Publications

OBJECTIVE

The majority of orthopaedic surgeons rely on a lateral fluoroscopic image to assess reduction during patella fracture osteosynthesis. However, a comprehensive radiographic description of the lateral view of the patella has not been performed previously, and no accessory views to better visualize specific anatomic features have been developed. The purpose of this study was to provide a detailed anatomic description of all radiographic features of the true lateral of the patella, describe reproducible accessory views for assessing specific features of the patella, and demonstrate their utility in a fracture model.

METHODS

Twelve cadaver knee specimens free of patellofemoral pathology were used, and imaging was performed using standard C-arm fluoroscopy. For each specimen, a true lateral radiographic projection of the patella was obtained and distinct features were noted. Next, an arthrotomy was made and steel wire was contoured and fixed to various anatomic regions of the patella so as to obliterate the radiographic densities on the true lateral projection, thus confirming their anatomic correlation. Ideal views of the lateral and medial facets themselves were determined using radiographic markers and varying amounts of internal or external rotation of the specimen. Last, a transverse osteotomy was created in each patella and the ability of the true lateral and accessory views to detect malreduction was assessed.

RESULTS

The true lateral projection of the patella was obtained with the limb in neutral alignment. Constant radiographic features of the lateral view of the patella include the articular tangent, a secondary articular density of variable length, and a dorsal cortical density. The articular tangent was produced by the central ridge between the medial and lateral facets in all specimens. The secondary articular density was created by a confluence of the edge of the lateral and edge of the medial facets in 5 patellas, a confluence of the edge of the lateral facet and the intersection of the odd and medial facets in 6 patellas, and the edge of the lateral facet alone in 1 patella. The edge of the lateral facet gave a constant contribution to the appearance of the secondary articular density in all cases. A distinct accessory view of the tangent of the lateral facet could be seen with an average of 17 degrees of patella external rotation (range, 12-35 degrees), and the tangent of the medial facet with an average of 26.5 degrees of internal rotation (range, 15-45 degrees). These accessory views were better able to visualize malreduction than the single lateral projection in a fracture model in all specimens.

CONCLUSIONS

Described here is a comprehensive description of the true lateral radiographic view of the patella and accessory views. These views can be used in the evaluation of minimally displaced patella fractures if a computerized tomography is not desired to better assess the true amount of displacement and when assessing intraoperative reduction during patella fracture osteosynthesis.

OBJECTIVE

To report and synthesize patterns of disease-modifying antirheumatic drug (DMARD) use reported in observational studies of patients with established and early rheumatoid arthritis (RA) after publication of the American College of Rheumatology guidelines promoting universal DMARD use.

METHODS

We searched PubMed for full-length articles in English published between January 1, 2002 and October 1, 2012 that examined DMARD use. The data abstracted from articles included the patient characteristics, country of study, time period studied, patient source, and treating physician type. Study quality was assessed using a modified Newcastle-Ottawa Quality Assessment Scale.

RESULTS

We reviewed 1,287 abstracts; 98 full-length articles were selected for additional review and 27 studies describing 28 cohorts of patients were included. Twelve studies described data from cohorts of patients with established RA, and DMARD use in this group of studies ranged from 73-100%. Five studies described data from patients sourced through administrative data and demonstrated consistently lower DMARD use, ranging from 30-63%. Three studies conducted population-based surveys to define cases of RA where DMARD use ranged from 47-73%. Eight studies investigated patients with early RA. DMARD use among patients followed by rheumatologists ranged from 77-98%, whereas DMARD use reported for patients seen by a mix of physicians was significantly lower (39-63%).

CONCLUSION

DMARD use in studies from RA cohorts or registries (in which patients were followed by rheumatologists) ranged from 73-100%, compared with 30-73% in studies from administrative data or population-based surveys (in which patients were not necessarily receiving rheumatology subspecialty care).

Hypothermia is neuroprotective against many acute neurological insults, including ischemic stroke. We and others have previously shown that protection by hypothermia is partially associated with an anti-inflammatory effect. Phagocytes are thought to play an important role in the clearance of necrotic debris, paving the way for endogenous repair mechanisms to commence, but the effect of cooling and phagocytosis has not been extensively studied. Triggering receptor expressed on myeloid cells-2 (TREM2) is a newly identified surface receptor shown to be involved in phagocytosis. In this study, we examined the effect of therapeutic hypothermia on TREM2 expression. Mice underwent permanent middle cerebral artery occlusion (MCAO) and were treated with one of the two cooling paradigms: one where cooling (30°C) began at the onset of MCAO (early hypothermia [eHT]) and another where cooling began 1 hour later (delayed hypothermia [dHT]). In both groups, cooling was maintained for 2 hours. A third group was maintained at normothermia (NT) as a control (37°C). Mice from the NT and dHT groups had similar ischemic lesion sizes and neurological performance, but the eHT group showed marked protection as evidenced by a smaller lesion size and less neurological deficits up to 30 days after the insult. Microglia and macrophages increased after MCAO as early as 3 days, peaked at 7 days, and decreased by 14 days. Both hypothermia paradigms were associated with decreased numbers of microglia and macrophages at 3 and 7 days, with greater decreases in the early paradigm. However, the proportion of the TREM2-positive microglia/macrophages was actually increased among the eHT group at day 7. eHT showed a long-term neurological benefit, but neuroprotection did not correlate to immune suppression. However, hypothermic neuroprotection was associated with a relative increase in TREM2 expression, and suggests that TREM2 may serve a beneficial role in brain ischemia.