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Parnes and Tomaino present a case study of a 32-year-old man who suffered chronic pectoralis major rupture. The patient was an active man who worked in the military and was presented with left shoulder pain and weakness 6 months after sustaining an injury while bench-pressing 175 kg. On physical examination, he has a diminished anterior axillary fold deformity of the left pectoralis muscle with dimpling. The left nipple was sitting and pointing more downward than the contralateral nipple. He reported weakness and pain with adduction and internal rotation of the shoulder but had normal muscle power and sensation. He was unable to perform his required military duties, which involved heavy lifting and a mandatory physical fitness test, or recreational weight lifting. Chest magnetic resonance imaging showed complete rupture of the sternal head of the pectoralis major muscle at the musculotendinous junction. This distinctive chest deformity resulted from medial retraction of the ruptured sternal head. Pectoralis major rupture is a highly debilitating injury, typically characterized at early presentation with a large subcutaneous hematoma and swelling.

This article describes the clinical application of gene therapy to a nonlethal disease, rheumatoid arthritis (RA). Intraarticular transfer of IL-1 receptor antagonist (IL-1Ra) cDNA reduces disease in animal models of RA. Whether this procedure is safe and feasible in humans was addressed in a phase I clinical study involving nine postmenopausal women with advanced RA who required unilateral sialastic implant arthroplasty of the 2nd-5th metacarpophalangeal (MCP) joints. Cultures of autologous synovial fibroblasts were established and divided into two. One was transduced with a retrovirus carrying IL-1Ra cDNA; the other provided untransduced, control cells. In a dose escalation, double-blinded fashion, two MCP joints were injected with transduced cells, and two MCP joints received control cells. One week later, injected joints were resected and examined for evidence of successful gene transfer and expression by using RT-PCR, ex vivo production of IL-1Ra, in situ hybridization, and immunohistochemistry. All subjects tolerated the protocol well, without adverse events. Unlike control joints, those receiving transduced cells gave positive RT-PCR signals. Synovia that were recovered from the MCP joints of intermediate and high dose subjects produced elevated amounts of IL-1Ra (P = 0.01). Clusters of cells expressing high levels of IL-1Ra were present on synovia of transduced joints. No adverse events occurred. Thus, it is possible to transfer a potentially therapeutic gene safely to human rheumatoid joints and to obtain intraarticular, transgene expression. This conclusion justifies additional efficacy studies and encourages further development of genetic approaches to the treatment of arthritis and related disorders.

Using a probe to retract the long head of the biceps tendon (LHBT) into the joint is common practice for visualizing the extra-articular portions during arthroscopy. However, extra-articular lesions may be missed in up to half of cases. Greater excursion of the LHBT may be achieved with an Allis clamp grasper. Our goal was to quantify portions of the extra-articular LHBT that could be visualized during shoulder arthroscopy with the Allis clamp and probe techniques. Shoulder arthroscopy was performed on 8 forequarter cadaveric specimens in the simulated beach chair position, and the most distal extent of the intra-articular LHBT was marked. The tendon was pulled into the joint with both techniques, and the additional exposed tendon portion was marked. An open approach was performed, and the locations of the 3 marks were assessed relative to total tendon length. Mean LHBT total length was 96.25 mm. Diagnostic arthroscopy allowed visualization of a mean of 21.75 mm of the intra-articular tendon (22.6% of the total length). The traditional probe technique provided visualization of 31.13 mm (32.8%). The Allis clamp technique provided visualization of 49.38 mm (52%) and increased visualization of the LHBT by 58.6% (P<.0001). A mean of 46.87 mm (48%) of the LHBT remained unvisualized. The Allis clamp technique maximizes arthroscopic visualization of extra-articular LHBT. The distal 48% eludes evaluation, but can be visualized when combined with an open technique without the need to divide the transverse humeral ligament. The Allis clamp technique facilitates additional identification of LHBT pathology that could otherwise remain hidden during shoulder arthroscopy. Because the LHBT is a major source of pain in the shoulder, this technique may improve outcomes of shoulder arthroscopy and reduce the need for revision because of remnant anterior shoulder pain. [Orthopedics. 2022;45(1):38–42.]

Interest in reconstruction of the interosseous ligament (IOL) of the forearm in the setting of longitudinal radio-ulnar dissociation has increased in recent years with hopes of improving clinical outcomes. This increased interest has been accompanied by research on biomechanics of the IOL. However, little is known about stress and strain in the IOL under externally applied forearm loads. This information is needed to help guide reconstruction. Mechanical properties of the IOL are needed to properly model the IOL for analyses such as finite element models. The objective of this study was to document the bi-directional mechanical properties along the fiber direction (longitudinal) and perpendicular to the fiber direction (transverse). Twenty specimens were mounted in a materials testing machine to perform preconditioning and a load to failure tensile test in each direction. Strain markers on the surface of the specimens were tracked with a video system. Data analysis provided stress–strain curves for each specimen. The elastic moduli of longitudinal and transverse specimens were 515 ± 277 and 1.82 ± 2.93 MPa, respectively. The tensile strength and ultimate strain of longitudinal and transverse specimens were 54.1 ± 25.2 and 0.18 ± 0.20 and 16 ± 5% and 34 ± 32%, respectively. The bi-directional mechanical properties of the IOL compared well with those published for the medial collateral ligament of the knee. The mechanical properties in the longitudinal direction were much greater than those in the transverse direction, which is indicative of the IOL's role in resisting longitudinal loading. The results of this study can be used to generate mathematical models of stress and strain in the IOL.

Interest in reconstruction of the interosseous ligament (IOL) of the forearm in the setting of longitudinal radio-ulnar dissociation has increased in recent years with hopes of improving clinical outcomes. This increased interest has been accompanied by research on biomechanics of the IOL. However, little is known about stress and strain in the IOL under externally applied forearm loads. This information is needed to help guide reconstruction. Mechanical properties of the IOL are needed to properly model the IOL for analyses such as finite element models. The objective of this study was to document the bi-directional mechanical properties along the fiber direction (longitudinal) and perpendicular to the fiber direction (transverse). Twenty specimens were mounted in a materials testing machine to perform preconditioning and a load to failure tensile test in each direction. Strain markers on the surface of the specimens were tracked with a video system. Data analysis provided stress-strain curves for each specimen. The elastic moduli of longitudinal and transverse specimens were 515+/-277 and 1.82+/-2.93 MPa, respectively. The tensile strength and ultimate strain of longitudinal and transverse specimens were 54.1+/-25.2 and 0.18+/-0.20 and 16+/-5% and 34+/-32%, respectively. The bi-directional mechanical properties of the IOL compared well with those published for the medial collateral ligament of the knee. The mechanical properties in the longitudinal direction were much greater than those in the transverse direction, which is indicative of the IOL's role in resisting longitudinal loading. The results of this study can be used to generate mathematical models of stress and strain in the IOL.

ABSTRACT This study reviews the principles of reconstructive microsurgery for lower limb salvage after severe open tibial fractures. Initial decision-making principles are reviewed with reference to useful scoring systems directed at appropriate patient selection for limb salvage. Soft tissue reconstruction is discussed with emphasis on timing and selection. Skeletal reconstruction focuses on available options and indications.

While other health care providers may fear that they are unable to match or exceed new levels of convenience, access and quality, Strong's plan to build an outpatient facility in Greece will help ensure that patients in Greece and surrounding communities who require tertiary care in an inpatient setting will have the choice of being directed to Strong hospitals, rather than having that decision made for them.

Many schools have been cutting physical education (PE) classes due to budget constraints, which raises the question of whether policymakers should require schools to offer PE classes. Evidence suggests that PE classes can help address rising physical inactivity and obesity prevalence. However, it would be helpful to determine if requiring PE is cost-effective. We developed an agent-based model of youth in Mexico City and the impact of all schools offering PE classes on changes in weight, weight-associated health conditions and the corresponding direct and indirect costs over their lifetime. If schools offer PE without meeting guidelines and instead followed currently observed class length and time active during class, overweight and obesity prevalence decreased by 1.3% (95% CI: 1.0%-1.6%) and was cost-effective from the third-party payer and societal perspectives ($5,058 per disability-adjusted life year [DALY] averted and $5,786/DALY averted, respectively, assuming PE cost $50.3 million). When all schools offered PE classes meeting international guidelines for PE classes, overweight and obesity prevalence decreased by 3.9% (95% CI: 3.7%-4.3%) in the cohort at the end of five years compared to no PE. Long-term, this averted 3,183 and 1,081 obesity-related health conditions and deaths, respectively and averted ≥$31.5 million in direct medical costs and ≥$39.7 million in societal costs, assuming PE classes cost ≤$50.3 million over the five-year period. PE classes could cost up to $185.5 million and $89.9 million over the course of five years and still remain cost-effective and cost saving respectively, from the societal perspective. Requiring PE in all schools could be cost-effective when PE class costs, on average, up to $10,340 per school annually. Further, the amount of time students are active during class is a driver of PE classes' value (e.g., it is cost saving when PE classes meet international guidelines) suggesting the need for specific recommendations.