Facial nerve communication with ansa cervicalis - An unusual anatomical variation

Neural connections of the seventh cranial nerve with its neighboring nerves are common and well documented; however, communication with ansa cervicalis is as yet unknown. We present a case with such a connection found during cadaveric dissection, with hitherto unknown consequences. In this specimen, after giving the marginal mandibular and cervical branches, the cervicofacial division continued distally to communicate with the distal loop of ansa cervicalis. Presence of such connection may result in facial muscle paralysis on injury to the ansa or strap muscle paralysis on injury to the facial nerve, depending on the direction of nerve fibers. Such unusual connections bring to light the need for extreme care during surgeries in the neck to safeguard any such connections and when using the ansa as donor.

Future demand for primary hip and knee arthroplasty in Scotland

INTRODUCTION

The rising prevalence of osteoarthritis, associated with an ageing population, is expected to deliver increasing demand for arthroplasty services in the future. Understanding the scale of potential change is essential to ensure adequate provision of services and prevent prolonged waiting times that can cause patient harm.

METHODS

We set out to provide projections of future primary knee and hip arthroplasty out to 2038 utilising historical trend data (2008-2018) from the Scottish Arthroplasty Project. All analyses were performed using the Holt's exponential smoothing projection method with the forecast package in R statistics. Results were adjusted for projected future population estimates provided by National Records of Scotland. Independent age group predictions were also performed.

RESULTS

The predicted rise of primary hip arthroplasty for all ages is from 120/100k/year in 2018 to 152/100k/year in 2038, a 28% increase. The predicted rise of primary knee arthroplasty for all ages is from 164/100k/year in 2018 to 220/100k/year in 2038, a 34% increase. Based on a static 3-day length of stay average this would see 4280 and 7392 additional patient bed days required for primary hip and knee arthroplasty patients respectively per annum. The associated additional cost is anticipated to be approximately £26 million.

CONCLUSIONS

Anticipated future demand for arthroplasty will require significant additional resource and funding to prevent deterioration in quality of care and an increase in patient wait times, additional to that already required to clear the COVID-19 backlog. Understanding presented projections of changes to arthroplasty demand is key to future service delivery.

Glyphosate, AMPA and glufosinate in soils and earthworms in a French arable landscape

Although Glyphosate-based herbicides are often marketed as environmentally friendly and easily biodegradable, its bioavailability and risks to wildlife raise significant concerns. Among non-target organisms, earthworms which live in close contact with the soil can be directly exposed to pesticides and harmed. We investigated soil contamination and the exposure of earthworms to glyphosate, its metabolite AMPA, and glufosinate in an arable landscape in France, both in treated (i.e. temporary grasslands and cereal fields under conventional farming), and nontreated habitats (i.e. hedgerows, permanent grasslands and cereal fields under organic farming) (n = 120 sampling sites in total). Glyphosate, AMPA and glufosinate were detected in 88%, 58% and 35% of the soil samples, and in 74%, 38% and 12% of the earthworm samples, respectively. For both glyphosate and AMPA, concentrations in soils were at least 10 times lower than predicted environmental concentrations. However, the maximum glyphosate soil concentration measured (i.e., 0.598 mg kg-1) was only 2 to 3 times lower than the concentrations revealed to affect earthworms (survival and avoidance) in the literature. These compounds were found both in conventional and organic farming fields, thus supporting a recent study, and for the first time they were detected in hedgerows and grasslands. However, glyphosate and AMPA were more frequently detected in soils from cereal fields and hedgerows than in grasslands, and median concentrations measured in soils from cereal fields were significantly higher than in the two other habitats. Bioaccumulation of glyphosate and AMPA in earthworms was higher than expected according to the properties of the molecules. Our findings raised issues about the high occurrence of glyphosate and AMPA in soils from cropped and more natural areas in arable landscapes. They also highlight the potential for transfer of these molecules in terrestrial food webs as earthworms are prey for numerous animals.

The 50 Top-Cited Articles on the Posterior Cruciate Ligament: A Bibliometric Analysis and Review

Background:

Limited attention has been paid to the natural history, management, and treatment outcomes related to the posterior cruciate ligament (PCL)–deficient knee joint.

Purpose:

To perform a comprehensive bibliometric analysis to evaluate the 50 top-cited articles in PCL research.

Study Design:

Cross-sectional study.

Methods:

We performed a keyword-based search in the Thomson Reuters Web of Science to generate a list of the 50 most cited articles relevant to the PCL. The included articles were analyzed according to journal, country of origin, publication year, total number of citations, citations per year, citation trends, and type of study (clinical vs basic science).

Results:

The 50 top-cited articles were published between 1975 and 2012, and the number of individual article citations ranged between 98 and 410. The listed articles were published in 7 journals, with the American Journal of Sports Medicine contributing to more than half of the articles and citations. The United States contributed the most articles (84%) and citations (n = 4873). There were 32 clinical studies and 18 basic science studies. All clinical studies had level 4 clinical evidence, and topics included the natural history of PCL tears, factors predicting the need for surgical intervention, and long-term outcomes of isolated PCL injuries and combined capsuloligamentous injuries. Most (77.8%) of the top-cited basic science articles consisted of experimental or biomechanical studies on human cadaveric knees.

Conclusion:

The current analysis suggests that PCL research is still evolving and needs high-quality prospective evidence to establish sound recommendations.

Orthopaedic assessment unit: a service model for the delivery of orthopaedic trauma care in a major trauma centre during the global pandemic (COVID-19)

INTRODUCTION

We describe a new service model, the Orthopaedic Assessment Unit (OAU), designed to provide care for trauma patients during the COVID-19 pandemic. Patients without COVID-19 symptoms and isolated musculoskeletal injuries were redirected to the OAU.

METHODS

We prospectively reviewed patients throughput during the peak of the global pandemic (7 May 2020 to 7 June 2020) and compared with our historic service provision (7 May 2019 to 7 June 2019). The Mann-Whitney and Fisher Exact tests were used to test the statistical significance of data.

RESULTS

A total of 1,147 patients were seen, with peak attendances between 11am and 2pm; 96% of all referrals were seen within 4h. The majority of patients were seen by orthopaedic registrars (52%) and nurse practitioners (44%). The majority of patients suffered from sprains and strains (39%), followed by fractures (22%) and wounds (20%); 73% of patients were discharged on the same day, 15% given follow up, 8% underwent surgery and 3% were admitted but did not undergo surgery. Our volume of trauma admissions and theatre cases decreased by 22% and 17%, respectively (p=0.058; 0.139). There was a significant reduction of virtual fracture clinic referrals after reconfiguration of services (p<0.001).

CONCLUSIONS

Rapid implementation of a specialist OAU during a pandemic can provide early definitive trauma care while exceeding national waiting time standards. The fall in trauma attendances was lower than anticipated. The retention of orthopaedic staff in the department to staff the unit and maintain a high standard of care is imperative.

Neglected medial swivel talonavicular dislocation treated with arthrodesis: A case report and literature review

Talonavicular dislocation is a rare injury. It usually occurs in conjunction with a variety of midfoot and hindfoot injuries. Isolated medial or lateral talonavicular dislocations without disruption of subtalar joint are known as medial or lateral swivel dislocations respectively, both being extremely rare. We describe a case of neglected medial swivel dislocation with articular impaction injury of talar head, which was managed with open reduction and arthrodesis with two 4 mm cannulated cancellous screws. At 6 months follow-up, patient was pain free and walking full weight bearing. All movements were painless and there was no footwear related problems. Radiographs showed sound arthrodesis of talonavicular joint. Although a rare injury, good results can be obtained by prompt recognition and treatment. In neglected cases, arthrodesis of the talonavicular joint is a viable option, especially if articular injury is present.

Morphometric analysis of the anterior column of the acetabulum and safety of intramedullary screw fixation for its fractures in Indian population: a preliminary report

INTRODUCTION

Morphometric variations of the anterior column of the acetabulum have been described in the literature for its complex structure, which can influence the safe containment of intramedullary screw for fixation of its fractures. The purpose of this CT-based study is to present a preliminary report on the morphometric variations and safety of intramedullary screw fixation of the anterior column of the acetabulum in the Indian population.

METHODS

CT-based data from 102 uninjured pelves were retrospectively analyzed in iPlanⓇ BrainLab AG, Feldkirchen, Germany. Narrowest zones around acetabulum and superior pubic ramus were measured. We calculated the axis of the anterior column of the acetabulum by joining the centres of these narrowest zones. Standard screws trajectories were directed along this axis. Screw length up to the first cortical perforation, the distance of the exit point from the pubic symphysis, and the length of the anterior column up to the pubic tubercle were measured.

RESULTS

The osseous corridor of the anterior column of acetabulum had variable cross-section along its length with two constriction zones, first in the acetabular region and second in the superior pubic ramus. Only 54% of our cases allowed safe applicability of 6.5-mm-diameter screw trajectories with safety margin of 2 mm on either side of the screw. Significant morphometric and screw applicability-related differences were observed among male and female cases with males having a wider osseous corridor in general. Elimination of safety margin results in a significant increase in the screw applicability.

CONCLUSION

The osseous corridor of the anterior column varies in its dimensions from individual to individual. Standard screws of 6.5-mm and 7.3-mm diameters may not be safe for intramedullary screw fixation in every patient and carry a risk of cortical violation when a 2 mm of width around the screw is considered as a safety margin. However, with a precise screw placement within the extents of the cortices of the anterior column, 6.5-mm screws can be applied in most of the female cases and 7.3-mm screws can be applied in most of the male cases for anterior column fixation.

In vivo comparison of a fixed loop (EndoButton CL) with an adjustable loop (TightRope RT) device for femoral fixation of the graft in ACL reconstruction: A prospective randomized study and a literature review

INTRODUCTION

There is a lack of in vivo studies comparing the functional outcome and knee stability after anterior cruciate ligament reconstruction (ACLR) using fixed loop (EndoButton (EB) CL) and adjustable loop (TightRope (TR) RT) devices for femoral fixation of soft tissue grafts.

MATERIALS AND METHODS

Functional outcomes were assessed in terms of the International Knee Documentation Committee (IKDC) and Lysholm scores, knee stability by anteroposterior laxity and side-to-side difference (SSD) using KT-1000 arthrometer. The evaluation was performed preoperatively and post-operatively at 6 months and 2 years.

RESULTS

Both groups were matched in terms of demographic, preoperative, intraoperative and post-operative covariates. EB ( n = 52) appeared to have better IKDC and Lysholm scores at 6 months post-operative when compared to TR ( n = 50). However, at a final follow-up of 2 years, the results were similar. The anterior tibial translation and SSD were statistically insignificant between the two groups at 6 months and 2 years.

CONCLUSION

ACLR using EB or TR for femoral fixation gives substantially equivalent functional results and knee stability at mid-term follow-up.

Clinical outcome and predictors of severity in scrub typhus patients at a tertiary care hospital in Chandigarh, India

BACKGROUND & OBJECTIVES

Scrub typhus is an under-reported rickettsial illness caused by Orientia tsutsugamushi which is transmitted by trombiculid mites. Serious complications are not uncommon and multiorgan dysfunction may develop leading to death. Paucity of data on the clinical spectrum and determinants of aftermath may be contributing to higher mortality in the region. A prospective study was done to describe the spectrum of organ dysfunction in serologically confirmed cases of scrub typhus and document predictors of adverse outcomes.

METHODS

This prospective study was carried out in patients diagnosed to have scrub typhus by IgM ELISA. The clinical features, investigations and complications among survivors were statistically compared to those in the deceased. Fisher's exact test, t-test and logistic regression have been applied where appropriate.

RESULTS

The study population comprised of 123 patients. Majority of patients (62%) had one or more organ dysfunction. Ten patients (8.1%) did not survive. Complications documented were acute kidney injury (AKI) in 35%, hepatitis in 29.2%, acute respiratory distress syndrome (ARDS) in 26%, shock in 13%, meningitis in 5.7%, disseminated intravascular coagulation (DIC) in 2.6%, pancreatitis in 2.6% and myocarditis in 1.6%. Certain clinical features, biochemical parameters and complications had statistically significant correlation with the outcome. The mean SOFA score was considerably higher in those who did not survive. Interpretation &conclusion: Patients developing hepatic dysfunction, acute kidney injury and respiratory distress should be identified early and intensively monitored. The SOFA score can be utilized to assess the severity at admission and rapidly triage the sicker patients.

Femoral Component Sizing in Oxford Unicompartmental Knee Replacement: Existing Guidelines Do Not Work for Indian Patients

Oxford unicompartmental knee replacement (OUKR) has shown excellent long-term clinical outcomes as well as implant survival when used for correct indications with optimal surgical technique. Anteromedial osteoarthritis is highly prevalent in Indian patients, and OUKR is the ideal treatment option in such cases. Uncertainty prevails about the best method to determine femoral component size in OUKR. Preoperative templating has been shown to be inaccurate, while height- and gender-based guidelines based on European population might not apply to the Indian patients. Microplasty instrumentation introduced in 2012 introduced the sizing spoon, which has the dual function of femoral component sizing and determining the level of tibia cut. We aimed to check the accuracy of sizing spoon and also to determine whether the present guidelines are appropriate for use in the Indian patients. A total of 130 consecutive Oxford mobile bearing medial cemented UKR performed using the Microplasty instrumentation were included. The ideal femoral component size for each knee was recorded by looking for overhang and underhang in post-operative lateral knee radiograph. The accuracy of previous guidelines was determined by applying them to our study population. Previously published guidelines (which were based on Western population) proved to be accurate in only 37% of cases. Hence, based on the demographics of our study population, we formulated modified height- and gender-based guidelines, which would better suit the Indian population. Accuracy of modified guidelines was estimated to be 74%. The overall accuracy of sizing spoon (75%), when used as an intraoperative guide, was similar to that of modified guidelines. Existing guidelines for femoral component sizing do not work in Indian patients. Modified guidelines and use of intraoperative spoon should be used to choose the optimal implant size while performing OUKR in Indian patients.

CT based management of high energy tibial plateau fractures: A retrospective review of 53 cases

OBJECTIVES

The management of high energy tibial plateau fractures is a surgical challenge. Recently described Luo's classification is based on CT scans and is more objective with a better inter-observer agreement as compare to Schatzker and AO/OTA classifications. We describe the functional results of a series of 53 cases classified and managed according to the Luo's column concept.

METHODS

A retrospective review of 53 high energy tibial plateau fractures, operated between January 2012 and March 2015 at a Level I trauma center, was performed. CT scans were used to classify these injuries based on the number of columns involved. Plating configuration and surgical approach were chosen based on the number of independent articular fragments on axial sections at the level of fibular head.

RESULTS

1 one-column, 51 two-column and 1 three-column fractures were studied. Triple plating was done in 5 patients. Mean follow-up was 2.7 years and mean Insall Knee score was 95.42. Four patients had varus malalignment and 1 had joint depression in the post-operative period. These were due to imperfect reduction during the surgery itself, and no case of late collapse was detected.

CONCLUSION

Utilizing Luo's classification for treating these complex injuries will assist in better understanding of fracture pattern and hence help in achieving a better functional outcome. Each fractured column needs to be independently addressed.

Safe corridor for iliosacral and trans-sacral screw placement in Indian population: A preliminary CT based anatomical study

OBJECTIVES

Nonsurgical management of unstable pelvic ring injuries is associated with poor outcomes. Posterior pelvic ring injuries include sacroiliac joint disruption and sacral fractures or a combination of the two. Morbidity is high in non-operatively managed patients. Screw fixation is being increasingly used to manage unstable posterior pelvic injuries. Limitations include a steep learning curve and potential for neurovascular injury. This is the first study in Indian population to describe the safe corridor for screw placement and check the feasibility of screw in both upper and lower sacral segments.

METHODS

This study involved retrospective analysis of 105 pelvic CT scans of patients admitted to the emergency department of a Level 1 trauma centre. Vertical height at the level of constriction (vestibule) of S1 and S2 was measured in coronal sections and anteroposterior width of constrictions was measured in axial sections. We created a trajectory for 7.3 mm cylinder keeping additional 2 mm free bony corridor around it and confirmed that bony limits were not breached in axial, coronal and sagittal sections. Whenever there was breach in bony limit we checked applicability of 6.5 mm screw.

RESULTS

The vertical height and anteroposterior width of vestibule/constriction of S1 was significantly higher in males, whereas S2 vestibule height and width were similar in males and females. Both male and female pelves were amenable to S1 Trans-sacral and S1 Iliosacral screw fixation with a 7.3 mm screw when a safe corridor of 2 mm was kept on all sides. However, when S2 segment was analysed, only 42.9% of male pelves and 25.7% of female pelves were amenable to insertion of trans-sacral 7.3 mm screw.

CONCLUSION

An individualized approach is necessary and each patient's CT must be carefully studied before embarking on sacroiliac screw fixation in Indian population.

Quantitative correlation of mechanoreceptors in tibial remnant of ruptured human anterior cruciate ligament with duration of injury and its significance: an immunohistochemistry-based observational study

BACKGROUND

Proprioception is a specialized sensory modality encompassing the movement of the joint and its position in space. Reconstruction of the anterior cruciate ligament (ACL) does not always yield expected outcome, suggesting that successful reconstruction depends on not only the ultimate strength of the graft but also recovery of proprioception. Treatment delay is a significant concern in developing countries, e.g., in Asia. Thus, presence of mechanoreceptors is one of the factors having paramount importance for successful outcome. We conducted this study to identify mechanoreceptors via immunohistochemical staining and correlate their presence with duration of injury.

MATERIALS AND METHODS

A total of 38 injured native ACL stumps were harvested from patients undergoing ACL reconstruction and stained with neurofilament protein stain to detect functional mechanoreceptors.

RESULTS

Of the specimens, 44.7% stained positive for monoclonal antibody. No association was found between duration of injury and presence of mechanoreceptors (p = 0.897). No correlation was seen between age and side.

CONCLUSIONS

No correlation was found between duration of injury and presence of viable mechanoreceptors, hence it is beneficial to preserve the native ACL stump irrespective of the time interval between injury and surgery.

LEVEL OF EVIDENCE

III.

Early Results of Oxford Mobile Bearing Medial Unicompartmental Knee Replacement (UKR) with the Microplasty Instrumentation: An Indian Experience

BACKGROUND

Oxford medial unicompartmental knee replacement (UKR) is indicated in patients with anteromedial osteoarthritis (AMOA) of the knee. Microplasty (MP) instrumentation was introduced in 2012 as an improvement over phase 3 instrumentation. Advantages of this instrumentation include conservative tibial cut, decreased tibial re-cut rate and improved component alignment. We report the results of UKR with the new instrumentation in a consecutive series with a minimum follow-up of 2 years.

METHODS

A prospective study of 115 cemented medial Oxford UKRs implanted in 89 patients was done. Post-operative alignment of the tibial and femoral components was analysed. Patient reported outcome measures were recorded using Oxford Knee Score (OKS) and the American Knee Society Score (KSS). Tegner Activity Scale (TAS) was used to record the activity level.

RESULTS

115 consecutive medial Oxford UKRs were studied. All patients were followed up annually in this prospective ethically approved study. The mean follow-up was 36 months and the minimum follow-up was 25 months. No patient died and none were lost to follow-up. At the final follow-up, the average OKS of the cohort was 39.5 (SD: 5.7). 91.2 % of the patients had good or excellent OKS with only 3.5 % reporting poor OKS. The overall limb alignment was 4.8⁰ varus (0 - 14⁰ varus). Tibia was recut in 5.2 % of cases. Median bearing size was 3 (range: 3 to 6). There was one case of bearing dislocation and one case of aseptic tibial loosening.

CONCLUSION

This is the first study to report results of MP instrumentation at a minimum follow-up of 2 years. Our study indicates that the new instrumentation results in reliable and accurate implantation of femoral and tibial components in majority of the cases, with a decrease in number of alignment outliers, and also a reduced rate of bearing dislocation.

Functional outcome of extra-articular distal humerus fracture fixation using a single locking plate: A retrospective study

PURPOSE

The optimal method for fixation of extra-articular distal humerus factures poses a management dilemma. Although various plate configurations have been proposed, anatomic shaped extra-articular distal humerus locking plates have emerged as a viable solution for these complex injuries. We assessed clinico-radiologic outcome in our retrospective case series of extra-articular distal humerus fractures managed with these plates.

METHODS

Forty-five patients of extra-articular distal humerus fractures, who were operated at our level 1 trauma centre between January, 2012 and December, 2016, were identified. After exclusion, 36 patients were available for the final assessment. All patients were operated with the triceps-reflecting modified posterior approach. Regular clinico-radiologic follow-up was done evaluating elbow functionality, fracture union, secondary displacement, non-union, implant failure and any complications; Mayo Elbow Performance score (MEPS) was used for the final functional assessment.

RESULTS

Twenty-four (66.7%) male and 12 (33.3%) female patients constituted the study group, who had an average follow-up of 15 months. Preoperatively three patients and post-operatively one patient had radial nerve palsy; all had neurapraxia and recovered completely. Overall, 34 (94.4%) patients were adjudged to have complete radiological union within 3 months; 2 (5.5%) patients developed non-union. Mean flexion achieved was 122.9° ± 23°, and mean extension was -4.03° ± 6.5°; 1 patient with head injury developed flexion deformity of 45°. Average MEPS at the final follow-up was 90.8° ± 9.9°.

CONCLUSION

Stable reconstruction and early initiation of physiotherapy are utilitarian to envision optimal outcome; the use of precontoured extra-articular distal humerus locking plates has yielded satisfactory results with minimal complications in our hands.

Analysis of functional outcome of Hoffa fractures: A retrospective review of 32 patients

PURPOSE

Hoffa fractures are uncommon intra-articular fractures of femoral condyle in coronal plane. The purpose of our study is to assess radiologic and functional outcome in operatively treated Hoffa fractures.

METHODS

We retrospectively reviewed 32 patients of isolated Hoffa fracture from January 2010 to March 2015. All were treated with open reduction and internal fixation using lateral approach for lateral Hoffa and medial approach for medial Hoffa fracture. Cancellous screws in lag mode and/or antiglide plate were employed for fixation in accordance with fracture anatomy. All patients were subjected to aggressive physical therapy postoperatively. Knee Society Score (KSS), International Knee Documentation Committee Score (IKDC), and Knee range of motion (ROM) were documented at final follow-up for functional evaluation.

RESULTS

All fractures united by mean time of 11.56 ± 1.5 weeks. No evidence of subsequent displacement or fixation failure, arthritis, Avascular necrosis (AVN) of femoral condyle was elicited in any of the patients. Documented mean KSS and mean IKDC Score at final follow-up were 83.19 ± 8.43 and 81.62± 6.95, respectively. ROM at final follow-up was ranging from 0° to mean 116.41° ± 13.98°. Complications included stiffness of the involved knee in four patients, including one patient who developed infection and had to undergo implant removal after fracture union.

CONCLUSION

Operative treatment of Hoffa fractures yields fairly good functional outcome. One must endeavor to achieve adequate intraoperative exposure and stable congruous articular reconstruction. Early aggressive physical therapy is a harbinger of optimal outcome.

Posterior Dislocation of Subtalar Joint without Associated Fracture: A Case Report and Review of Literature

Posterior subtalar dislocation is an exceedingly rare entity. Clinically, the appearance of the foot can simulate a complex fracture dislocation. It is important to recognize that not all posterior subtalar dislocations are true posterior dislocations. We report a true posterior subtalar dislocation in a 34-year-old female, managed promptly with closed reduction and resulting in an excellent functional outcome. A chronic dislocation or an irreducible dislocation may need open reduction.

Functional Outcome of Resection versus Reconstruction in Mason II-III Radial Head Fractures; A Short-Term Prospective Study

Objective

To compare the short-term functional outcome between resection and reconstruction in Mason Type II and Type III radial head fractures using Broberg and Morrey score.

Methods

A prospective cohort study was conducted in the Department of Orthopedic Surgery of SMS Medical College and attached Hospitals. A total of 29 patients (15 in resection group, 14 in reconstruction group) between the age group of 20-60 years with Mason Type II and Type III fresh closed radial head fractures were included in the study. The functional outcome including the range of motion, extension lag and Broberg Morrey score were determined and compared between two groups.

Results

The mean age of resection group was 44.5 ± 6.6 years and mean age of reconstruction group was 37.1 ± 6.2 years. The baseline characteristics . At 12-months follow-up, in Mason type II fracture, radial head reconstruction group with mean extension lag of 9.4 ± 4.1 and mean Broberg Morrey score of 94.9 ± 5.1 showed better results compared to radial head resection group with mean extension lag of 15.7 ± 4.1 (p=0.022) and mean Broberg Morrey score 88.3 ± 5.1 (p=0.045) respectively. In Mason type III fractures, radial head resection with mean supination of 79.4 ± 4.7, mean pronation of 74.4 ± 4.1 and mean Broberg Morrey score of 89.8 ± 6 showed better results when compared with radial head reconstruction group with mean supination of 64.2 ± 4 (p<0.001), mean pronation of 59.2 ± 8.4 (p=0.003) and mean Broberg Morrey score of 81.9 ± 5 (p=0.031).

Conclusion

The procedure suggested in Mason type II, is reconstruction of radial head. In Mason type III due to difficulty in achieving anatomical reduction results were not good with reconstruction when compared with resection. We recommend radial head excision in Mason type III fractures where anatomical and stable fixation is not possible.

Functional Outcome of Resection versus Reconstruction in Mason II-III Radial Head Fractures; A Short-Term Prospective Study

Objective

To compare the short-term functional outcome between resection and reconstruction in Mason Type II and Type III radial head fractures using Broberg and Morrey score.

Methods

A prospective cohort study was conducted in the Department of Orthopedic Surgery of SMS Medical College and attached Hospitals. A total of 29 patients (15 in resection group, 14 in reconstruction group) between the age group of 20-60 years with Mason Type II and Type III fresh closed radial head fractures were included in the study. The functional outcome including the range of motion, extension lag and Broberg Morrey score were determined and compared between two groups.

Results

The mean age of resection group was 44.5 ± 6.6 years and mean age of reconstruction group was 37.1 ± 6.2 years. The baseline characteristics . At 12-months follow-up, in Mason type II fracture, radial head reconstruction group with mean extension lag of 9.4 ± 4.1 and mean Broberg Morrey score of 94.9 ± 5.1 showed better results compared to radial head resection group with mean extension lag of 15.7 ± 4.1 (p=0.022) and mean Broberg Morrey score 88.3 ± 5.1 (p=0.045) respectively. In Mason type III fractures, radial head resection with mean supination of 79.4 ± 4.7, mean pronation of 74.4 ± 4.1 and mean Broberg Morrey score of 89.8 ± 6 showed better results when compared with radial head reconstruction group with mean supination of 64.2 ± 4 (p<0.001), mean pronation of 59.2 ± 8.4 (p=0.003) and mean Broberg Morrey score of 81.9 ± 5 (p=0.031).

Conclusion

The procedure suggested in Mason type II, is reconstruction of radial head. In Mason type III due to difficulty in achieving anatomical reduction results were not good with reconstruction when compared with resection. We recommend radial head excision in Mason type III fractures where anatomical and stable fixation is not possible.

Negative pressure wound therapy versus gauze dressings for the treatment of contaminated traumatic wounds

OBJECTIVE

This compares hospital suction negative pressure wound therapy (NPWT) with conventional gauze dressings in traumatic soft-tissue injury at a tertiary care centre.

METHODS

A prospective control study was conducted between September 2012 and November 2014. Patients with one or more traumatic soft-tissue injuries with contaminated wounds were allocated to either a test group (received NPWT) or control group (received conventional gauze). Wounds were assessed by two orthopaedic surgeons. If grade A was achieved, the wound was covered with split-thickness skin graft, flap or delayed primary closure; otherwise, revision debridement and NPWT/saline gauze dressings were applied. Descriptive statistics (mean, standard deviation and proportions) were used to summarise the study variables. The 95% confidence intervals (CI) for difference of mean were used. Chi-square test and Fisher's exact test were used to observe an association between the qualitative data and outcome variables. Unpaired T-Test and Mann-Whitney U test were used for analysis of the quantitative data. A p<0.05 was considered statistically significant.

RESULTS

A total of 104 patients were included. The mean number of dressings per patient was significantly lower in the NPWT group (3.4) than in the control group (20.7) (p<0.001). The time between injury and complete closure (12.5 versus 21.4 days) as well as duration of hospital stay (17.3 versus 23.8 days) was significantly less in the NPWT group (p<0.05).

CONCLUSION

NPWT has a role in healing traumatic wounds and can be delivered effectively through hospital suction NPWT, which can also reduce the cost of therapy. We recommend its regular use in all patients presenting with post-traumatic, soft-tissue injuries when primary coverage is not possible.

The scope of upper limb surgery for tetraplegics: Role of tendon transfers and Universal Cuff

Objective

The aim of this study was to evaluate the role of tendon transfers and universal cuff in restoring hand function in tetraplegic patients.

Methods

Twenty-one upper limbs on 12 tetraplegic patients (9 males and 3 females); mean age: 42.2 years (range 22–58 years) with a spinal cord injury at or distal to C6, were included in this study. Key pinch was restored using Brachioradialis to Flexor Pollicis Longus transfer and hook using Pronator Teres to Flexor Digitorum Profundus transfer. The gains achieved were measured objectively at six months and at final follow up, the average follow up being 26 months. The functional outcome was assessed using the Modified Lamb and Chan score.

Results

Average value was 1.67 kg for key pinch and 2.58 kg for hook grip at final follow up. The Modified Lamb and Chan score revealed good to fair outcome in 75% of patients. Complications resulted from stretching of transfer and mal-tensioning and were salvaged by the use of a ‘Universal Cuff’.

Conclusion

Surgery should be routinely offered to tetraplegic patients with deficient hand function in whom no recovery is expected after six months following spinal cord injury. Universal Cuff is a good salvage method for patients who refuse re-surgery.

Level of evidence

Level IV, Therapeutic study.

Atraumatic Acute Compartment Syndrome of Forearm Following Artificial Mehndi (Henna) Dermatitis - A Rare Case Report

Atraumatic compartment syndrome of the forearm is a rare entity. There are several papers available in the literature on the adverse effects of mehndi application; however Acute Compartment Syndrome (ACS) following mehndi application has never been reported. We present the case of a 25-year-old female, who presented with sudden onset swelling and pain in the left forearm. The patient had applied mehndi all over her left palm and forearm just two days prior to presentation. The patient had stretch pain and other clinical features suggestive of compartment syndrome of forearm and was hence taken up for an emergency fasciotomy. The fasciotomy wound healed without skin grafting and the patient achieved near normal range of movement of the affected elbow, wrist and fingers.

Dynamic hip screw versus proximal femur locking compression plate in intertrochanteric femur fractures (AO 31A1 and 31A2): A prospective randomized study

INTRODUCTION

Intertrochanteric fractures are common in elderly population and pose a significant financial burden to the society. Anatomically contoured proximal femur locking compression plate (PFLCP) is the latest addition in the surgeons' armamentarium to deal with these fractures. It creates an angular stable construct, which will theoretically lessen the risk of failure by screw cut-out and varus collapse, the common mode of DHS failure. We compared DHS with PFLCP in AO type 31A1 and 31A2 intertrochanteric fractures.

MATERIALS AND METHODS

A randomized prospective study was carried out between June 2011 and June 2013. 26 cases each of DHS and PFLCP were included.

RESULTS

Functional and radiological outcome was similar in both groups.

CONCLUSION

Both DHS and PFLCP are good choices for stable intertrochanteric fractures, and both lead to excellent functional outcomes, but non-union might be more common with PFLCP.

Comparative study between staples and eight plate in the management of coronal plane deformities of the knee in skeletally immature children

PURPOSE

To compare two commonly used methods of temporary hemiepiphysiodesis (staples and figure of eight plate) in the management of coronal plane deformities of the knee in skeletally immature children.

METHODS

This prospective study was conducted between November 2012 and November 2015. A total of 40 patients with 67 affected knee joints, having at least 1 year of skeletal growth remaining, were included in the study. Angular correction was measured by recording the mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), and anatomical tibio-femoral angle (TFA) (for the overall alignment of lower limbs). Implant removal was done after 5° of overcorrection was achieved. The rate of correction (° per month) and complications related to each technique were recorded.

RESULTS

The most common diagnosis was idiopathic genu valgum. The overall rate of correction (TFA) was 1.2° for staples and 1.4° for eight plate (p = 0.70, not statistically significant). The correction in mLDFA was statistically better in the eight plate group, whereas an opposite trend was recorded in mMPTA. Implant-related complications were present in two cases of the staples group.

CONCLUSION

Although the overall correction rate was similar in both groups, implant-related complications were lower with figure of eight plate. In idiopathic genu valgum (the most common diagnosis), the correction was statistically better in the eight plate group. We recommend figure of eight plate over staples in managing these deformities.

Plantar fasciitis: A randomized comparative study of platelet rich plasma and low dose radiation in sportspersons

BACKGROUND

Plantar Fasciitis makes up about 15% of patients requiring professional care due to foot symptoms. The treatment methods are numerous with none proving to be clearly superior to others. We aimed to compare two common treatment methods in search of the best treatment.

METHOD

All consecutive sportspersons presenting to our OPD with clinical diagnosis of plantar fasciitis underwent treatment consisting of stretching exercises, activity modification, and NSAID's for 6 months. First 40 patients who did not respond to the treatment were divided randomly into two groups of 20 patients each, Group A (Platelet rich plasma - PRP) and Group B (low dose radiation - LDR). At the time of final follow-up (6 months) the mean improvement in the pain score (Visual-Analogue-Scale), American Orthopaedic Foot and Ankle Score (AOFAS) and Plantar fascia thickness on ultrasound were compared.

RESULT

Significant improvement in all 3 parameters was noted at the time of final follow up within both groups. When compared to each other, the difference in outcome of both these Groups on the given 3 parameters came out to be insignificant (p>0.05).

CONCLUSION

PRP is as good as LDR in patients with chronic recalcitrant plantar fasciitis not responding to physical therapy.

A rare combination of sagittal plane fracture of talar body with medial malleolus fracture: Case report and review of literature

Fractures of talus are relatively uncommon injuries with majority of them involving the neck region. Talar body fracture in sagittal plane in combination with medial malleolus fracture is very rare with few cases being reported in the literature earlier. We report such an unusual combination in an adolescent, which was treated with open reduction and internal fixation with screws for both talus and medial malleolus. This was followed by physiotherapy and non-weight bearing till the fracture united.

Intramedullary nailing versus proximal plating in the management of closed extra-articular proximal tibial fracture: a randomized controlled trial

BACKGROUND

Extra-articular proximal tibial fractures account for 5-11 % of all tibial shaft fractures. In recent years, closed reduction and minimally invasive plating and multidirectional locked intramedullary nailing have both become widely used treatment modalities for proximal and distal tibial metaphyseal fractures. This study was performed to compare plating and nailing options in proximal tibia extra-articular fractures.

MATERIALS AND METHODS

This randomized prospective clinical study was conducted on 58 skeletally mature patients with a closed extra-articular fracture of the proximal tibia treated with minimally invasive proximal tibial plating (PTP) or intramedullary nailing (IMN) by trained surgeons at a tertiary trauma center.

RESULTS

Postoperative hospital stay (p = 0.035), time to full weight-bearing, and union time (p = 0.004) were significantly less in the IMN group than in the PTP group, but there was no clear advantage of either technique in terms of operative time (p = 0.082), infection rate (p = 0.738), range of motion of the knee (p = 0.462), or degrees of malunion and nonunion.

CONCLUSION

Both implants have shown promising results in extra-articular proximal tibial fractures, and provide rigid fixation that prevents secondary fracture collapse.

LEVEL OF EVIDENCE

Level 2, randomized controlled trial.

The establishment rate of a sheep nematode: Revisiting classics using a meta-analysis of 87 experiments

Strongyle nematode establishment rate in their host is a highly variable life history trait, which makes it difficult to estimate. A meta-analysis was applied to the nematode Teladorsagia circumcincta of sheep in order to acquire a general framework of the factors modulating this life trait. A linear model was built with individual data on 540 infected lambs extracted from 13 articles. Lambs breed and age, time lag between last infection and the interaction between infection mode, infective dose and the number of repeated infective doses were significantly related with the establishment rate. The influence of infection mode on nematode establishment rate was also evaluated by comparing nematode establishment rate distributions within lamb populations infected under different conditions. Natural and repeated experimental infections lead to similar distribution of establishment rate. Conversely, these infection conditions resulted in different parasite establishment rates in average (12.7 and 23.4%, respectively). Three hypotheses are discussed to explain this result: immune protective response, host avoidance behaviour and parasite virulence.

Estimation of abomasum strongyle nematode infections in sheep at necropsy: Tentative proposals for a simplified technique

Several necropsy techniques are available for estimating the abundance of gastro-intestinal nematodes in abomasum of ruminants. Standardization of techniques is needed to allow accurate comparisons between laboratories. Here we propose a standardized technique for estimating the abundance of worms. We intend to compare the worms' number estimations in lambs and ewes based on contents and washings, to determine the uniformity of worm counts in aliquots, and to estimate the total worm number from washings. The digesta (or "contents") and the washings of the abomasum are treated separately. The worms of each subsample are diluted with water and the total number of worms is estimated on a small volume (aliquots) of these subsamples. The use of aliquots assumes that the worms are uniformly distributed in the whole volume of each subsample. We first confirmed that the use of aliquots is appropriate in most cases. We then show that the use of the washings alone allows a faster and a suitable estimation of the total worm burden for all strongyle species of the abomasum in both ewes and lambs. The evaluation of our necropsy procedure is a first step to a standardized technique which should be improved by validation in other laboratories.

The early drug selection of nematodes to anthelmintics: stochastic transmission and population in refuge

We have developed an individual-based model to reflect the complexity of the early phase of drug resistance selection in a nematode/sheep model. The infection process consists of the stochastic ingestion of infective larvae spatially aggregated in clumps. Each clump corresponds to infective larvae, which are the offspring of the mature nematodes from a given sheep. We studied the dynamics of the parasitic population and the frequency of the recessive resistance alleles during selection by anthelmintic treatments. The interaction between genetic and demographic processes illustrated the trade-off between the control of the infection and the delay of resistance selection. We confirmed the importance of the number of treatments and their timing. The same treatment frequency may result in different outcomes on resistance selection in relation to the size of the refuge (infective larvae on pasture). Treatment applied during the summer (when the mortality of infective larvae on pasture was high), may lead to a rapid selection of drug resistance and a lack of control of sheep and pasture contamination. We showed that higher stocking rates were also a force in promoting the resistance allele selection.

Estimation of methicillin-resistant Staphylococcus aureus transmission by considering colonization pressure at the time of hospital admission

Our objective was to evaluate the accuracy of a methicillin-resistant Staphylococcus aureus (MRSA) rate using the imported MRSA reservoir identified at the time of hospital admission. Two indicators were used: the number of imported MRSA patient-days/total number of patient-days [representing colonization pressure (CP) at the time of admission] and the incidence of hospital-acquired MRSA isolated from clinical samples expressed as density/100 patient-days for carriers identified at the time of admission [representing the incidence taking CP into account (ICP)]. The variations of these indicators were analysed and compared with two more common indicators: percentage of MRSA acquired in our hospital and the incidence of hospital-acquired MRSA isolated from clinical samples expressed as density/1000 patient-days within three four-month periods during 2002. Common indicators varied similarly, with marked decline during the third period; first-period CP was twice that of other periods (P<10(-6)) and the highest (>two-fold) ICP was seen in the summer (second) period (P<0.001) when the personnel/patient ratio was the lowest. Thus, comparison of different indicators within four-month periods underlines important differences between common and novel indicators. Despite several limitations, ICP should be helpful in the interpretation of MRSA surveillance data, particularly for estimating the extent of MRSA transmission.

[Consequences of replacing abacavir for indinavir in successful antiretroviral treatment of a patient with HIV infection]

INTRODUCTION

Simplification of combined antiretroviral therapy in HIV-infected patients is possible, but virological success can be compromised by the development or emergence of resistant viruses.

CASE

Worsening renal functioning in a patient under successful combination antiretroviral therapy resulted led to the replacement of indinavir by abacavir. Eight weeks later, his viral load rose and he developed a mutant virus resistant to all the nucleoside analogs.

DISCUSSION

Our case report illustrates the danger of streamlining combined antiretroviral therapy composed only of nucleoside analogs in patients already successfully treated with nucleoside analogs, by exposing them to the risk of the emergence of a mutant virus.

Modelling macroparasite aggregation using a nematode-sheep system: the Weibull distribution as an alternative to the Negative Binomial distribution?

Macroparasites are almost always aggregated across their host populations, hence the Negative Binomial Distribution (NBD) with its exponent parameter k is widely used for modelling, quantifying or analysing parasite distributions. However, many studies have pointed out some drawbacks in the use of the NBD, with respect to the sensitivity of k to the mean number of parasites per host or the under-representation of the heavily infected hosts in the estimate of k. In this study, we compare the fit of the NBD with 4 other widely used distributions on observed parasitic gastrointestinal nematode distributions in their sheep host populations (11 datasets). Distributions were fitted to observed data using maximum likelihood estimator and the best fits were selected using the Akaike's Information Criterion (AIC). A simulation study was also conducted in order to assess the possible bias in parameter estimations especially in the case of small sample sizes. We found that the NBD is seldom the best fit for gastrointestinal nematode distributions. The Weibull distribution was clearly more appropriate over a very wide range of degrees of aggregation, mainly because it was more flexible in fitting the heavily infected hosts. Moreover, the Weibull distribution estimates are less sensitive to sample size. Thus, when possible, we suggest to carefully check on observed data if the NBD is appropriate before conducting any further analysis on parasite distributions.

Impact of screening for MRSA carriers at hospital admission on risk-adjusted indicators according to the imported MRSA colonization pressure

We evaluated the impact of the different components of a screening programme of methicillin-resistant Staphylococcus aureus (MRSA) carriers at hospital admission on the value of two risk-adjusted rates: the proportion of imported MRSA and an indicator of the MRSA colonization pressure (ICP), and the incidence of MRSA acquired and detected in our hospital. Indicators were calculated: (1) with no screening programme; (2) with a programme limited to the intensive care unit (ICU); (3) with a programme extended to patients with risk factors for MRSA carriage hospitalized in non-ICU wards. The programme included an automatic alert. Systematic sampling of patients with risk factors hospitalized in non-ICU settings detected nearly 50% of carriers at admission. The proportion of MRSA imported into our hospital varied from 35.4% without any screening programme to 71.8% when all components of our screening programme were considered (P<10(-4)). The ICP varied from 3.1% (31/985) with the complete programme to 10.4% (31/297) without any screening programme (P<10(-6)). Screening patients with risk factors for MRSA carriage hospitalized in non-ICU wards resulted in a 51% increase of the calculated proportion of imported strains and a 58% decrease of the ICP. The two studied indicators were strongly dependent on the screening strategy for MRSA carriers implemented at admission. The screening strategy for patients admitted to non-ICU wards who have risk factors for MRSA carriage seems to be the determinant for the interpretation of certain risk-adjusted indicators of MRSA cross-transmission. Comparisons of these indicators must consider the setting in which the screening programmes are implemented.

Cardiovascular disease in patients with diabetes: clinical considerations

Cardiovascular disease is the major cause of morbidity and mortality in patients with diabetes. Diabetic individuals have a 200% to 400% greater risk for vascular disease than nondiabetics, with a disproportionately greater burden of disease complications in non-white minorities. Although the atherosclerotic plaques in the two groups are similar, diabetics have more severe and more diffuse disease than nondiabetics. Recent advances in the treatment of coronary disease have improved survival for diabetics and nondiabetics, but diabetics still have double the case fatality rate as nondiabetics, and diabetic women have particularly poor outcomes. Diabetic individuals also have an increased frequency of silent ischemia, systolic and diastolic left ventricular dysfunction, and cardiac autonomic neuropathy. The high frequency of modifiable risk factors provides great opportunities for prevention, the cornerstones of therapy being glycemic control, aggressive risk factor modification, and ongoing patient surveillance and monitoring to facilitate early disease detection and prompt intervention. In patients with coronary disease who require revascularization, both mechanical coronary interventions and bypass surgery are effective therapies. Patients with multivessel coronary disease have better results following bypass surgery with arterial grafts than following coronary interventions. However, diabetic patients are at increased risk for poor long-term outcome following either revascularization modality, with high rates of restenosis following mechanical interventions and the development of atherosclerosis in conduits following bypass surgery.

Spectroscopic studies on angiotensin I-converting enzyme

We used near and far UV spectrophotometry for the re-evaluation of the molar extinction coefficient at 280 nm (epsilon 280) of pulmonary angiotensin-converting enzyme (ACE), for the determination of its tryptophan and tyrosine contents and to follow-up guanidine denaturation. ACE purity was assessed by both SDS-PAGE and capillary electrophoresis performed in denaturing conditions. The maxima of the near UV spectrum of purified ACE, dissolved in phosphate buffer pH 6.5, was at 279 nm; with an estimated M(r) of 160 kD, epsilon 280 of native ACE was 1.5 +/- 0.05 x 10(5) (mol/l)-1 x cm-1. Denaturation of ACE by 6 mol/l guanidine hydrochloride produced a hypochromic effect of 23% at 280 nm and led to a blue shift of 3.5 nm. In guanidine solution, absorbance measurements at 288 and 280 nm predicted a ratio of 1 between tyrosine and tryptophan, whereas it was 1.8 with the measure of the amplitude of the spectral bands at 283 and 292 nm of the second derivative of the near UV spectrum. Unfolding of the peptide chain in 6 mol/l guanidine was also well characterized by the second derivative of the far UV spectrum, in parallel with the complete loss of enzymatic activity although the protein remained whole as judged on SDS-PAGE. We also re-evaluated ACE zinc content by atomic absorption spectroscopy and demonstrated that ACE molecule obviously contains two zinc atoms.

[Vascular effects of adenosine-triphosphate]

This study assessed the effects of adenosine triphosphate (ATP) on systemic vascular resistances during the hypothermic cardiopulmonary bypass phase of cardiac surgery. Twenty patients scheduled for cardiac surgery were randomly divided into an ATP group (n = 10), and a placebo group (n = 10). Anaesthesia was similar for all the patients (diazepam, fentanyl and pancuronium). During the heart arrest phase, and as soon as the arterial pressure, the level in the venous return reservoir, and the pump flow rate had all been in steady state for 5 min, ATP or placebo was injected into the venous line of the oxygenator. Injection speed was doubled every three minutes, twice. The following ATP doses were administered: 0.012, 0.025 and 0.05 mg.kg-1.min-1. The level in the venous return reservoir was kept constant. Mean arterial pressure (MAP) and pump flow rate (DP) were assessed every half minute. Systemic vascular resistances were calculated with the relationship MAP/DP. Changes in vascular capacitance were directly proportional to changes in DP as the heart had been excluded, and all the blood returned to the pump, the blood volume being kept constant. MAP and DP remained unchanged in the placebo group. In the opposite ATP induced a dose-related systemic vasodilation: MAP decreased from 82.8 +/- 12.5 mmHg (control) to 66.0 +/- 14.8 mmHg, 59.8 +/- 10.6 mmHg, and 49.0 +/- 4.7 mmHg with 0.012, 0.025 and 0.05 mg.kg-1.min-1 ATP respectively. The MAP returned to preinfusion control levels when the ATP infusion was discontinued (90.0 +/- 17.8 mmHg). The DP, and therefore venous return, did not change, neither during ATP infusion, nor after its discontinuation.(ABSTRACT TRUNCATED AT 250 WORDS)