination. Advanced diagnostics would be required for further evaluation. While a common tool in human medicine, MRI is of limited use in canines due to cost and the need for general anesthesia. Musculoskeletal ultrasound (MSK-US) can be performed without anesthesia but there are no current studies to date evaluating its usefulness in detecting partial tears of the cruciate ligaments Evidentiary value This is a retrospective case series (n=32) of dogs that underwent diagnostic MSK-US of the stifle who later had a surgical procedure (stifle arthroscopy/arthrotomy) to evaluate the intra-articular space. Methods Medical records were evaluated between May 2014 - April 2020 for canines with clinically stable stifles that underwent both an MSK-US of the stifle followed by stifle surgery. Ultrasound findings of the CCL were compared to surgical findings (considered gold standard). Results Compared to arthroscopy, ultrasound was a very sensitive test in detecting CCL pathology however it is less specific. Its sensitivity (SN), specificity (SP), positive predictive value (PPV) and negative predictive value (NPV) were 100%, 58.3%, 81.5%, and 100% respectively. Conclusion MSK-US is a non-invasive test that can be performed with little to no sedation. Using a high frequency 18-5MHz linear transducer, MSK-US is a sensitive test for detecting partial CCL injuries in dogs and may aid in its diagnosis for canines without stifle instability and be useful in guiding treatment. As it is less specific, arthroscopy would be necessary to further confirm the intra-articular pathology. Application Diagnostic MSK-US is a non-invasive tool that can be used to detect CCL pathology in the stifle. Its application can help guide treatment recommendations prior to a more invasive diagnostic/therapeutic procedure such as surgery or arthroscopy.

Regeneration of Partial Anterior Cruciate Ligament Tears Using the Technique of Biologic Augmentation with Bone Marrow Concentrate and Platelet-Rich Plasma Under Arthroscopic Visualization

To present clinical outcomes in a preliminary patient cohort using a biologic augmentation technique consisting of intra-ligamentous and intra-articular infiltration of bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) under arthroscopic visualization for treatment of isolated and acute partial anterior cruciate ligament (ACL) tears. Athletes with an acute symptomatic partial ACL injury with clinical examination findings of increased anterior tibial translation without rotational instability were treated with the biologic augmentation technique. Patients were followed for 2 years postoperatively. The Lysholm Knee Questionnaire, IKDC Objective score, physical examination findings, MRI, and the KT-1000 arthrometer were used to assess clinical outcomes. Five patients were included in the analysis with a median age of 22. All patients were determined to have a healed ACL on MRI 8 months postoperatively. The median Lysholm Score at the final follow-up of 99 was significantly increased from the median pre-operative score (p = 0.042). In addition, the objective IKDC score improved in all patients postoperatively, and no clinical examination findings of knee instability were identified at the final follow-up. The median side-to-side difference in KT-1000 arthrometer testing was 3 mm pre-operatively and 0 mm at the last follow-up (p = 0.038). The treatment of appropriately indicated partial ACL injuries in this study has demonstrated that restoration of ligamentous structure and function may be achieved by a biologic augmentation technique using intra-ligamentous and intra-articular infiltration of BMAC and PRP. This technique is performed with minimal technical difficulty, leading to excellent 2-year clinical outcomes in this preliminary series of patients.

Tracing causes of tubule atrophy in vivo

Acute kidney injury (AKI) is a known risk factor for chronic kidney disease (CKD). The mechanisms for AKI-CKD transition may involve failed tubule repair and progressive interstitial fibrosis but are incompletely understood. Which events lead to failed tubule repair? Can injury spread over time? And are these processes steered by myofibroblasts and fibrotic tissue remodeling?Here, we combined serial intravital 2-photon microscopy and a novel model of partial ischemia-reperfusion injury (partial IRI), which allowed us to investigate injured tissue alongside uninjured tissue in the same kidney and over time. Thus, we occluded only one branch of the left renal artery for 21 min, rendering half the kidney ischemic. We then tracked tubule necrosis and remodeling alongside myofibroblast dynamics for up to 3 weeks. Necrotic cell death was detected by in vivo propidium iodide staining. PDGFRβ-CreERT2-Salsa6F mice (N=5) identified main myofibroblast precursor cells, by tdTomato-expression. Myofibroblast-differentiation was confirmed by ex vivo αSMA staining. Proximal tubule (PT) function was assessed by in vivo uptake of fluorescent albumin.Necrotic cell death was solely detectable upon reperfusion. Border areas in between post-ischemic and non-ischemic tissue presented severely necrotic PTs alongside uninjured PTs. From 1 day after partial IRI, we observed formation of granular casts in the lumen of necrotic tubules, which 1-2 days later also appeared in initially non-necrotic PTs downstream. Tubule necrosis and granular cast accumulation preceded thinned epithelium that lacked albumin endocytosis (day 3-7) and recruitment of myofibroblasts (peaking D4-10). Of note, non-necrotic tubules, without granular cast accumulation, didn’t remodel nor recruit myofibroblasts.Among all remodeling tubule segments, 24% turned atrophic. Importantly, preceding necrotic cell death was higher in atrophic than in recovering tubules (55±13% vs. 39±18% necrotic cells/total segment cell number, (mean±SD), p&lt;.0001). Preceding granular casts accounted for 38±15% vs. 12±11% (mean ±SD) of the luminal area in atrophic and recovering tubules, respectively (p&lt;.0001). Ex vivo staining for pro-fibrotic VCAM-1 demonstrated selective positivity in atrophic tubules, which appeared scattered at D8 while at D21, entire atrophic tubules stained positive (n=3, each). Consistently, we detected persistent myofibroblast enclosure of atrophic tubule, while recruitment around recovered PTs resolved by day 14 (50±21% vs. 23±18% of coverage, p&lt;.001).Tracking the same tubules in vivo and over time, we demonstrated early proximal tubule necrosis, which induced luminal granular cast formation and injury propagation. These events preceded myofibroblast accumulation and predicted tubule atrophy. We further documented de novo expression of pro-inflammatory VCAM-1 and persistent myofibroblast recruitment selectively in atrophic tubules, suggesting an active role of this tubule state in AKI-CKD transition. Novo Nordisk Foundation, Augustinus Foundation, Aarhus University Research Foundation (AUFF) This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Treatment of C5 Palsy: An International Survey of Peripheral Nerve Surgeons.

International survey. C5 palsy (C5P) is a neurological complication affecting 5-10% of patients after cervical decompression surgery. Most cases improve with conservative treatment; however, nearly 20% of patients may be left with residual deficits. Guidelines are lacking on C5P management and timing of surgical intervention. Therefore, we sought to survey peripheral nerve surgeons on their management of C5P. An online survey was distributed centered around a patient with C5P after posterior cervical decompression and fusion. Questions included surgeon demographics, diagnostic modalities, and timing and choice of operation. Responses were summarized and the chi-squared and Kruskal-Wallis H tests were used to examine differences across specialties. A total of 154 surgeons responded to the survey, of which 59 (38%) indicated that they manage C5P cases. Average time prior to operating was 4.5 ± 2.2months for complete injuries and 6.6 ± 3.2months for partial injuries, with neurosurgeons significantly more likely to wait longer periods for complete (P = .01) and partial injuries (P = .03). Foraminotomies were selected by 19% of surgeons, while 92% selected nerve transfers. Transfer of the ulnar nerve to the musculocutaneous nerve was the most common choice (81%), followed by transfer of the radial nerve to the axillary nerve (58%). Consensus exists among peripheral nerve surgeons on the use of nerve transfers for surgical treatment in cases with severe motor weakness failing to improve. Most surgeons advocate for early intervention in complete injuries. Disagreement concerns the type of nerve transfer employed, timing of surgery, and efficacy of foraminotomy.

Minimally invasive management of pathologic fractures of the pelvis and sacrum: Tumor ablation and fracture stabilization.

Pathologic fractures of the pelvis/sacrum due to metastatic bone disease (MBD) cause pain and dysfunction due to mechanical instability of the pelvic ring. This study presents our multi-institutional experience with percutaneous stabilization of pathologic fractures and osteolytic lesions from MBD throughout the pelvic ring. The records of patients undergoing this procedure from 2018 to 2022 were reviewed retrospectively from two institutions. Surgical data and functional outcomes were recorded. Fifty-six patients underwent percutaneous stabilization, with a median operative duration of 119 min (interquartile range [IQR]: 92.8, 167) and median estimated blood loss of 50 mL (IQR: 20, 100). The median length of stay was 3 days (IQR: 1, 6), and 69.6% (n = 39) of patients were discharged home. Early complications included one partial lumbosacral plexus injury, three acute kidney injuries, and one case of intra-articular cement extravasation. Late complications included two infections and one revision stabilization procedure for hardware failure. Mean Eastern Cooperative Oncology Group (ECOG) scores improved from 3.02 (SD 0.8) preoperatively to 1.86 (SD 1.1) postoperatively (p < 0.001). Ambulatory status also improved (p < 0.001). Percutaneous stabilization of pathologic fractures and osteolytic defects of the pelvis and sacrum is a procedure that improves patient function, ambulatory status and is associated with a limited complication profile.

Partial Scapholunate Interosseous Ligament Injuries: A Systematic Review of Treatment Options.

Purpose This systematic review summarizes the existing evidence on treatment options and outcomes for partial scapholunate interosseous ligament (pSLIL) injuries. Methods A systematic electronic search of Medline, Embase, and CINAHL was performed from inception through to February 13, 2022. All primary research articles addressing the treatment of pSLIL tears were eligible for inclusion regardless of timing of surgery, surgical technique, or rehabilitation. The PRISMA Checklist guided the reporting and data abstraction. Descriptive statistics and forest plots are presented. Results A total of 14 studies with 342 patients were included for analysis. Treatments were categorized into four groups: electrothermal shrinkage (ES), arthroscopic capsuloplasty (AC), open capsulodesis (OC), and no treatment (NT). There were five studies in the ES group ( N = 69, mean age = 34.3 ± 3.3 years), three studies in the AC group ( N = 138, mean age = 32.2 ± 3.8 years), five studies in the OC group ( N = 123, mean age of 30.7 ± 7.8 years), and one study in the NT group ( N = 12, mean age = 43 years, range = 28-67 years). The average postintervention visual analog scale pain score for the ES group was 1.4 ± 0.5 (from 5.7 ± 1.8), for the AC group was 3.2 ± 1.3 (from 6.6 ± 0), for the OC group was 2.3 ± 2.1 (from 5.6 ± 1.6), and for the NT group was 3.2 (from 7.6). The wrist extension range of motion improved postoperatively for all intervention groups (ES = 66.3°-70.7°; AC = 67°-74.5°; and OC = 48.9°-63.5°), whereas it remained unchanged for the NT group (46°-45°). Grip strength also improved in all intervention groups (ES = 17.9-29.9 kg; AC = 24.0-32.2 kg; and OC = 15.8-26.6 kg), while the NT group remained unchanged (25-24 kg). The radiographic scapholunate gap improved postoperatively in all groups that reported pre- and postintervention (ES = 2.2-1.9 mm; OC = 2.5-1.8 mm) and slightly worsened in the NT group (2.5-2.7 mm). In the ES group, there were three complications (11.5%, no major complications), in the AC group there was one major complication (0.9%, complex regional pain syndrome [CRPS]), and in the OC group there were six complications (15.4%, four major complications-CRPS). Conclusion All interventional treatment options (ES, AC, and OC) provided significant improvements in patient-reported pain, range of motion, grip strength, and radiographic parameters, with low complication rates. In comparison, no improvement in range of motion or grip strength was noted in the NT group. Therefore, surgical management of pSLIL injuries is an effective and relatively safe treatment option. Further studies comparing the outcomes of specific surgical treatments are warranted to further elucidate the optimal management option for pSLIL tears. Level of Evidence Level III, systematic review of Level III-IV studies.