Impact of Syndesmotic Screw Removal on Quality of Life, Mobility, and Daily Living Activities in Patients Post Distal Tibiofibular Diastasis Repair

Background and Objectives: While numerous studies have been conducted on syndesmotic screw management following distal tibiofibular diastasis repair, a clear consensus remains unclear. This research aims to evaluate whether the postoperative removal of syndesmotic screws leads to improved patient outcomes, specifically in quality of life, mobility, and daily living activities, and whether it offers a cost-effective solution. Materials and Methods: Patients with a history of unimalleolar or bimalleolar ankle fractures, classified according to the Danis-Weber and Lauge-Hansen systems, were included. Comprehensive evaluations were made via standardized questionnaires like the SF-36 Health Survey, HADS, and WHOQOL-BREF, distributed approximately 2 months post surgery. A total of 93 patients underwent syndesmotic screw removal while 51 retained the screws (conservative approach). Results: Patients who underwent screw removal reported superior satisfaction in mobility, with a score of 7.8, compared to 6.7 in the conservative approach (p = 0.018). Similarly, their ability to perform daily activities scored 8.1, higher than the 6.5 from the conservative cohort (p < 0.001). Pain levels were also more favorable in the screw removal group, with a score of 5.3 against 6.8 in the conservative group (p = 0.003). On the SF-36 physical domain, the screw removal group achieved a mean score of 55.9 versus 53.3 for the conservative group (p = 0.027). Notably, the HADS anxiety subscale highlighted reduced anxiety levels in the screw removal cohort with a mean score of 5.8 against 7.3 in the conservative group (p = 0.006). However, overall quality of life and recommendations to others showed no significant difference between the groups. Conclusions: Syndesmotic screw removal postoperatively leads to marked improvements in patients' mobility, daily activity abilities, and reduced postoperative pain and anxiety levels. However, overall quality of life was similar between the two approaches. The findings offer valuable insights for orthopedic decision making and patient-centered care concerning the management of syndesmotic screws after distal tibiofibular diastasis repair.

Theoretical and Computational Analysis of the Thermal Quasi-Geostrophic Model

This work involves theoretical and numerical analysis of the thermal quasi-geostrophic (TQG) model of submesoscale geophysical fluid dynamics (GFD). Physically, the TQG model involves thermal geostrophic balance, in which the Rossby number, the Froude number and the stratification parameter are all of the same asymptotic order. The main analytical contribution of this paper is to construct local-in-time unique strong solutions for the TQG model. For this, we show that solutions of its regularised version α -TQG converge to solutions of TQG as its smoothing parameter α → 0 and we obtain blow-up criteria for the α -TQG model. The main contribution of the computational analysis is to verify the rate of convergence of α -TQG solutions to TQG solutions as α → 0 , for example, simulations in appropriate GFD regimes.

Asymptotic behavior of the forecast-assimilation process with unstable dynamics

Extensive numerical evidence shows that the assimilation of observations has a stabilizing effect on unstable dynamics, in numerical weather prediction, and elsewhere. In this paper, we apply mathematically rigorous methods to show why this is so. Our stabilization results do not assume a full set of observations and we provide examples where it suffices to observe the model's unstable degrees of freedom.

Avoiding the Removal of Syndesmotic Screws after Distal Tibiofibular Diastasis Repair: A Benefit or a Drawback?

There is still no general agreement about the most effective form of syndesmosis fixation with syndesmotic screws for patients affected by ankle fractures that are accompanied by syndesmotic injuries. In the same manner, no consensus has been reached yet on whether or not the tibiofibular syndesmotic screw is more beneficial if removed or not, as well as the exact timing of removal if this proves superiority. The purpose of this research was to verify whether or not removing syndesmotic screws reduces the risk of developing a diastasis and compare outcomes in patients whose syndesmotic screw was or was not removed at all. A retrospective observational study was carried out to cover a period of five years and a computed sample size of almost 300 cases. Patients were included in the current study if their history was positive for ankle fracture with distal tibiofibular diastasis repair with syndesmotic screws. Loss of reduction was more frequent after screw removal (8.5% vs. 2.1%), although the quality of reduction was generally excellent in both groups. The mean AOFAS score was significantly better in patients who had their tibiofibular screw removed (92.6 vs. 88.4), but the tibiofibular clear space and incisura fibularis depth widened more following the second intervention (3.8 mm vs. 3.6 mm, and, respectively, 4.3 vs. 4.1). Lastly, the same patients with tibiofibular screw removal had a significantly higher cost of total interventions and more days of medical leave (21 vs. 15 days on average). It seems that a strong conclusion in favor of removing or not removing syndesmotic screws after distal tibiofibular diastasis repair cannot be given. However, several radiographic findings lean toward the benefit of those patients whose tibiofibular screws were not removed, although mobility was notably better after the screw was removed. Furthermore, treatment expenses are greatly lowered if a subsequent operation for screw removal is avoided, as well as if individuals who have a single surgery take a shorter medical leave.

Novel Parathyroid Hormone-Based Bone Graft, KUR-113, in Treatment of Acute Open Tibial Shaft Fracture: A Phase-2 Randomized Controlled Trial

BACKGROUND

Treatment of an open tibial shaft fracture (TSF) is complex, and many cases are associated with delayed bone union or malunion. Parathyroid hormone (PTH) plays a key role in bone metabolism. A peptide fragment of PTH (PTH1-34) has been shown to promote bone healing. The objective of this study was to evaluate the safety and efficacy of a novel PTH-based bone graft (KUR-113) in the treatment of subjects with an open TSF.

METHODS

The study was a randomized, controlled, open-label (dose-blinded), dose-finding study of 200 subjects who had an open TSF secondary to trauma. Subjects were randomized into 1 of 4 groups to receive the standard of care (SoC) alone (control) or the SoC plus a single application of 4 mL of KUR-113 containing TGplPTH1-34 in fibrin at a concentration of 0.133 mg/mL (KUR-113-low), 0.4 mg/mL (KUR-113-mid), or 1.0 mg/mL (KUR-113-high). KUR-113 was administered at the fracture site after internal fracture fixation and before wound closure. Subjects were followed for up to 12 months after treatment. The primary outcome measure was fracture healing at 6 months assessed by the study investigator using radiographic and clinical measures. The primary end point was the proportion of subjects with fracture healing at 6 months.

RESULTS

A total of 200 subjects were enrolled and randomized to 1 of the 4 treatments. The primary end point was met in the KUR-113-mid group, which showed a significantly higher prevalence of healing at 6 months than the control group (37 of 46; 80.4% versus 31 of 48; 64.6%). By 12 months, healing had occurred in the majority of subjects in all treatment groups, with the control group requiring more surgical interventions to achieve fracture healing. Adverse events occurred at similar frequencies between the KUR-113 groups and the SoC group. No ectopic bone formation or abnormal bone resorption at the fracture site was observed in any of the treatment groups.

CONCLUSIONS

KUR-113 has the potential to be a good adjunctive therapy in the treatment of open TSFs.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Well-posedness for a stochastic 2D Euler equation with transport noise

We prove the existence of a unique global strong solution for a stochastic two-dimensional Euler vorticity equation for incompressible flows with noise of transport type. In particular, we show that the initial smoothness of the solution is preserved. The arguments are based on approximating the solution of the Euler equation with a family of viscous solutions which is proved to be relatively compact using a tightness criterion by Kurtz.

Semi-martingale driven variational principles

Spearheaded by the recent efforts to derive stochastic geophysical fluid dynamics models, we present a general framework for introducing stochasticity into variational principles through the concept of a semi-martingale driven variational principle and constraining the component variables to be compatible with the driving semi-martingale. Within this framework and the corresponding choice of constraints, the Euler–Poincaré equation can be easily deduced. We show that the deterministic theory is a special case of this class of stochastic variational principles. Moreover, this is a natural framework that enables us to correctly characterize the pressure term in incompressible stochastic fluid models. Other general constraints can also be incorporated as long as they are compatible with the driving semi-martingale.

Association between PNPLA3[G]/I148M variant, steatosis and fibrosis stage in hepatitis C virus - genetic matters

There is an established correlation between the PNPLA3 rs738409 C > G single nucleotide polymorphism (SNP) and hepatic steatosis and fibrosis in hepatitis C virus (HCV) infected patients. However not all data is convergent regarding the exact impact of this SNP on the pattern of disease progression in different clinical settings. In this study, we aimed to further bridge the knowledge gap on this topic by investigating the role of the G allele in promoting steatosis, fibrosis and disease progression in relation to other metabolic and anthropometric host factors. Two hundred and fifty consecutive patients, previously diagnosed with chronic hepatitis C (CHC) underwent liver biopsy. Histology was assessed using the Metavir scoring system. Transient elastography was used for follow-up. Ninety-eight patients were genotyped for PNPLA3 rs738409 and followed up for fibrosis progression. PNPLA3 rs738409[G] allele was significantly correlated with severe steatosis (P = 0.04), severe fibrosis at the time of enrollment (P = 0.0005) and fibrosis progression with an OR of 10.31 (95% CI 1.06 - 99.59, P = 0.04), after a mean follow-up time of 62.85 (95%CI: 52.21 - 76.15) months. Severe steatosis at the time of enrollment had an OR of 11.02 (95% CI 1.48 - 82.09, P = 0.01) for the association with fibrosis progression. The HOMA-IR index was also positively correlated with severe fibrosis (P = 0.03) and fibrosis progression on univariate analysis (P = 0.02). PNPLA3 rs738409[G] allele is a reliable predictor for steatosis and fibrosis in CHC. The presence of G allele, along with severe steatosis and insulin resistance are significant predictors for fibrosis progression.

Pointwise gradient bounds for degenerate semigroups (of UFG type)

In this paper, we consider diffusion semigroups generated by second-order differential operators of degenerate type. The operators that we consider do not , in general, satisfy the Hörmander condition and are not hypoelliptic. In particular, instead of working under the Hörmander paradigm, we consider the so-called UFG (uniformly finitely generated) condition, introduced by Kusuoka and Strook in the 1980s. The UFG condition is weaker than the uniform Hörmander condition, the smoothing effect taking place only in certain directions (rather than in every direction, as it is the case when the Hörmander condition is assumed). Under the UFG condition, Kusuoka and Strook deduced sharp small time asymptotic bounds for the derivatives of the semigroup in the directions where smoothing occurs. In this paper, we study the large time asymptotics for the gradients of the diffusion semigroup in the same set of directions and under the same UFG condition. In particular, we identify conditions under which the derivatives of the diffusion semigroup in the smoothing directions decay exponentially in time. This paper constitutes, therefore, a stepping stone in the analysis of the long-time behaviour of diffusions which do not satisfy the Hörmander condition.

Uniform approximations of discrete-time filters

Throughout recent years, various sequential Monte Carlo methods, i.e. particle filters, have been widely applied to various applications involving the evaluation of the generally intractable stochastic discrete-time filter. Although convergence results exist for finite-time intervals, a stronger form of convergence, namely, uniform convergence, is required for bounding the error on an infinite-time interval. In this paper we prove easily verifiable conditions for the filter applications that are sufficient for the uniform convergence of certain particle filters. Essentially, the conditions require the observations to be accurate enough. No mixing or ergodicity conditions are imposed on the signal process.

The stochastic filtering problem: a brief historical account

Onwards from the mid-twentieth century, the stochastic filtering problem has caught the attention of thousands of mathematicians, engineers, statisticians, and computer scientists. Its applications span the whole spectrum of human endeavour, including satellite tracking, credit risk estimation, human genome analysis, and speech recognition. Stochastic filtering has engendered a surprising number of mathematical techniques for its treatment and has played an important role in the development of new research areas, including stochastic partial differential equations, stochastic geometry, rough paths theory, and Malliavin calculus. It also spearheaded research in areas of classical mathematics, such as Lie algebras, control theory, and information theory. The aim of this paper is to give a brief historical account of the subject concentrating on the continuous-time framework.

Occult fractures of the proximal femur: imaging diagnosis and management of 82 cases in a regional trauma center

BACKGROUND

Occult hip fractures are often difficult to identify in busy trauma units. We aimed to present our institutions experience in the diagnosis and treatment of occult fractures around the hip and to help define a clinical and radiological management algorithm.

METHOD

We conducted a seven-year retrospective hospital medical record analysis. The electronic database was searched for ICD-10 CM codes S72.0 and S72.1 used for proximal femoral fractures upon patient discharge. We identified 34 (4.83 %) femoral neck fractures and 48 (4.42 %) trochanteric fractures labeled as occult.

RESULTS

The majority of the cases were diagnosed by primary MRI scan (57.4 %) and 12 were diagnosed by emergency CT scan (14.6 %). For the remaining cases the final diagnosis was confirmed by 72 h CT scan in 9 patients (representing 39 % of the false negative cases) or by MRI in the rest of 14 patients. MRI was best at detecting incomplete pertrochanteric fracture patterns (13.45 % of total) and incomplete fractures of the greater trochanter (3.65 % of total) respectively. It also detected the majority of Garden I femoral neck fractures (20.7 % of total). CT scanning accurately detected 100 % of Garden 2 fractures (2.44 %) and 25 % (3.65 %) of the complete pertrochanteric fractures (false negative 25 %).

CONCLUSION

Occult fractures should be suspected in all patients with traumatic onset of hip pain that is inconsistent with normal radiographic findings. MRI is the golden standard but not as readily available not as cheap and not quite as quick to perform as as a CT scan. The latter which in turn can provide falsely negative results in the first 24 h. Improved imaging protocols could expedite management and improve treatment.

Combined bilateral femoral head necrosis and pertrochanteric fracture: a case report

INTRODUCTION

Modular femoral implants have become a regular feature of revision hip surgery. However, for a primary hip arthroplasty, such as a femoral neck fracture case, the implant of choice is a standard femoral component, while compelling literature evidence have made osteosynthesis the standard procedure for the vast majority of trochanteric fractures.

CASE PRESENTATION

We present the case of a 66-year-old Caucasian woman presenting with two trochanteric fractures associated with primary and secondary hip osteoarthritis that were treated with an uncemented total hip replacement with a modular femoral component.

CONCLUSIONS

We found that a modular femoral component can address the issues of stability and, in our case, proved to be a viable solution for treating cases that are complicated by concomitant acetabular or femoral head and neck pathology.

A Kusuoka–Lyons–Victoir particle filter

The aim of this paper is to introduce a new numerical algorithm for solving the continuous time nonlinear filtering problem. In particular, we present a particle filter that combines the Kusuoka–Lyons–Victoir (KLV) cubature method on Wiener space to approximate the law of the signal with a minimal variance ‘thinning’ method, called the tree-based branching algorithm (TBBA) to keep the size of the cubature tree constant in time. The novelty of our approach resides in the adaptation of the TBBA algorithm to simultaneously control the computational effort and incorporate the observation data into the system. We provide the rate of convergence of the approximating particle filter in terms of the computational effort (number of particles) and the discretization grid mesh. Finally, we test the performance of the new algorithm on a benchmark problem (the Beneš filter).

A novel pathophysiological-based panel of biomarkers for the diagnosis of nonalcoholic steatohepatitis

Non-invasive biochemical markers are useful to distinguish between nonalcoholic steatohepatitis (NASH) and simple steatosis. The aim of this study was to test the diagnostic value of a panel of biomarkers derived from the pathophysiological events involved in the development of NASH. A total of 79 patients: 20 not-NASH and 59 NASH were included in the study. Definitive NASH was defined according to Kleiner's classification. In all subjects, parameters of the metabolic syndrome, insulin resistance (HOMA-IR), adiponectin, interleukin-6 (IL-6) and total cytokeratin-18 (M65 antigen) were determined. Univariate and multivariate analysis were used to identify independent predictors of NASH. In multivariate analysis three markers were independently predictors of NASH: adiponectin, IL-6 and M65 levels. In decreasing order, the independent predictors of NASH (NAS≥5) were M65 with an AUROC of 0.791, IL-6 with an AUROC of 0.727 and adiponectin with an AUROC of 0.709. The combination of two biomarkers yelded an AUROC of 0.828 for M65 and IL-6, 0.841 for adiponectin and M65 and 0.852 for adiponectin and IL-6. The best value was obtained by triple combination: adiponectin, M65 and IL-6 with and AUROC of 0.903, Sp=85.7% (PPV=94.2%) and Se=84.5% (NPV=66.7%). In conclusion, a novel pathophysiological - based panel of biomarkers combining total CK-18, IL-6 and adiponectin may be useful to predict NASH.

Hepatosplenic gamma/delta T-cell lymphoma in immunocompromised patients. Report of two cases and review of literature

We describe 2 male patients in whom hepatosplenic gamma/delta T-cell lymphoma (HSTL) developed 6 and 10 years after renal transplantation. The onset was abrupt with systemic symptoms, cytopenia, and hepatosplenomegaly. The histologic examination of the spleen (case 1), liver, and bone marrow revealed sinusoidal infiltrates of markedly abnormal lymphocytes. The neoplastic cells in these cases were CD2+, CD3+, CD4-, CD5-, CD7+, CD8+, CD16+, CD56+, beta F1-negative, and TIA-1-negative. Both cases displayed clonal rearrangement of the T-cell receptor (TCR) delta gene and the TCR beta gene. The spleen in case 1 was positive for Epstein-Barr virus genome and showed TCR-gamma gene rearrangement by polymerase chain reaction. Isochromosome 7 [i(7)(q10)] was found in each case. Both patients died within 4 months of diagnosis. HSTL has been reported in only 5 renal transplant recipients. HSTL may be relatively more frequent in immunocompromised patients compared with the general population.