Double-Row Achilles Insertional Repair With Rip-Stop Increases Construct Strength Compared to Traditional Techniques: A Biomechanical Study

BACKGROUND

Although double-row suture-anchored (DRSA) techniques for Achilles insertional tendinosis has proven successful, a reoccurring failure mode not yet addressed is suture tearing through the tendon. This study aims to address suture tearing by incorporating a rip-stop element. Authors hypothesized that the Rip-Stop group would demonstrate increased strength compared with more traditional techniques.

METHODS

12 paired cadaveric feet were used in this study (n = 24). One sample from each pair was assigned to receive the standard double-row (SDR) Achilles repair with 4.75-mm knotless anchors (n = 12). The control's matched sides were divided between 2 DRSA bridge groups: modified double-row (MDR) bridge with 3.9-mm anchors or rip-stop double-row (RS-DR) bridge repair with soft proximal anchors and 3.9-mm anchored distal row. In neutral position, specimens underwent 1000 cycles (20-100 N) followed by load to failure. Displacements, stiffness, ultimate load, and failure mode were recorded.

RESULTS

RS-DR had the lowest initial displacement values followed by SDR and MDR (1.3 ± 0.4, 2.7 ± 1.4, and 3.2 ± 1.3 mm, respectively). Significance was detected when comparing initial displacement of RS-DR to MDR (P = .038). Cyclic displacement was lowest for RS-DR, followed by MDR and SDR (1.6 ± 0.9, 2.2 ± 1.1, and 4.5 ± 3.2 mm, respectively). Cyclic stiffness was similar for RS-DR and MDR (89.1 ± 24.6 and 81.9 ± 5.6 N/mm, respectively). RS-DR ultimate load (1116.8 ± 405.7 N) was statistically greater than SDR (465.6 ± 352.7, P = .003).

CONCLUSION

RS-DR-repaired specimens demonstrated a decrease in displacement values and increased ultimate load and stiffness when compared to other groups. Results of this cadaveric model suggest that the addition of a rip-stop to DRSA Achilles repair is more impactful than anchor size. Limitations include that this was a time-zero biomechanical study, which cannot simulate the performance of the repairs during postoperative healing and recovery.

CLINICAL RELEVANCE

A rip-stop technique for Achilles repair effectively improves dynamic mechanical characteristics and may mitigate suture tearing through tendon in a patient cohort.

Two-Year Survivorship and Patient-Reported Outcomes of a Prospectively Enrolled Cohort of INFINITY Total Ankle Arthroplasties

BACKGROUND

The INFINITY total ankle implant is a widely and successfully used option for total ankle arthroplasty. The purpose of this study is to assess the 2-year survivorship, complication rates, patient-reported outcomes, and radiologic findings of prospectively enrolled patients undergoing a fixed-bearing total ankle arthroplasty (TAA). This study sought to determine if factors such as traditional vs patient-specific instrumentation, preoperative degree of arthritis, deformity, or etiology of arthritis impact surgical or clinical outcomes.

METHODS

A total of 143 prospectively enrolled patients (148 ankles) underwent TAA with a fixed-bearing total ankle implant between 2017 and 2019 at 9 different institutions by 9 different surgeons. A total of 116 completed 2-year follow-up. Patients were stratified by instrumentation used, degree of preoperative deformity, the Canadian Orthopaedic Foot and Ankle Society (COFAS) grading system, and etiology of arthritis. Outcomes used included implant survivorship and adverse events within 2 years of surgery. Additionally, patient-reported outcomes and radiographs were collected at 6-month, 1-year, and 2-year postoperatively. PROMs used included Ankle Osteoarthritis Score (AOS), Patient-Reported Outcomes Measurement Information System (PROMIS) global health score, the Foot and Ankle Outcome Score (FAOS), and patient satisfaction (rated from excellent to poor).

RESULTS

Implant survivorship at 2 years was 97.79%. There were 17 reoperations (11.5%), with 4 of the implants requiring revision (2.7%). Significant improvements in all PROMs were observed among all subgroups at all postoperative time points without significant variation between subgroups. Patients classified as COFAS type 2 arthritis preoperatively demonstrated significantly more improvement in FAOS Total Symptom Score at the 1- and 2-year measurements than COFAS type 3 patients at both time points.

CONCLUSION

Total ankle arthroplasty with a fixed-bearing implant system is a safe and reliable treatment option for patients with end-stage arthritis regardless of degree of deformity or COFAS grading.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Minimal residual disease and outcome characteristics in infant KMT2A-germline acute lymphoblastic leukaemia treated on the Interfant-06 protocol

BACKGROUND

The outcome of infants with KMT2A-germline acute lymphoblastic leukaemia (ALL) is superior to that of infants with KMT2A-rearranged ALL but has been inferior to non-infant ALL patients. Here, we describe the outcome and prognostic factors for 167 infants with KMT2A-germline ALL enrolled in the Interfant-06 study.

METHODS

Univariate analysis on prognostic factors (age, white blood cell count at diagnosis, prednisolone response and CD10 expression) was performed on KMT2A-germline infants in complete remission at the end of induction (EOI; n = 163). Bone marrow minimal residual disease (MRD) was measured in 73 patients by real-time quantitative polymerase chain reaction at various time points (EOI, n = 68; end of consolidation, n = 56; and before OCTADAD, n = 57). MRD results were classified as negative, intermediate (<5∗10^-4), and high (≥5∗10^-4).

RESULTS

The 6-year event-free and overall survival was 73.9% (standard error [SE] = 3.6) and 87.2% (SE = 2.7). Relapses occurred early, within 36 months from diagnosis in 28 of 31 (90%) infants. Treatment-related mortality was 3.6%. Age <6 months was a favourable prognostic factor with a 6-year disease-free survival (DFS) of 91% (SE = 9.0) compared with 71.7% (SE = 4.2) in infants >6 months of age (P = 0.04). Patients with high EOI MRD ≥5 × 10^-4 had a worse outcome (6-year DFS 61.4% [SE = 12.4], n = 16), compared with patients with undetectable EOI MRD (6-year DFS 87.9% [SE = 6.6], n = 28) or intermediate EOI MRD <5 × 10^-4 (6-year DFS 76.4% [SE = 11.3], n = 24; P = 0.02).

CONCLUSION

We conclude that young age at diagnosis and low EOI MRD seem favourable prognostic factors in infants with KMT2A-germline ALL and should be considered for risk stratification in future clinical trials.

Traditional Modified Broström vs Suture Tape Ligament Augmentation

BACKGROUND

The modified Broström (MB) procedure has long been the mainstay for the treatment of chronic lateral ankle instability (CLAI). Recently, suture tape (ST) has emerged as augmentation for this repair. The clinical benefit of such augmentation has yet to be fully established. The purpose of this study was to determine if ST augmentation provides an advantage over the traditional MB.

METHODS

Adult patients were identified for inclusion in the study based on indications for primary lateral ligament reconstruction for CLAI. The primary outcome measure was time to return to preinjury level of activity (RTPAL). Secondary outcome measures included complications, ability to participate in an accelerated rehabilitation protocol (ARP), patient-reported outcomes (PROs), and visual analog pain scale (VAS). A total of 119 patients with CLAI were enrolled and randomized to the MB (59 patients) or ST (60 patients) treatment arm.

RESULTS

Average RTPAL was 17.5 weeks after MB and 13.3 weeks after ST (P < .001). At 26 weeks, 12.5% of patients in the MB group and 3.6% of patients in the ST group had not managed RTPAL (P = .14). The complication rate was 8.5% in the MB group vs 1.7% in the ST group (P = .12). Four patients in the MB group failed to complete the ARP vs 1 in the ST group (P = .144).

CONCLUSION

Results from this multicenter, prospective, randomized trial suggest that ST augmentation allows for earlier RTPAL than MB alone. ST augmentation may support successful accelerated rehabilitation and did not result in increased complications or morbidity.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Cost of Headless vs Headed Screw Fixation for Calcaneal Osteotomy and Subtalar Arthrodesis

Background:

Screw head prominence in the heel following fixation for calcaneal osteotomy or subtalar arthrodesis has resulted in high rates of symptomatic hardware and screw removal. A cost analysis was performed to determine the financial implications of screw removal. Furthermore, we compared the rate of nonunion following fixation.

Methods:

Current Procedural Terminology codes were used to identify all patients who had a subtalar arthrodesis or calcaneal osteotomy (with screw fixation) performed between 2010 and 2016. The cohort was divided into 2 groups: 7.0-mm headless screw or 6.7-mm headed screw. The primary outcome measure was the rate of symptomatic screw removal. Secondary outcomes included the rate of nonunion. The expense associated with symptomatic hardware removal was determined by cost analysis.

Results:

Seventy-six patients underwent headless screw fixation, and 2 patients (2.6%) required screw removal. Fifty-four patients underwent headed screw fixation and 12 patients (22.2%) required screw removal. Symptomatic hardware removal was performed more frequently in the headed screw group (P < .001). There was no difference in the rate of nonunion after subtalar arthrodesis between the 2 groups (P = .363). The calcaneal osteotomy united in 100% of patients. There was a $51 755 cost savings per 100 cases using headless screw fixation.

Conclusion:

The rate of symptomatic screw removal was lower with headless screw fixation. The calcaneal osteotomy healed in 100% of patients, and there was no difference in the rate of subtalar nonunion between the 2 groups. Cost analysis demonstrated a significant benefit when the expense of hardware removal was considered.

Level of Evidence:

Level III, retrospective cohort study.

Practical consensus recommendations on ovarian suppression in early breast cancer (adjuvant)

Substantial survival benefits exist for patients with early-stage breast cancer who undergo treatment with single-modality ovarian suppression, but its value is uncertain. Expert oncologist discussed to determine whether additional benefits exist with ovarian suppression plus multiple adjuvant therapy which provides a new treatment option that reduces the risk of recurrence in early breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Posterior Ankle Impingement and Flexor Hallucis Longus Pathology

Posterior ankle pain is a common complaint, and the potential causative pathologic processes are diverse. The constellation of these numerous etiologies has been collectively referred to as posterior ankle impingement syndrome. The pain associated with posterior ankle impingement is caused by bony or soft tissue impingement of the posterior ankle while in terminal plantar flexion. This condition is most frequently encountered in athletes who participate in sports that involve forceful, or repetitive, ankle plantar flexion. This article discusses the associated pathology, diagnosis, conservative treatment, and surgical techniques associated with flexor hallucis longus and posterior ankle impingement syndrome.

Descriptions of diabetes burnout from individuals with Type 1 diabetes: an analysis of YouTube videos

AIM

The purpose of the study was to analyse self-descriptions of diabetes burnout in individuals with Type 1 diabetes via YouTube videos.

METHODS

In this qualitative descriptive study, a systematic approach was used to search YouTube videos with a title, description or content specifically about diabetes burnout dated between 2007 and 2017. Irrelevant or duplicated videos were excluded using eligibility criteria. All videos meeting inclusion criteria (n = 32) from individuals with Type 1 diabetes were transcribed verbatim and analysed using a qualitative content analysis approach. Descriptive statistics were used to analyse video characteristics.

RESULTS

The four major themes associated with diabetes burnout were: (i) feeling mentally drained and physically tired of dealing with self-care; (ii) experiencing a detachment from self, diabetes care and support system; (iii) being powerless and paralysed to 'climb out' of diabetes burnout; and (iv) contributing potential factors to diabetes burnout.

CONCLUSIONS

Self-descriptions of diabetes burnout suggest that it is a combination of emotions and behaviours on a spectrum from exhaustion to detachment accompanied by an overwhelming sense of powerlessness. More studies are needed to further clarify diabetes burnout and its distinction from, or overlap with, other related psychosocial concepts in diabetes care.

Eugenia jambolana extract reduces the systemic exposure of Sitagliptin and improves conditions associated with diabetes: A pharmacokinetic and a pharmacodynamic herb-drug interaction study

Eugenia jambolana (EJ) is an Indian traditional herb widely used for the treatment of diabetes mellitus. This herb is globally marketed as single or multi herb formulations. Many diabetes patients consume EJ extract oral hypoglycemic drugs together. This calls for a need to assess risks versus benefit of this co-administration.

In present investigation, pharmacodynamic and pharmacokinetic interactions of aqueous extract of EJ seeds at the dose of 400 mg/kg are studied with 10 mg/kg of oral hypoglycaemic drug sitagliptin (SITA) by co-administrating them for 28 days in streptozotocin (STZ) induced diabetic rats. The pharmacokinetic parameters of SITA were determined using HPLC-ESI-MS/MS and it was found that the combination treatment reduces the systemic exposure of SITA by showing 38.70% reduction in concentration maximum (Cmax) and 22.40% reduction in area under curve (AUC). Despite low levels of SITA, the combination demonstrated a significant reduction in blood glucose level when compared with individual drug and individual extract administered groups during pharmacodynamic study. In addition, the liver function, the kidney function and the lipid parameters were found to be significantly improved and beneficial effects were found with respect to food intake and water intake and urine output in case of combination treatment groups when compared with individual treatment groups. Histopathological examination of pancreatic tissue suggests its significant recovery of having normal acinus with better cell protection in combination treatment. In conclusion, the combination treatment demonstrated reduced systemic exposure of SITA without compromising on its antihyperglycemic activity and improvement in conditions associated with diabetes.

Does Ankle Muscle Performance Mirror Improved Pain Following Total Ankle Arthroplasty?

Category:

Ankle Arthritis

Introduction/Purpose:

Total ankle arthroplasty (TAA) outcomes include pain reduction and improved gait speed. Ankle push off power, which requires gastroc-soleus muscle strength, is a critical aspect of healthy gait and increases as gait speed increases. It appears that improvements in pain translate to improved ankle muscle performance. However, ankle power after TAA is surprisingly low. It is possible years of arthritis and latent muscle memory result in reduced gastroc-soleus muscle strength and a gait pattern reliant on proximal joints for power. Evaluating these hypotheses will drive postoperative care. The purpose of this ongoing prospective study is to be the first to evaluate the interplay of pain, gait speed, and ankle muscle performance (strength and power) in people following TAA for end-stage ankle arthritis.

Methods:

Twelve people [Mean (SD): Age 61 (14.3) years; BMI 30.0 (5.4) Kg/m2; 83% male] with end-stage ankle arthritis who were candidates for TAA participated (12 preoperative and 9 six-month postoperative visits). Performance of adjunct soft tissue procedures and postoperative care were patient specific. A twenty point numeric pain rating scale was used to measure worst pain in the past week. Three dimensional multi-segment foot motion analysis was performed while participants walked barefoot on level ground over a force plate. Ankle peak push-off power (joint torque x segmental velocity) was calculated. Ankle peak isokinetic plantarflexion strength (torque at 60 degrees / second) and ankle sagittal plane passive range of motion were measured with a dynamometer. Participants also completed the six minute walk test. Wilcoxon Signed Rank tests were used to evaluate preoperative to postoperative changes and between limb differences postoperatively.

Results:

Pain decreased (postoperative mean = 2.8; p = 0.01) and gait speed increased following TAA (p = 0.02). Ankle plantarflexion strength and ankle power during walking were preserved following TAA (both p > 0.8) (Figure 1). Postoperative group mean dorsiflexion was 25.1 degrees and plantarflexion was 18.9 degrees, suggesting sufficient ankle motion was present for plantarflexor muscle performance. However, between limb differences were significant for both strength and power (both p < 0.05) postoperatively. The involved ankle produced 36% less strength and generated 45% less power during walking in comparison to the uninvolved limb. This asymmetry demonstrates that involved limb ankle muscle performance was not normalized at six-month follow up, despite improvements in pain.

Conclusion:

Study findings provide preliminary evidence that improved pain and gait speed are disconnected from ankle muscle performance following TAA. Postoperative improvements in gait speed were likely driven by more proximal joints (i.e. hip). Without additional targeted postoperative plantarflexion strengthening and gait training to improve ankle muscle involvement, gains in ankle power, a symmetrical gait pattern, and patient tolerance to higher level activity (i.e. stairs) are unlikely to occur long-term. The underpinning mechanisms limiting the necessary strength to drive power generation (i.e. length-tension relationship, atrophy), and the possible cumulative effect of how abnormal gait may influence implant survivorship deserve further attention.

Does Total Ankle Arthroplasty Preserve Midfoot Function and Mitigate Excessive Adjacent Joint Loading?

Category:

Ankle Arthritis

Introduction/Purpose:

The progressive decline of ankle motion secondary to ankle arthritis increases midfoot joint loading during forward propulsive activities. Preservation or improvement of ankle motion following total ankle arthroplasty (TAA) is theorized to preserve adjacent joint function and potentially mitigate the cumulative effect of midfoot joint loading. If this theory were sound, the biomechanical profile of midfoot function would not change following TAA. Examination of this theory may inform TAA operative care and will directly impact postoperative rehabilitation paradigms. The purpose of this ongoing study was to be the first to prospectively evaluate the effect of TAA on midfoot function during walking, as measured by midfoot range of motion and power, at six month follow up.

Methods:

Nine adults [Mean (SD): Age 60.2 (3.5) years; BMI 30.4 (1.4) Kg/m2; 100% male] who received a TAA for end-stage ankle arthritis walked barefoot on level ground preoperatively and six months postoperatively. Three dimensional motion analysis was used to record three-segment foot motion (forefoot, rearfoot, tibia) and ground reaction forces. Midfoot (forefoot with respect to rearfoot) sagittal and transverse plane range of motion were measured. Inverse dynamic calculations were used to obtain midfoot negative (absorption) and positive (generation) peak power (joint torque x segmental velocity), since these metrics are biomechanical correlates of midfoot instability and stability, respectively. Accordingly, greater midfoot joint loading would be characterized by increased power absorption. Greater power generation would indicate an increased midfoot contribution to forward propulsion. Paired t-tests were used to evaluate differences across time in the involved limb and between limbs postoperatively for power variables.

Results:

Midfoot dorsiflexion / plantarflexion and abduction / adduction range of motion were not significantly different pre to postoperatively (mean differences < 0.4 degrees; both p > 0.7). Similarly, involved limb midfoot negative and positive power did not change (mean differences < 0.1 W/Kg; negative power p = 0.1; positive power p = 1.0). Postoperatively, negative power was minimally different between sides (mean difference 0.1 W/Kg; p = 0.4). However, involved limb midfoot positive power was 44% less than the uninvolved limb postoperatively (mean difference 0.3 W/Kg; p = 0.1) (Figure 1).

Conclusion:

Study findings provide preliminary substantiation to the theory that midfoot function is preserved following TAA. At six months, the biomechanical profile of individuals receiving TAA for end-stage ankle arthritis was not different from preoperative measures. Further, since postoperative power absorption was similar between limbs, the current TAA operative approach may help mitigate midfoot joint loading. However, the asymmetrical power generation (44% less on the involved limb) suggests the midfoot is unprepared to respond to anticipated ankle power improvements as patients advance to higher level activities. Accordingly, rehabilitation targeting midfoot stability through strengthening is recommended to complement current postoperative efforts.

Prospective evaluation of quality of life in children treated in UKALL 2003 for acute lymphoblastic leukaemia: A cohort study

BACKGROUND

Health-related quality of life (HRQoL) from diagnosis until end of treatment for children with acute lymphoblastic leukaemia was investigated, examining effects of age, gender, risk-stratified treatment regimen, and therapy intensity (one vs. two 'delayed intensifications' [DIs]).

METHOD

In a multi-centre prospective study, parents reported their child's generic and disease-specific HRQoL and their own care-giving burden at five time points. From 1,428 eligible patients, 874 parents completed questionnaires at least once during treatment.

RESULTS

At each time point, generic HRQoL was significantly lower than equivalent norm scores for healthy children. HRQoL decreased significantly at the start of treatment, before recovering gradually (but remained below pre-treatment levels). Parents reported that older children worried more about side effects and their appearance, but showed less procedural anxiety than younger children. Concern for appearance was greater among girls than boys. Compared to Regimen B (i.e. additional doxorubicin during induction and additional cyclophosphamide and cytarabine during consolidation chemotherapy), patients receiving Regimen A had fewer problems with pain and nausea. There were no statistically significant differences in HRQoL by number of DI blocks received.

INTERPRETATION

HRQoL is compromised at all stages of treatment, and is partly dependent on age. The findings increase understanding of the impact of therapy on children's HRQoL and parental care-giving burden, and will contribute to the design of future trials.

What to Do with the Spring Ligament

The spring ligament complex is an important static restraint of the medial longitudinal arch of the foot and its failure has been associated with progressive flatfoot deformity. Reconstruction of the spring ligament complex is most appropriate in stage II posterior tibial tendon dysfunction, before severe peritalar subluxation and rigid deformity develops. Although an understanding of the spring ligament complex and its contribution to medial arch stability has grown, there is no unanimously accepted surgical technique that has consistently demonstrated satisfactory outcomes. This article reviews the pathoanatomy of the spring ligament complex and the role of spring ligament reconstruction in acquired flatfoot deformity, and highlights current research.

A Cross-sectional Cohort Analyses Assessing Response to Levosalbutamol Bronchodilatory Cough Formulations in Outpatient Community Settings of India: 'BUS' analyses

INTRODUCTION

Cough is significant health problem with greater implication for impaired quality of life. Acute and chronic cough due to infective (viral/bacterial), allergic conditions or bronchial asthma including cough variant asthma are often treated with combination of mucolytics, expectorants and bronchodilators. Bronchodilators reduces cough sensitivity, promotes clearance of cough secretions while reducing protrusive inflammatory mediator release.

AIMS AND OBJECTIVES

To further understand the clinical utility and safety of Bronchodilatory cough formulations (BCF) containing Levosalbutamol in real world settings.

MATERIAL AND METHODS

A prospective, cross sectional, cohort analyses (Bronchodilatory coUgh formulary Survey, BUS) assessing Levosalbutamol cough formulations utilization at 40 centers involving general and consultant physicians across India.

RESULTS

Consecutive prescription records (n=1367) involving Levosalbutamol were collated for analyses. Baseline demographics included adults (21%) and children (79%) with mean age 11.1 yrs, male (60%) and female(40%). Levosalbutamol BCF was commonly prescribed for LRTI (69.7%), AECB (14.8%), Bronchial asthma (8.5%), Allergic rhinitis (5%). The predominant risk factors in both adults and children included smoking and allergic rhinitis respectively. In most cases cough severity was assessed utilizing Fisman scale score (0-4). Mean cough score improved from baseline score of 3 to 0.8 with parallel improvement in associated symptoms of wheeze and sputum. Antibiotics were prescribed in most of LRTI or acute exacerbation cases with purulent sputum. Side effects noted included tremor (1%), palpitation (0.9%), vomiting (0.7%) that were mild and transient in most cases with none requiring treatment withdrawal. In two cases (0.1%), further treatment with nebulization and antibiotics were provided.

CONCLUSIONS

Levosalbutamol containing Bronchodilatory Cough formulation remains as safe and effective option for adults and children while managing acute or chronic cough primarily due to allergic rhinitis, bronchial asthma or COPD.

Clinical presentation, management, and outcomes in the Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF) registry

Aim

A national atrial fibrillation (AF) registry was conducted under the aegis of the Indian Heart Rhythm Society (IHRS), to capture epidemiological data-type of AF, clinical presentation and comorbidities, current treatment practices, and 1-year follow-up outcomes.

Methods

A total of 1537 patients were enrolled from 24 sites in India in the IHRS-AF registry from July 2011 to August 2012. Their baseline characteristics and follow-up data were recorded in case report forms and subsequently analyzed.

Results

The average age of Indian AF patients was 54.7 years. There was a marginal female preponderance – 51.5% females and 48.5% males. At baseline, 20.4% had paroxysmal AF; 33% had persistent AF; 35.1% had permanent AF and 11% had first AF episode. At one-year follow-up, 45.6% patients had permanent AF.

Rheumatic valvular heart disease (RHD) was present in 47.6% of patients. Hypertension, heart failure, coronary artery disease, and diabetes were seen in 31.4%, 18.7%, 16.2%, and 16.1%, respectively.

Rate control was the strategy used in 75.2% patients, digoxin and beta-blockers being the most frequently prescribed rate-control drugs. Oral anticoagulation (OAC) drugs were used in 70% of patients. The annual mortality was 6.5%, hospitalization 8%, and incidence of stroke 1%.

Conclusions

In India, AF patients are younger and RHD is still the most frequent etiology. Almost two-third of the patients have persistent/permanent AF. At one-year follow-up, there is a significant mortality and morbidity in AF patients in India.

Impact of PTEN abnormalities on outcome in pediatric patients with T-cell acute lymphoblastic leukemia treated on the MRC UKALL2003 trial

PTEN gene inactivation by mutation or deletion is common in pediatric T-cell acute lymphoblastic leukemia (T-ALL), but the impact on outcome is unclear, particularly in patients with NOTCH1/FBXW7 mutations. We screened samples from 145 patients treated on the MRC UKALL2003 trial for PTEN mutations using heteroduplex analysis and gene deletions using single nucleotide polymorphism arrays, and related genotype to response to therapy and long-term outcome. PTEN loss-of-function mutations/gene deletions were detected in 22% (PTEN(ABN)). Quantification of mutant level indicated that 67% of mutated cases harbored more than one mutant, with up to four mutants detected, consistent with the presence of multiple leukemic sub-clones. Overall, 41% of PTEN(ABN) cases were considered to have biallelic abnormalities (mutation and/or deletion) with complete loss of PTEN in a proportion of cells. In addition, 9% of cases had N- or K-RAS mutations. Neither PTEN nor RAS genotype significantly impacted on response to therapy or long-term outcome, irrespective of mutant level, and there was no evidence that they changed the highly favorable outcome of patients with double NOTCH1/FBXW7 mutations. These results indicate that, for pediatric patients treated according to current protocols, routine screening for PTEN or RAS abnormalities at diagnosis is not warranted to further refine risk stratification.

Anatomical reconstruction of the spring ligament complex: "internal brace" augmentation

The calcaneonavicular (spring) ligament complex is a critical static support of the medial arch of the foot. Compromise of this structure has been implicated as a primary causative factor of talar derotation leading to the clinical deformity of peritalar subluxation. Few procedures have been described to address this deficiency. The technique we describe here is a simple yet effective method to reconstruct the spring ligament complex that can easily be used in conjunction with other more commonly used procedures for extra-articular reconstructions of this deformity. We believe this procedure allows for a more powerful deformity correction and may decrease dependency on other nonanatomic reconstructive procedures.

Early weightbearing using Achilles suture bridge technique for insertional Achilles tendinosis: a review of 43 patients

Posterior heel pain caused by insertional Achilles tendinosis can necessitate surgical intervention when recalcitrant to conservative care. Surgical treatment can necessitate near complete detachment of the Achilles tendon to fully eradicate the offending pathologic features and, consequently, result in long periods of non-weightbearing. A suture bridge technique using bone anchors is available for reattachment of the Achilles tendon. This provides restoration of the Achilles footprint on the calcaneus, including not only contact, but also actual pressure between the tendon and bone. We performed a review of 43 patients who underwent surgical treatment of insertional Achilles tendinosis with reattachment of the Achilles tendon using the suture bridge technique. The mean age was 53 (range 29 to 87) years. The mean follow-up period was 24 (range 13 to 52) months. The mean postoperative American Orthopaedic Foot and Ankle Society score was 90 (range 65 to 100). The mean preoperative visual analog scale pain score was 6.8 (range 2 to 10) and the mean postoperative visual analog scale pain score was 1.3 (range 0 to 6). The mean interval to weightbearing was 10 (range 0 to 28) days. No postoperative ruptures occurred. Of the 43 patients, 42 (97.6%) successfully performed the single heel rise test at the final postoperative visit. Concomitant procedures were performed in 35 patients, including 33 (77%) requiring open gastrocnemius recession and 2 (5%) requiring flexor hallucis longus tendon transfer. A total of 42 patients (97.6%) returned to regular shoe gear, and 42 (97.6%) returned to their activities of daily living, including running for 20 athletic patients (100%). Complications included postoperative wound dehiscense requiring surgical debridement in 2 patients (5%) and soft tissue infection requiring antibiotics and surgical debridement in 1 (2%) patient. Our findings support using the Achilles tendon suture bridge for reattachment of the Achilles tendon in the surgical treatment of insertional Achilles tendinosis.

Impact of NOTCH1/FBXW7 mutations on outcome in pediatric T-cell acute lymphoblastic leukemia patients treated on the MRC UKALL 2003 trial

Activating mutations in the NOTCH1 pathway are frequent in pediatric T-cell acute lymphoblastic leukemia (T-ALL) but their role in refining risk stratification is unclear. We screened 162 pediatric T-ALL patients treated on the MRC UKALL2003 trial for NOTCH1/FBXW7 gene mutations and related genotype to response to therapy and long-term outcome. Overall, 35% were wild-type (WT) for both genes (NOTCH1(WT)FBXW7(WT)), 38% single NOTCH1 mutant (NOTCH1(Single)FBXW7(WT)), 3% just FBXW7 mutant (NOTCH1(WT)FBXW7(MUT)) and 24% either double NOTCH1 mutant (NOTCH1(Double)FBXW7(WT)) or mutant in both genes (NOTCH1(MUT)FBXW7(MUT)), hereafter called as NOTCH1±FBXW7(Double). There was no difference between groups in early response to therapy, but NOTCH1±FBXW7(Double) patients were more likely to be associated with negative minimal residual disease (MRD) post-induction than NOTCH1(WT)FBXW7(WT) patients (71% versus 40%, P=0.004). Outcome improved according to the number of mutations, overall survival at 5 years 82%, 88% and 100% for NOTCH1(WT)FBXW7(WT), NOTCH1(Single)FBXW7(WT) and NOTCH1±FBXW7(Double) patients, respectively (log-rank P for trend=0.005). Although 14 NOTCH1±FBXW7(Double) patients were classified as high risk (slow response and/or MRD positive), only two had disease progression and all remain alive. Patients with double NOTCH1 and/or FBXW7 mutations have a very good outcome and should not be considered for more intensive therapy in first remission, even if slow early responders or MRD positive after induction therapy.

Clinical outcomes and health-related quality of life (HRQOL) following haemopoietic stem cell transplantation (HSCT) for paediatric leukaemia

BACKGROUND

Haemopoietic stem cell transplantation (HSCT) is a life-saving but intensive procedure associated with potentially severe adverse late effects. We aimed to determine morbidity and health-related quality of life (HRQOL) in a sample of survivors aged 8-18 years at least 1 year post HSCT for paediatric acute leukaemia, compared with a non-transplanted group of survivors matched for age, gender, initial disease and time since treatment.

METHODS

Families (N = 54; HSCT n= 29) recruited from four UK centres completed measures of child behaviour and school attendance, HRQOL and finances. Mothers completed measures of their own well-being. Clinical outcome data were extracted from medical records.

RESULTS

Children in the HSCT group had significantly more late effects and had received more tests for vision, bone, dental and skin health, and thyroid, lung, and gonadal function than the non-transplanted group. HRQOL scores for the HSCT group were significantly lower in all domains compared with the non-transplanted group and population norms, but were not significantly related to clinical indices. Mothers in the HSCT group had significantly poorer mental well-being than population norms.

CONCLUSION

Significant morbidity and compromised HRQOL was found in survivors of HSCT. The burden of caring for a child after HSCT has a continuing toll on mothers' well-being.The importance of counselling families about possible long-term consequences is emphasized.

Analysis of risk factors influencing outcome in children with myelodysplastic syndrome after unrelated cord blood transplantation

We describe 70 children with myelodysplastic syndrome (MDS) (refractory cytopenia (n=31) and refractory anemia with excess blasts (n=30) or blasts in transformation (n=9)) who received umbilical cord blood (UCB) transplantation with a single UCB unit and a myeloablative conditioning regimen. Approximately 20% of children had secondary MDS. Median age at transplantation was 7 years and the median follow-up was 3 years. The day-60 probability of neutrophil recovery was 76%; recovery was faster after transplantation of matched or 1-locus mismatched UCB, irradiation-containing conditioning regimen, cell dose >6 × 10(7)/kg and monosomy 7. Risks of treatment failure (recurrent disease or death) were lower in patients with monosomy 7 and transplantations after 2001. The 3-year disease-free survival (DFS) was 50% for transplantations after 2001 compared with 27% for the earlier period (P=0.018). Transplantations after 2001 occurred within 6 months after diagnosis and used UCB units with higher cell dose. DFS was highest in patients with monosomy 7 (61%) compared with other karyotypes (30%), P=0.017. These data suggest that transplantation of mismatched UCB graft is an acceptable alternative for children without a matched sibling or suitably matched unrelated adult donor.

Suture-button versus screw fixation of the syndesmosis: a biomechanical analysis

BACKGROUND

The treatment of ankle fractures with syndesmotic injuries associated with disruption of the deltoid ligament complex is controversial. The purpose of this study was to compare both the biomechanical and physiologic properties of suture-button fixation to the intact syndesmosis and screw fixation.

MATERIALS AND METHODS

Eight fresh frozen human cadaveric ankles were used in three different groups. One group had an intact syndesmosis and deltoid ligamentous complex and two groups had fixation of the syndesmosis after its disruption along with disruption of the deltoid ligaments. One fixation group used a suture-button and the other used a 3.5-mm tricortical syndesmotic screw. The syndesmotic gap after cycling at submaximal loads, laxity due to cycling, and fibular movement allowed in the sagittal plane were all measured and analyzed for statistical significance.

RESULTS

The syndesmotic gap after cycling was not significantly different between the intact group (9.1 mm) and the suture-button group (8.8 mm) (p = 0.1509). The screw fixation group had a significantly smaller gap (7.9 mm) as compared to the other two groups (screw versus intact, p = 0.00004; screw versus suture-button, p = 0.0004). The intact group did not demonstrate a significant difference in laxity before (9.0 mm) and after (9.1 mm) cycling (p = 0.0670), whereas the suture-button group did have a significant difference (before, 8.01 mm; after, 8.28 mm) (p = 0.000251). The movement of the fibula in the sagittal plane was significantly greater in the suture-button group (3.17 mm) as compared to the intact group (2.77 mm) (p = 0.00554). Screw fixation allowed significantly less fibular movement in the sagittal plane (1.16 mm) as compared to the intact (p = 0.00014) and suture-button (p = 0.0000012) groups.

CONCLUSION

Suture-button fixation maintained reduction after cycling with submaximal loads that compared favorably to the intact syndesmosis. It also allowed more physiologic movement of the fibula in the sagittal plane when compared to tricortical screw fixation.

CLINICAL RELEVANCE

Syndesmotic injury fixation has traditionally used screws to provide a rigid construct in which healing can take place. We believe a less rigid fixation method, such as suture-button fixation, provides a more physiologic type of healing of the syndesmosis.

Remyelination can be extensive in multiple sclerosis despite a long disease course

Experimental studies using models of multiple sclerosis (MS) indicate that rapid and extensive remyelination of inflammatory demyelinated lesions is not only possible, but is the normal situation. The presence of completely remyelinated MS lesions has been noted in numerous studies and routine limited sampling of post mortem MS material suggests that remyelination may be extensive in the early stages but eventually fails. However, visual macroscopic guided sampling tends to be biased towards chronic demyelinated lesions. Here we have extensively sampled cerebral tissue from two MS cases to investigate the true extent of remyelination. Sections were cut from 185 cerebral tissue blocks and stained with haematoxylin and eosin (H&E), luxol fast blue and cresyl fast violet (LFB/CFV) and anti-myelin oligodendrocyte glycoprotein, human leucocyte antigen-DR (HLA-DR) and 200 kDa neurofilament protein antibodies. Demyelinated areas were identified in 141 blocks, comprising both white matter (WMLs) and/or grey matter lesions. In total, 168 WMLs were identified, 22% of which were shadow plaques, 73% were partially remyelinated and only 5% were completely demyelinated. The average extent of lesion remyelination for all WMLs investigated was 47%. Increased density of HLA-DR(+) macrophages and microglia at the lesion border correlated significantly with more extensive remyelination. Results from this study of two patients with long standing disease suggest that remyelination in MS may be more extensive than previously thought.

Status of geriatric oncology in India: A national multicentric survey of oncology professionals

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Background: Elderly cancer patients are underrepresented in cancer services utilization and clinical research in India. National data on providers’ knowledge, attitude and practices with regard to elderly cancer patients is sparse and is urgently required to address needs of this vulnerable and growing population. Methods: A self administered questionnaire was mailed to nationally representative sample of practicing oncologists all over India. 112 Oncologists (Medical Oncologists-51%; Radiation Oncologists-25%; Surgical Oncologists-20%; allied fields-4%) responded out of 250 mailed Questionnaires. Results: A designated Geriatric Oncology unit is in existence in very few (<5%) centers. Majority (51%) considered patients with chronological age of >60 years as elderly for India. Although 75% of elderly patients receive some therapy, only 50% of potentially curable patients and a similar percentage of potentially incurable patients receive standard of care. Also, 50% patients require modification in their treatment and only two-third of treated patients complete therapy. The existent barriers to treatment included poor performance status (53%), advanced stage (16%), and co-morbidities (15%). Only 51% Oncologists always discussed and 28% always enrolled elderly patients in clinical trials. Standard of care and evidence based recommendations for elderly patients were felt to be lacking by 49% and 92% of respondents respectively. The need of separate trials for elderly and a separate discipline of Geriatric Oncology was voiced by 93% and 89% of respondents respectively. Major differences in treatment practice between medical oncologists and non medical oncologists are shown in table . Conclusions: Treatment practices and accrual of elderly cancer patients in clinical trials in India is far from optimal. Formation of a National Geriatric Oncology society and creation of designated Geriatric oncology services at key centers may enhance the understanding and clinical care of this population.

[Table: see text]

No significant financial relationships to disclose.