Identification of novel inhibitor phytoconstituents for Influenza A H3N2: an in silico approach

Influenza A virus subtype H3N2 is a highly infectious respiratory virus that is responsible for global seasonal flu epidemics. The current study was designed to investigate the antiviral activity of 150 phytocompounds of North Western Himalayas medicinal plants by molecular docking. Two target proteins of hemagglutinin of influenza virus A (PDB ID 4WE8) and Influenza virus H3N2 nucleoprotein - R416A mutant (PDB ID 7NT8) are selected for this study. Molecular docking was done by AutoDock vina tool, toxicity and drug-likeness prediction was done by protox II and Moleinspiration. MD simulation of best protein-ligand complexes was done by using Gromacs, version 2021.5. Molecular docking and toxicity data revealed that clicoemodin and rumexocide showed the best binding with both target proteins 4WEB & 7NT8. Clicoemodin showed the -7.5 KJ/mol binding energy with 4WE8 and 7NT8. Similarly, rumexoside showed the -7.6 KJ/mol binding energy with 4WE8 and -7.6 KJ/mol with 7NT8. Furthermore, Molecular dynamic simulation and MMPBSA binding free energy validated the stability of protein-ligand complexes. The current study suggested that clicoemodin and rumexocide are the promising inhibitors of H3N2 proteins hemagglutinin of influenza virus A and Influenza virus H3N2 nucleoprotein - R416A mutant, though there is further in vitro and in vivo validation is required.Communicated by Ramaswamy H. Sarma.

Comparison of "ligamentization" process between preserved insertion hamstring tendon autograft and bone-patellar tendon-bone autograft

BACKGROUND

Ligamentization is a complex process and effect of preservation of hamstring tendon graft insertion on this process is not well studied. Present study was conducted to analyze and compare the ligamentization of semitendinosus gracilis graft with preserved tibial insertion (STGPI) and bone-patellar tendon-bone (BPTB) autografts.

METHODS

A total of 50 sportspeople who underwent ACL reconstruction using either BPTB (group A; n = 25) or STGPI (group B; n = 25) autografts were included in the study. Contrast enhanced MRI was done at 8 months and 14 months post-ACL reconstruction to evaluate the ligamentization using Signal noise quotient (SNQ), graft intensity and enhancement index. Clinical outcomes (Lysholm score) and knee laxity were also assessed at 8 months and 14 months.

RESULTS

18/23 (78%) patients in group A and 14/23 (61%) patients in group B had hyperintense graft signal at 8 months (n.s.) and at 14 months, 1/23 patients in group A and none of the patients in group B had hyperintense graft. SNQ at 8 months was 3.6 ± 2 and 3.7 ± 2 in group A and B respectively (n.s.) and at 14 months, SNQ was 2.5 ± 1.5 in group A and 2.4 ± 1.3 in group B (n.s.). Enhancement index at 8 months was 1.5 ± 0.3 and 1.2 ± 0.3 in group A and B respectively (p = 0.0001). Enhancement index at 14 months was 1.21 ± 0.2 in group A and 1.07 ± 0.2 in group B (p = 0.003). Functional outcomes and knee laxity were comparable in both the groups at 8 and 14 months (n.s.).

CONCLUSION

Both the grafts i.e. BPTB and STGPI are similar in terms of rate and extent of ligamentization. Clinical outcomes and knee laxity are also comparable between two grafts.

A comprehensive insight on the challenges for COVID-19 vaccine: A lesson learnt from other viral vaccines

The aim of this study is to comprehensively analyze previous viral vaccine programs and identify potential challenges and effective measures for the COVID-19 vaccine program. Previous viral vaccine programs, such as those for HIV, Zika, Influenza, Ebola, Dengue, SARS, and MERS, were evaluated. Paramount challenges were identified, including quasi-species, cross-reactivity, duration of immunity, revaccination, mutation, immunosenescence, and adverse events related to viral vaccines. Although a large population has been vaccinated, mutations in SARS-CoV-2 and adverse events related to vaccines pose significant challenges. Previous vaccine programs have taught us that predicting the final outcome of the current vaccine program for COVID-19 cannot be determined at a given state. Long-term follow-up studies are essential. Validated preclinical studies, long-term follow-up studies, alternative therapeutic approaches, and alternative vaccines are necessary.

High Prevalence of Vitamin D Deficiency among North Indian Athletes

Background

Vitamin D deficiency is high in athletes and has an impact on athletes' performance.

Introduction

Assessment of serum Vitamin D levels in healthy North Indian sportspersons and its correlation with serum parathyroid hormone (PTH) levels and bone mineral density (BMD).

Materials and Methods

Three-hundred and sixty-nine healthy athletes' aged 18-45 years were enrolled. Depending upon Vitamin D levels athletes were categorized into three groups: deficient (<20 ng/ml), insufficient (20-30 ng/ml), and sufficient (>30 ng/ml). BMD and serum PTH levels were assessed in all athletes and correlation was seen with Vitamin D levels.

Results

Two-hundred and fifty-eight (69.9%) athletes were Vitamin D deficient, 51/369 (13.8%) were Vitamin D insufficient, and 60/369 (16.3%) athletes were Vitamin D sufficient. There was a direct correlation between low serum Vitamin D levels and low BMD (r = 0.473; P < 0.05). Overall, 114/369 (30%) athletes had low BMD and out of these 114 athletes, 108 (95%) were Vitamin D deficient. Serum PTH levels were found to have inverse relations with both Vitamin D (r= -0.629) and BMD (r=-0.267).

Conclusions

Vitamin D deficiency is highly prevalent among the North Indian athletes and the presence of low Vitamin D (<20 ng/ml) levels is associated with low BMD and high PTH levels.

Strong association of meniscus tears with complete Anterior Cruciate Ligament (ACL) injuries relative to partial ACL injuries

BACKGROUND

Anterior Cruciate Ligament (ACL) injuries are often associated with meniscus tears. These meniscus tears in long term may affect the functional outcomes after ACL reconstruction. The present study aims to identify the incidence and relative association of meniscus injuries in complete and partial ACL injuries.

METHODS

This was a retrospective study. Patients were divided into 2 groups; group I: partial ACL tear and group 2: complete ACL tear. Both groups were assessed for meniscal tears; either isolated medial/lateral or combined and odds ratio was measured between two groups.

RESULTS

A total of 43 and 219 patients were enrolled in group I and II respectively. The mean age (years) in group I and II were 25.32 ± 7.12 and 28.64 ± 10.84 respectively. There were a total of 5 and 28 females in group I and II respectively. Mean pre-injury Tegner score in group I and II was 7.02 ± 2.87 and 6.82 ± 3.14 respectively. Mean time from injury to surgery (months) in group I and II was 8.04 ± 6.43 and 7.62 ± 4.83 respectively. In group 1 There were a total of 6 with lateral meniscus tears, 9 with medial meniscus tears And 3 with combined meniscal tears in group 1 while in group 2, 47 had lateral meniscal tears, 71 had medial meniscal tears and 71 had combined tears. Group II patients had stronger association for isolated meniscal tears compared to group I, with an odds ratio of 5.05(p < 0.05). Combined meniscal tears had non-significant relation in two groups (p = 0.58).

CONCLUSION

Partial ACL injuries present with less risk of acquiring isolated meniscus tears, compared to complete ACL injuries.

Concepts in wound irrigation of open fractures: 'Where we came from, and where are we now?

Wound irrigation is described as the flow of a solution through an exposed fracture surface to reduce the microbial colonization, to remove apparent foreign particles and wound exudates. . While recent literature and various in-vitro and in-vivo trials have cleared some clouds of doubt from the mind, it still remains a topic of debate. Normal saline remains the standard irrigation solution as it is non tissue toxic and has the same tonicity as body fluids. The quantity and duration of washing though is not standardized and is the surgeon's choice. This adds to the dilemma in the minds of the surgeon, with the timing of the debridement and the duration of wound irrigation depending on the surgeon's discretion. Future studies should aim to regulate the duration of the wound irrigation besides guiding about the ideal fluid volume to be used for the irrigation. Further, secondary end-points like the duration of hospital stay, rate of infections and use of hospital resources, should be computed to know about the adequacy of the wound debridement and irrigation. Antimicrobial solutions can kill microorganisms in the wound but are toxic to the host tissues as well, which limits their use. In addition, pulsatile (high pressure) lavage has not been seen to increase overall effectiveness. Recent research trials have found cumulative use of innovative solutions like phenols and EDTA along with enzymes to be encouraging though large randomized controlled trials are lacking.

Comparison of Bone-Patellar Tendon-Bone Graft, Semitendinosus-Gracilis Graft and Semitendinosus-Gracilis with Preserved Tibial Insertion Graft in Anterior Cruciate Ligament Reconstruction in Sports Persons

Introduction

Bone-patellar tendon-bone (BPTB) and semitendinosus-gracilis (STG) are the commonest grafts used for ACL reconstruction. However even after having been debated for years, there is no consensus about the ideal graft. Moreover, the literature is deficient about STG graft with preserved tibial insertion (STGPI) which preserves the proprioception. Our aim is to compare the outcome of BPTB, free STG and STGPI grafts after ACL reconstruction in professional sports persons. We compared the outcome in terms of mechanical stability, functional outcome, return to sports activity and degenerative changes.

Material and Methods

Professional sports persons aged between 16-50 years operated for ACL tear using BPTB, free STG and STGPI grafts with minimum follow-up of two years were identified from hospital records. Patients with associated knee injuries were excluded. Patients, divided in three groups according to graft used, were compared in terms of mechanical stability (arthrometric examination KT-1000 score), functional outcome (Lysholm Score), return to sports activity (Tegner score and difference in thigh circumference) and degenerative changes (KL grading).

Results

BPTB graft group was found to be better than free STG and STGPI graft groups in terms of KT-1000 score. There was no statistically significant difference among the groups in terms of Lysholm score, Tegner score, difference in thigh circumference and KL grading.

Conclusion

BPTB graft is better than free STG and STGPI grafts in terms of knee stability. When compared for patient reported outcome, return to sports activity, osteoarthritic changes and graft failure there is no significant difference among the three types of grafts.

There is an Association of Synovial Interleukin-6 Levels With Chondral Damage in Anterior Cruciate Ligament-Deficient Knees

Background: Osteoarthritis (OA) in the anterior cruciate ligament (ACL)-deficient knee is seen in approximately 50% of affected patients. Possible causes include biochemical or biomechanical changes. Purpose: We sought to study the correlation between inflammatory cytokines and chondral damage in ACL-deficient knees. Methods: Seventy-six male patients who underwent ACL reconstruction were enrolled in a cross-sectional study. Synovial fluid was aspirated before surgery and analyzed for levels of the inflammatory cytokines tumor necrosis factor-α, interleukin-1 (IL-1), and interleukin-6 (IL-6). At the time of ACL reconstruction, the severity of chondral damage was documented as described by the Outerbridge classification. Results: Patients with grade 2 or higher chondral damage were observed to have elevated IL-6 levels when compared to patients who had no chondral damage. Interleukin-6 levels had no correlation with the duration of injury. Conclusion: Elevated levels of IL-6 in synovial fluid were associated with chondral damage in ACL-deficient knees. Further study is warranted to determine whether inflammatory cytokines contribute to the development of OA of the knee after ACL injury.

Unusual Combination of Hip Dislocation with Ipsilateral Femoral Neck and Acetabulum Fracture: A Rare Case Report

Introduction:

Traumatic dislocation of hip associated with ipsilateral femur neck and acetabulum fracture is a rare and devastating injury as a result of high-energy trauma, with potential complications of femur head aseptic necrosis and hip joint degenerative arthritis. Patients, postoperatively, may encounter decreased functional outcomes and serious challenge, during activities of daily living. Management guidelines lack clarity, with possible options including fracture fragments fixation or hip joint replacement.

Case Report:

A 45-year-old patient was diagnosed with posterior dislocation of hip with ipsilateral femur neck and acetabulum fracture. Plan for emergent hip reduction and primary surgical fixation of fracture fragments was made. Intraoperatively, posterior wall acetabulum fracture was found to be excessively comminuted and non-amenable for fixation and femoral head was found to be avascularized. Subsequently, plan was changed to total hip replacement with acetabular defect reconstruction. At 1-year follow-up, no aseptic loosening was observed on radiographic views of pelvis, with total Harris Hip Score of 91.

Conclusion:

Early operative management for such complex injuries is a necessity. Definitive management in the form of primary fracture fixation/arthroplasty should be decided intraoperatively.

An unusual case of both bones forearm shaft fracture with ipsilateral distal radio-ulnar joint disruption

Objective: Distal radioulnar joint (DRUJ) subluxation with associated both bones forearm fracture is a rare clinical entity and is easily missed, leading to significant functional limitations. Case Presentation: A 28-year-old male fell on the outstretched hand and suffered left side both bones forearm shaft fracture with ipsilateral DRUJ disruption. Operative intervention in the form of plating was done for both bones forearm shaft fracture and DRUJ was stabilised with one k wire and above elbow plaster splint in full supination was given for 6 weeks. At one-year follow-up, fracture was united and Disabilities of the Arm, Shoulder and Hand (DASH) score was 11.7, and he was well satisfied. Conclusion: DRUJ disruption should be carefully evaluated in all the patients with associated shaft fractures of radius and ulna. Timely diagnosis and optimal intervention may prevent any functional limitations.

Femoral tunnel length has no correlation with graft rupture: A retrospective cohort study

BACKGROUND

Literature is controversial on femoral tunnel length as a risk factor for graft injury if the graft length in the tunnel is kept constant at ≥15 mm.

METHODS

A total of 1079 sportspersons, meeting our inclusion criteria, were assessed for graft rupture. Patients with femoral tunnel length (FTL) ≤30 mm were labeled as Group 1, while those with FTL > 30 mm were labeled as Group 2. Both groups were compared for potential risk factors for graft injury keeping graft length in the tunnel at ≥15 mm and statistical analysis was performed to study whether the femoral tunnel length acted as an additional risk factor.

RESULTS

Of 1079 sportspersons, 37 suffered from graft rupture. Patients with FTL > 30 mm were included in Group 1(n = 22) and patients with FTL ≤ 30 mm (n = 15) were included in Group 2. Both groups were comparable for risk factors for ACL injury: age (P = 0.37), gender (P = 0.53), mode of re-injury (P = 0.38), graft diameter (P = 0.71), level of sports activity (P = not significant), duration from injury to index surgery (P = 0.74), duration from index surgery to re-injury (P = 0.52), timing of return to sports after index surgery (P = 0.30), duration of sporting activity before second injury (P = 0.31), Tegner's level (P = not siginificant), Notch width index (P = 0.12) posterior slope (P = 0.77) and height (P = 0.41).

CONCLUSION

Because the graft length in the tunnel was kept at optimum and the risk factors for ACL injury were comparable in both groups at a follow up period, we suggest that femoral tunnel length is not a risk factor for graft failure.

Vitamin D deficiency in athletes and its impact on outcome of Anterior Cruciate Ligament surgery

BACKGROUND

Vitamin D deficiency is a worldwide pandemic problem. With vitamin D having some role in exercise-induced inflammation, skeletal muscle mass and endurance, we studied its effect on functional outcome of athletes' post-Anterior Cruciate Ligament (ACL) reconstruction.

METHODS

A total of 153 patients who underwent primary ACL reconstruction were enrolled in the study. All patients were screened for vitamin D levels preoperatively. Patients were divided into 3 groups on basis of vitamin D levels; Group 1 patients had < 20 ng/ml, group 2 patients 20-30 ng/ml and group 3 > 30 ng/ml. All patients were followed up for a minimum of 2 years.

RESULTS

A total of 153 patients were enrolled in study. The average age of the patients was 24.12 ± 2.12 years in group 1, 25.24 ± 3.20 years in group 2 and 24.74 ± 2.86 in group 3. The mean follow-up of patients was 2.8 ± 1.2 years. At 2 years, the mean Lysholm score was 96.12, 96.49 and 97.0, respectively (p = 0.75); mean WOMAC score was 3.33, 3.38 and 3.20, respectively (p = 0.91); mean difference between the pre-injury and post-surgery Tegner level of sports activity at 2 years follow-up was 0.78, 0.78 and 0.85, respectively (P = 0.51) and graft failure rate was 5.88%, 1.96% and 1.96%, respectively (p = 0.43).

CONCLUSION

Vitamin D has no effect on functional outcome and graft rupture rates in patients' post-primary ACL reconstruction.

LEVEL OF EVIDENCE

Prospective Cohort Study (Level III).

Predictors for Anterior Cruciate Ligament (ACL) Re-injury after Successful Primary ACL Reconstruction (ACLR)

Introduction:

Few authors have addressed risk factors related to an ipsilateral graft rupture and contralateral anterior cruciate ligament (ACL) injury after return to sports (RTS) following primary ACL reconstruction.

Material and Methods:

Patients with ACL re-injury to either knee after successful primary ACLR were included in Group I and those with no further re-injury were included in Group II. Variables including age, gender, side, body mass index (BMI), thigh atrophy, anterior knee laxity difference between both knees measured by KT-1000 arthrometer, mean time of return to sports (RTS), graft type, type of game, mode of injury, Tegner Activity Score, hormone levels, femoral tunnel length (FTL), posterior tibial slope (PTS) and notch width index (NWI) were studied. Binary logistic regression was used to measure the relative association.

Results:

A total of 128 athletes were included with 64 in each group. Mean age in Group I and II were 24.90 and 26.47 years respectively. Mean follow-up of Group I and Group II were 24.5 and 20.11 months respectively. Significant correlation was present between ACL re-injury and following risk factors; PTS of >10º, KT difference of >3.0mm, thigh atrophy of >2.50cm and time to RTS <9.50 months P value <0.05). No correlation was found with age, sex, BMI, type of game, Tegner Activity Score, mode of injury, NWI, size of graft, FTL and hormone levels.

Conclusion:

Possible risk factors include PTS of ≥ 10º, KT difference of ≥ 3.0mm at 1 year follow-up, thigh atrophy of ≥ 2.50cm at 1 year follow-up and RTS <9.5 months after primary ACLR.

Effect of COVID-19 on surgical management of open fractures and infection rates: A tertiary care experience in Indian set-up

BACKGROUND

Open fractures form one of the most common musculoskeletal injuries and are often complicated by infection. In this unprecedented situation, the additional infection rates, further add to the burden of the already compromised healthcare setup. The present study is done to see the effect of COVID-19 on management of open fractures.

METHODS

A retrospective evaluation of patients with open fractures from March 25th^, 2020 to July 21st^, 2020 (group 1) and March 25th^, 2019 to July 21st^, 2019 (group 2) was performed. These patients were assessed for demographic details, diagnosis, type of surgery, delay from injury to admission, delay from admission to surgery, postoperative hospital stay, acute infection rates, readmission rates and associated injuries.

RESULTS

A total of 52 patients with 59 open fractures in 2020 and 89 patients with 101 open fractures in 2019 met the inclusion criteria. The mean age was 34.76 years and 32.74 years in 2020 and 2019 respectively. Road side accidents were predominant in both the groups, comprising of 38 (73.07%) and 67 (75.28%) respectively(n.s.); adult patients were 42 (80.76%) and 79 (88.76%) respectively(n.s.); paediatric patients were 10 (19.23%) and 10 (11.23%) respectively(n.s.); tibia was the most common bone involved, comprising of 14 (23.72%) and 27 (26.73%) open fractures respectively(n.s.); external fixator was the most commonly used implant during COVID-19 time with 42 (71.18%) and 51 (50.49%) respectively(p = 0.005); the infection rate was 25.42% and 20.79% respectively(n.s.); the time for administration of first intravenous antibiotic dose was on 6.75 h and 4.04 h respectively(p < 0.0001); average time between the admission and surgical debridement was 24.04 h and 19.32 h respectively(n.s.); referral cases were 33 (63.46%) and 44 (49.43%) respectively(n.s.); re-admission rates were 7/52 (13.46%) and 10/89(11.23%) respectively(n.s.).

CONCLUSION

Despite the decrease in total trauma cases, a delay in presentation to the emergency room/administration of first dose of antibiotic and increase in temporary fixation in form of external fixator was observed. Further, an increase in infection rates, referral cases and readmission rates were observed, though not statistically significant.

Anterior cruciate ligament reconstruction with bone-patellar tendon-bone graft is associated with higher and earlier return to sports as compared to hamstring tendon graft

PURPOSE

To study the effect of age, duration of injury, type of graft and concomitant knee injuries on return to sports after anterior cruciate ligament (ACL) reconstruction.

METHOD

One-hundred and sixteen athletes underwent ACL reconstruction using either bone-patellar tendon-bone graft (BPTB; n = 58) or semitendinosus-gracilis graft (n = 58), depending upon their random number sequences. Five variables were analyzed in terms of their effect on return to sports-age, type of graft, time interval between injury and surgery, chondral damage and meniscal tears.

RESULTS

Fifty-three out of 73 (72.6%) athletes aged between 16 and 25 years and 21/43 (49%) athletes aged between 25 and 40 years returned to sports (p = 0.02). The mean time to return to sports was 9.7 ± 2.1 months and 10.8 ± 1.7 months in athletes aged < 25 years and 25-40 years, respectively (p = 0.04). ACL reconstruction with BPTB graft (43/58) was associated with higher rate of return to sports as compared to hamstring tendon graft (31/58; p = 0.02). The mean duration of return to sports with BPTB and STGPI graft was 9.7 ± 2.0 months and 10.7 ± 2.0 months, respectively (p = 0.02). 29/36 (80.5%) patients operated between 2 and 6 months, 18/29 (62%) operated in < 2 months, and 27/51 (53%) operated after 6 months of injury had returned to sports (p = 0.03). Athletes who were operated within 2 months of the injury were the earliest to return to sports (9.4 ± 2.1 months), followed by those operated within 2-6 months (9.9 ± 1.9 months) and lastly by the ones operated after 6 months of the injury (10.9 ± 2.1 months; p = 0.04).

CONCLUSIONS

The rate of return to sports was observed to be higher in athletes younger than 25 years as compared to older athletes (> 25 years). ACL reconstruction with BPTB graft was associated with higher and earlier returns to sports as compared to hamstring graft. The rate of return to sports was highest if surgery was performed between 2 and 6 months after the injury.

LEVEL OF EVIDENCE

III.

Pre-operative Joint Inflammation has no Bearing on Outcome of Arthroscopic Anterior Cruciate Ligament Reconstruction at 1-Year Follow-Up; a Prospective Study

BACKGROUND

To study the effect of pre-operative joint inflammation on clinical outcome at 1 year follow-up following ACL reconstruction surgery.

METHODS

Male patients, aged 18-40 years, suffering from isolated ACL injury were included. All patients were randomly divided into two groups based on the type of graft used: Group A: semitendinosus gracilis graft with preserved insertions (STG-PI), Group B: bone-patellar tendon-bone graft (BPTB). Patients were categorised based on the time of presentation after injury: (a) within 6 weeks of injury, (b) between 6 and 12 weeks of injury, (c) after 12 weeks of injury. Synovial fluid levels of Interlukin-1, Interlukin-6 and TNF-α were measured in all the ACL deficient knees by taking a joint fluid sample intra-operatively.

RESULTS

The total number of patients in the study was 59; 23 in group A (STG-PI) and 36 in group B (BPTB). Mean age of patients was 26 ± 5.146 years. 14 out of 59 (23.7%) patients presented within 6 weeks of injury, 16 (27.11%) patients presented between 6 and 12 weeks after injury and 29 (49.1%) patients presented after 12 weeks of injury. IL-6 levels were significantly high in group with < 6 weeks of injury than in group with > 12 weeks since injury. IL-6 had significant correlation with VAS scores, KT 1000, Lysholm knee scores and Tegner level of activity. There was no difference in outcome (pain scores, mechanical stability, Lysholm knee score and Tegner level of activity) at 1 year follow-up when patients with different time intervals since injury were compared.

CONCLUSION

The clinical outcome in terms of pain score, mechanical stability, functional scores and return to sporting activity is comparable, irrespective of the time since injury, at short term follow-up.

Anterior cruciate ligament tear due to non-contact mode of injury associated with higher incidence of meniscal and chondral damage

BACKGROUND

Forces acting on the knee are different in contact and non-contact mode of injuries causing anterior cruciate ligament (ACL) tear. Purpose of this study was to determine the effect of mode of injury on the occurrence of meniscal tear and chondral damage in ACL tear.

METHOD

72 athletes with acute ACL injury (<3 months) were enrolled in the study. Depending on the mode of injury, athletes were divided into two groups - group A (non-contact mode of injury) and group B (contact mode of injury). 49/72 athletes had the non-contact mode of injury (group A), and 23/72 athletes had contact mode of injury (group B). Meniscal tear and chondral damage seen at the time of ACL reconstruction surgery was noted. All athletes were assessed at 12 months follow-up for return to sports, Lysholm score, and WOMAC score.

RESULTS

In group A, 35/49 (71%) athletes and in group B, 9/23(39%) athletes had meniscal tear (p = 0.009). Medial meniscus was more commonly injured in group A [24/49] as compared to group B (5/23; p = 0.03). Chondral damage was also more commonly seen in group A [26/49] as compared to group B (5/23; p = 0.01). At one-year follow-up, 65% of the athletes from group B returned to sports as compared to 57% of the athletes from group A (p-value = 0.6). WOMAC score in group A and B was 95.5 ± 4.88 and 96 ± 4.39 respectively (p = 0.67). Lysholm score in group A and B was 1.02 ± 1.7 and 0.96 ± 1.2 respectively (p = 0.88).

CONCLUSION

Non-contact mode of injury was associated with a higher incidence of meniscal tear and chondral damage. However, the mode of injury does not affect the functional outcome of ACL reconstruction surgery.

Is anterior cruciate ligament graft rupture (after successful anterior cruciate ligament reconstruction and return to sports) actually a graft failure or a re-injury?

PURPOSE

The objective of this study is to discuss the fact that whether graft rupture after successful anterior cruciate ligament (ACL) reconstruction surgery is due to graft failure or re-injury to the reconstructed ACL.

METHODS

In total, 340 sportspersons, meeting our inclusion criteria, were assessed for rupture of ipsilateral ACL graft and ACL injury of the contralateral knee. Patients with ipsilateral ACL graft rupture were labelled as group 1, while those with contralateral ACL injury were labelled as group 2. Both groups were compared for potential risk factors for ACL injury, and statistical analysis was performed to study whether the graft acted as an additional risk factor.

RESULTS

Of the 340 sportspersons, 25 patients suffered a total of 26 injuries. Ipsilateral graft rupture rate was 2.4% (8 of 340) at a mean follow-up of 25.5 ± 40.57 months, and the contralateral ACL injury rate was 5.3% (18 of 340) at a mean follow-up of 18.11 ± 19.97 months, with an overall re-injury rate of 7.6%. Both groups were comparable for risk factors for ACL injury: age ( p = 0.255), gender ( p = 0.534), mode of re-injury ( p = 0.523), level of sports activity, type of graft used ( p = 0. 918), graft diameter ( p = 0.607), duration from injury to index surgery ( p = 0.492), duration from index surgery to re-injury ( p = 0.638), timing of return to sports after index surgery ( p = 0.303), duration of sporting activity before second injury ( p = 0.657), and Tegner's level of sports activity ( p = 0.486).

CONCLUSION

Because the rate of contralateral ACL injury is higher than the ipsilateral graft rupture and the risk factors for ACL injury are comparable in both groups at a follow-up period, which is suggestive of ligamentization of the graft, we suggest that it might be an ACL re-injury rather than graft failure. Level of Evidence: Level III (Retrospective cohort study).

Comparing the Role of Different Treatment Modalities for Plantar Fasciitis: A Double Blind Randomized Controlled Trial

INTRODUCTION

Although many treatment modalities including rest, stretching, strengthening, change of shoes, arch supports, orthotics, night splints and anti-inflammatory agents have been advocated for plantar fasciitis, there is no report in the literature which compares the independent effectiveness of each treatment modality without the concomitant use of any other one.

METHODS

A double blind, randomized controlled study was undertaken where 140 patients of plantar fasciitis were divided into four groups with 35 patients each. Patients in four groups received analgesics, hot water fomentation and silicon heel pads, plantar fascia stretching and calf stretching exercises, respectively. Heel pain was evaluated using Foot Function Index (FFI) and disability using Foot and Ankle Disability Index (FADI). Clinical evaluation was done weekly up to a period of 4 months and then at 6 months, 8 months, 10 months and 12 months.

RESULTS

Mean age of patients was 43.4 ± 10.6 years with average duration of symptoms being 27.26 weeks (range 4-200 weeks). Both FFI and FADI showed statistically significant improvement at 12 months in all the four groups (p value < 0.0001 for all groups). However, groups 2, 3 and 4 were observed to show statistically better results in terms of heel pain reduction (FFI) as compared to group 1 (ANOVA, p value < 0.0001 for group 1 vs. 2, group 1 vs. 3 and group 1 vs. 4). In terms of disability (FADI), best results were observed in group 3.

CONCLUSION

Plantar fascia stretching exercises resulted in most significant improvement in both the scores (FFI and FADI), followed by treatment with heat and silicone heel pad and calf stretching exercises.

No Difference in Outcome of Anterior Cruciate Ligament Reconstruction with "Bone-patellar Tendon-bone versus Semitendinosus-gracilis Graft with Preserved Insertion:" A Randomized Clinical Trial

BACKGROUND

The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction.

PURPOSE

This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone-patellar tendon-bone (BPTB) graft.

MATERIALS AND METHODS

One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score.

RESULTS

Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain.

CONCLUSION

There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.

Low re-rupture rate with BPTB autograft and semitendinosus gracilis autograft with preserved insertions in ACL reconstruction surgery in sports persons

PURPOSE

To compare the results of bone-patellar tendon-bone graft (BPTB), semitendinosus-gracilis graft with preserved insertions (STGPI) and semitendinosus-gracilis-free graft (STGF) in terms of graft failure, objective mechanical stability, functional outcome, and return to sports in elite and recreational sports persons. It was hypothesized that the STGPI graft provided superior outcome as compared to the other two grafts.

METHODS

Two hundred and forty-nine elite and recreational players who underwent ACL reconstruction surgery, with BPTB graft (N = 80), STGPI graft (N = 85), and STGF graft (N = 84) with a minimum follow-up of 2 years, were assessed using clinical tests, knee arthrometer (KT 1000™), single-leg hop test, Lysholm knee score, Tegner's activity scale, and return to sports. Groups were matched in terms of age, gender, mode of injury, side involved, the level of sports, associated injuries, and mean follow-up.

RESULTS

The median age of the patients was 24 years (range 16-46 years), with 227 males and 22 females, with a mean follow-up of 61.8 ± 25.9 months. At the final follow-up, the mean side-to-side difference by KT 1000™ was significantly superior in BPTB group (1.4 ± 2.1 mm) as compared to STGPI (1.9 ± 2.0 mm) and STGF group (2.5 ± 2.0 mm) (p = 0.002). The mean Lysholm knee score, Limb symmetry index (LSI) using single-leg hop test and the mean difference in pre-injury and post-surgery level of Tegner's activity scale were not significantly different. The rate of graft failure was significantly higher in STGF group (7.1%) as compared to BPTB (1.2%) and STGPI (1.2%) groups (p = 0.043).

CONCLUSION

BPTB graft is a better graft in terms of mechanical stability than STGPI and STGF grafts. STGPI graft and BPTB graft are superior to STGF graft in terms of graft failure rate. However, there is no statistically significant difference amongst the three grafts in terms of return to sports and clinical tests of instability. STGPI graft is another option in the clinical setting with low graft failure rate like that of BPTB graft and with the added advantage of not having significant donor site morbidity.

LEVEL OF EVIDENCE

III.

Functional Outcome of Modified Weaver Dunn Technique for Acromioclavicular Joint Dislocation

BACKGROUND

The debate about the ideal surgical procedure for acromioclavicular joint (ACJ) dislocation is still unresolved and newer techniques are being evolved continuously. The present study evaluates functional outcome of ACJ reconstruction using the modified Weaver Dunn procedure.

MATERIALS AND METHODS

35 patients (26 males, 9 females) with ACJ dislocation, between the age group of 18-48 years (mean age 31 years), were operated using modified Weaver Dunn procedure at our center from May 2005 to June 2010. The dominant side was involved in 25 patients (22 right, 13 left). The mean period from the time of injury to the surgery was 14 days (range 4-26 days). All the patients were assessed with Oxford shoulder score and the time required to return to preinjury level was recorded.

RESULTS

At the mean followup of 95 months (range 72-120 months), the mean Oxford Shoulder Score improved from 25 ± 7.2 to 43 ± 6.9. 85% (30 out of 35) patients had satisfactory results, while 15% (5 out of 35) had mild shoulder dysfunction using this scoring system. Five patients had radiological evidence of Grade 2 ACJ subluxation. Out of these five patients, two developed ossification around the coracoclavicular ligament. Three patients had intermittent mild pain without any functional disability, and one had a moderate restriction of shoulder movements.

CONCLUSION

ACJ reconstruction, using the modified Weaver Dunn procedure in ACJ dislocation, is a reproducible procedure and provides a good functional outcome.

Incidence, Risk Factors, and Management of Infection Following Anterior Cruciate Ligament Reconstruction Surgery

BACKGROUND

Infection after anterior cruciate ligament reconstruction surgery (ACLRS) is a rare complication. Although there are number of studies from various Caucasian population but only few studies are available from Asian population. The aim of the study is to assess the incidence, risk factors and, clinical outcome using our treatment protocol.

MATERIALS AND METHODS

Out of 1468 arthroscopic ACLRS, 26 patients with clinical suspicion of infection were critically analysed in terms of laboratory reports of arthrocentesis, erythrocyte sedimentation rate, C-reactive protein and risk factors such as the type of graft, gender, diabetes mellitus, smoking, intraarticular steroid injection, and obesity. At final followup, all these patients were evaluated using visual analog scale (VAS), Lysholm knee score, and Tegner activity level.

RESULTS

In nine patients, culture did not show any growth and they showed improvement with arthrocentesis and oral antibiotics. These patients were labeled as suffering from aseptic effusion. In the remaining 17 patients, there was no clinical improvement or instead worsening of symptoms after arthrocentesis and oral antibiotics. These patients were labeled as suffering from an infection and underwent surgical debridement along with administration of injectable antibiotics. The history of intraarticular steroid injection before ACLRS was a significant risk factor for developing infection (P = 0.001). At mean followup of 2.8 years, mean VAS improved to 1.18 ± 0.99 from 6.2 ± 2.3. The mean Lysholm knee score and Tegner's activity level at the final followup were 79.2 ± 10.52 and 4.8 ± 2.30, respectively.

CONCLUSION

The incidence of infection was 1.2% (17/1468). The step-ladder approach of differentiating between aseptic effusion and infection and accordingly, following a treatment protocol, i.e., oral antibiotics alone or surgical debridement along with injectable antibiotics or additional debridement of graft in refractory patients, yielded satisfactory results.

Retained Drain after Anterior Cruciate Ligament Surgery : A Silent Threat to an Athlete's Career: A Case Report

Introduction:

Breaking of surgical drain during the removal and retention of broken drain fragment is an avoidable complication. Such a complication brings disrepute to the operating team and causes psychological as well as further surgical trauma to the patient as a return to the operating room is required many a times to remove the retained drain fragment.

Case Report:

We report a case of an undetected retained drain fragment inside the knee joint of a 24-year-old male international kabaddi player, who remained asymptomatic for 5 months, when the residual drain fragment was removed arthroscopically. No such case has been reported earlier in the literature after arthroscopic surgery.

Conclusion:

Retained drain fragment after arthroscopic surgery can stay silent for months. Hence, a high index of suspicion should be maintained by surgeons to detect such a complication at the earliest. We suggest that every arthroscopic surgeon should follow a standard protocol while inserting and removing the drain to avoid this mistake.

Triceps tendon reconstruction using autologous semitendinosis graft in professional kabaddi player-A rare case report

Triceps tendon rupture is a rare injury occurs due to sudden forceful contraction of triceps against flexed elbow. Though there are case reports describing various treatment options for this injury, including primary repair as well as reconstruction using different technique, no standardised technique has been defined. We present, for the first time, a case of five month old neglected triceps tendon rupture in a professional kabaddi player. Ruptured tendon was reconstructed using free autologous semitendinous graft with good functional outcome.

Equation-based precise prediction of length of hamstring tendons and quadrupled graft diameter by various anthropometric variables for knee ligament reconstruction in Indian population

Preoperative prediction of hamstring tendon lengths and graft diameter for anterior cruciate ligament (ACL) reconstruction enables better preoperative planning. Presently, no study exists for Indian population where both derivation and verification of a mathematical equation for accurate prediction of hamstring graft dimensions have been done. This study was conducted in two phases: First phase ( derivation cohort): devoted to the study of correlation of length of hamstring tendons and graft diameter with various anthropometric measurements in 123 patients undergoing ACL reconstruction. Length of semitendinosus (ST) was observed to have a strong correlation with leg length ( r = 0.719), whereas that of gracilis (G) had a strong correlation with patient height ( r = 0.768). Quadrupled diameter (QD) had a strong correlation with patient height and thigh length ( r = 0.685 and 0.680, respectively). Using Pearson correlation coefficient, multiple stepwise linear regressions, and analysis of variance test, predictive equations were developed to predict the length of ST and G and QD. Second phase ( verification cohort): This was a blinded prospective study done on 300 patients to further authenticate and test the accuracy of equations developed. Here, a steady correlation was found between the observed and predicted values of length of ST, G and QD, with correlation coefficients being 0.838, 0.847, and 0.767, respectively. Thus, we can safely conclude that clinically measurable anthropometric variables can reliably predict hamstring graft dimensions. This is likely to prove useful in better preoperative planning of ligament reconstructions.

Correlation of femoral tunnel length with body height, limb length, and thigh length in Indian patients undergoing anterior cruciate ligament reconstruction

PURPOSE

To measure the femoral tunnel length created through a far medial portal and determine its correlation with body height, limb length, and thigh length in 404 Indian patients undergoing anterior cruciate ligament (ACL) reconstruction.

METHODS

364 male and 40 female Indian patients aged 18 to 51 (mean, 26.8) years underwent ACL reconstruction by a single surgeon using the hamstrings tendon autograft. Their body height, limb length, and thigh length were measured by a single assessor, as was the femoral tunnel length.

RESULTS

The mean femoral tunnel length was 34.5 mm. It was <30 mm in 28 patients and <25 mm in 2 patients. The correlation coefficients of the femoral tunnel length with body height, limb length, and thigh length were 0.485 (p<0.0001), 0.426 (p<0.0001), and 0.304 (p<0.0001). No patient had posterior wall blowout fracture.

CONCLUSION

The femoral tunnel length positively correlated with body height, limb length, and thigh length in 404 Indian patients.

Delay in surgery predisposes to meniscal and chondral injuries in anterior cruciate ligament deficient knees

BACKGROUND

Despite improvements in instability after anterior cruciate ligament (ACL) reconstruction, associated intraarticular injuries remain a major cause of concern and important prognostic factor for long term results as it may lead to osteoarthritis. Delay in ACL reconstruction has been in variably linked to increase in these injuries but there is lack of consensus regarding optimal timing of reconstruction. The goal of this study was to investigate delay in surgery and other factors, associated with intraarticular injuries in ACL deficient knees.

MATERIALS AND METHODS

A total of 438 patients (42 females; 396 males) enrolled for this prospective observational study. The average age of patients was 26.43 (range 17-51 years) years with a mean surgical delay of 78.91 (range 1 week - 18 years) weeks after injury. We analyzed the factors of age, sex, surgical delay, instability, and level of activity for possible association with intraarticular injuries.

RESULTS

Medial meniscus injuries had a significant association with surgical delay (P = 0.000) after a delay of 6 months. Lateral meniscus injuries had a significant association with degree of instability (P = 0.001). Medial-sided articular injuries were significantly affected by age (0.005) with an odds ratio (OR) of 1.048 (95% confidence interval [CI] of 1.014-1.082) reflecting 4.8% rise in incidence with each year. Lateral-sided injuries were associated with female sex (P = 0.018) with OR of 2.846 (95% CI of 1.200-6.752). The level of activity failed to reveal any significant associations.

CONCLUSION

Surgical delay predicts an increase in medial meniscal and lateral articular injuries justifying early rather than delayed reconstruction in ACL deficient knees. Increasing age is positively related to intraarticular injuries while females are more susceptible to lateral articular injuries.

Immediate post-operative pain in anterior cruciate ligament reconstruction surgery with bone patellar tendon bone graft versus hamstring graft

Background

Pain in the immediate post-operative period after anterior cruciate ligament (ACL) surgery, apart from an unpleasant experience for the patient, can act as a barrier for static quadriceps contractions and optimum execution of the initial rehabilitation protocol resulting in slow recovery and a later return to full function for a sportsperson. There is no report in the literature comparing pain in the immediate post-operative period after using the two most widely used autografts, bone patellar tendon bone (BPTB) graft and hamstring graft.

Methods

The present study compared the visual analogue scale (VAS) pain score in the immediate post-operative period after arthroscopic ACL reconstruction with the BPTB and hamstring autografts. Both groups consisted of 50 patients each. The mean age of the BPTB and hamstring cohorts was 26.9 ± 7.3 years (age range 18–59 years) and 26.7 ± 9.0 years (age range 17–52 years), respectively. Unpaired t test was applied to compare pain scores between the BPTB and hamstring cohorts.

Results

In the present study, patients in the BPTB cohort showed higher mean pain scores across all the post-operative time intervals except at 6 h. However, the difference in the mean VAS pain score at post-operative 6, 12,18, 24, 36 and 48 h in the two groups was statistically not significant (p value of 1, 0.665, 0.798, 0.377, 0.651 and 0.215 at 6, 12, 18, 24, 36 and 48 h, respectively).

Conclusions

Our study concludes that the arthroscopic ACL reconstruction with BPTB autograft and hamstring autograft is associated with similar pain in the immediate post-operative period. As a result, aggressive physiotherapy regime is not affected by the type of graft being used for ACL reconstruction, as the pain scores in the immediate post-operative period are similar for both techniques.

Trial registration

Clinical Trials Registry-India, CTRI/2016/01/006502

Anterior Cruciate Ligament Reconstruction Using Hamstring Tendon Autograft With Preserved Insertions

We present a technique for anterior cruciate ligament (ACL) reconstruction using hamstring tendon autograft with preserved tibial insertions. The tendons, harvested with an open-ended tendon stripper while their tibial insertions are preserved, are looped around to prepare a quadrupled graft. The femoral tunnel is drilled independently through a transportal technique, whereas the tibial tunnel is drilled in a standard manner. The length of the quadrupled graft and loop of the RetroButton is adjusted so that it matches the calculated length of both tunnels and the intra-articular part of the proposed ACL graft. After the RetroButton is flipped, the graft is manually tensioned with maximal stretch on the free end, which is then sutured to the other end with preserved insertions. We propose that preserving the insertions is more biological and may provide better proprioception. The technique eliminates the need for a tibial-side fixation device, thus reducing the cost of surgery. Furthermore, tibial-side fixation of the free graft is the weakest link in the overall stiffness of the reconstructed ACL, and this technique circumvents this problem. Postoperative mechanical stability and functional outcome with this technique need to be explored and compared with those of ACL reconstruction using free hamstring autograft.

Acute anterior cruciate ligament injuries in multisport elite players: Demography, association, and pattern in different sports

BACKGROUND

Anterior cruciate ligament (ACL) tear rates are known to vary from sport to sport. To the best of our knowledge, the relationship of ACL injury with different sports is not reported earlier. The objective of the present study is to investigate the association of ACL injury with different sports and to document various associated ligamentous, meniscal, and chondral lesions of the knee.

MATERIALS AND METHODS

Descriptive epidemiological study was carried out in a tertiary care center over a 10-year period. Data were collected of the 638 ACL injured elite sportspersons operated by us. Percentage of ACL injuries and other associated injuries of the knee in different games was calculated. Chi-square test was applied to analyze the relationship between injuries of the specific structures of knee and sports played. p values less than 0.05 were considered to be statistically significant with a confidence interval of 95%.

RESULTS

Kabaddi and football constituted the highest percentage (61%) of ACL injuries. Associated injuries were 10 posterior cruciate ligament tears, 11 posterolateral corner injuries, three medial collateral ligament tears, 390 meniscal tears (206 medial, 184 lateral), 201 femoral/tibial condylar lesions (128 medial, 40 lateral femoral condyle and 17 medial, 16 lateral tibial condyle), and two common peroneal nerve injuries. Lateral meniscal tears in kabaddi and medial femoral condylar lesions in badminton were significantly higher.

CONCLUSIONS

Kabaddi resulted in higher number of ACL injuries and other associated injuries to the knee. Further investigation is required to ascertain high-risk factors for such injuries.

Sports injury pattern in school going children in Union Territory of Chandigarh

OBJECTIVE

To determine incidence of various types of sport injuries and other associated factors, among competitive sports playing school children of Chandigarh.

DESIGN

This study is a survey based study, and spanned for a period of one year. School going students in age group 11-18 years of Chandigarh (Union Territory) India, who were in competitive sports, were included for this survey after taking informed consent from concerned school authorities. 33 schools consisting of 36.165 students were analysed in the study, 7230 students were found to participate in 40 different categories of sports.

RESULTS

Total of 246 filled questionnaires were analyzed making it an injury frequency of 3.40% among 7230 participating young athletes in 12 months study duration. Estimated incidence rate, considering hours of exposure in practice, came out to be 48.07 injuries per 1000 h of exposure in practice among 246 injured cases. 40.2% of the injured children (99/246) attributed their injury to poor ground condition while other 30.5% (75/246) to faulty techniques. Rest attributed their injuries to poor fitness levels, improper use of equipment and other reasons. Of the 33 schools surveyed, 27.3% (9/33) had a doctor as health professional, 9.1% (2/33) had a physiotherapist while 66.6% of the schools (22/33) had no health care professional.

CONCLUSION

The incidence of sports injuries in the region is high as compared to the global data. The findings has highlighted the need for a nationwide surveillance system and then taking appropriate measures for future injury prevention and appropriate management.

Abstract 553: High prevalence of human papilloma virus in esophageal squamous cell carcinoma: A preliminary study

Background:Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers with poor prognosis. ESCC has been associated with Human Papilloma Virus (HPV) genotypes 16 and 18. Incidence of HPV infection ranges from 0 to 67% in different parts of the world. Aim: to analyze prevalence of HPV infection in ESCC tumor and adjoining mucosa by HPV genotyping test. Material and method: Fresh tissue samples were obtained from ESCC tumor (group I) and adjoining mucosa (group II). Biopsies were subjected to frozen section for histological characterization. Aliquots of DNA extract was used for the linear array genotyping test. Results: There were 56 patients with paired samples, M:F=9:5. HPV was positive in 42/56 (75%), mean age of positive samples ranged from 41 to 63 years, the mean value in group I was 56.63±6.96 and in group II was 54.31±7.13 years (p&gt;0.05). Majority had more than one genotype. The common genotypes observed were HPV 52, 55, 31, 65 and 16 in carcinoma and adjoin mucosa as well. Smoking showed a significant association with HPV positivity. p63 and p16 oncoproteins correlated with degree of tumor differentiation, not with the viral subtypes or positive status. HPV 6 and 11 were also positive in certain number of cases. Conclusion: we documented high prevalence of high risk HPV infections in tumor and adjoining mucosa in ESCC, supporting the concept of persistent infection by oncogenic HPV in cancer development. HPV 52 was the commonest genotype. It highlights importance of documenting the prevalent viral genotype in a defined geographic area in cancer prevention and treatment. Key words: Human Papilloma Virus genotype; Human Papilloma Virus genotype 52; esophageal squamous cell carcinoma.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 553. doi:1538-7445.AM2012-553