Early Outcome of a Single Peri-Tendinous Hyaluronic Acid Injection for Mid-Portion Non-Insertional Achilles Tendinopathy - A Pilot Study

AIM

The aim of this study was to evaluate the efficacy and safety of a single, peri-tendinous injection of hyaluronic acid for mid-portion, non-insertional Achilles tendinopathy.

MATERIALS AND METHODS

A prospective, open labelled, single center, pilot study was conducted. All patients enrolled received a single peri-tendinous injection of Ostenil Tendon™ (40 mg/2 ml 2% HA with 0.5% mannitol). Outcome measures were Visual Analogue Scale (VAS) pain score and Manchester-Oxford Foot Questionnaire (MOxFQ) scores at 2 weeks and at final follow at 12 weeks. Any major and minor adverse effects were recorded. To assess change in VAS and MOxFQ scores, t test and Wilcoxon signed rank test were employed.

RESULTS

Seventeen patients were enrolled in this study with a mean follow-up of 12 weeks. Mean pre-injection VAS score was 9.38 cm (9-9.8), which significantly reduced post-injection to a mean score of 4.09 cm (2-8) at week-2 stage, and further improved to 3.01 cm (2-3.9) at the final follow-up (p < 0.0001). MOxFQ score showed a significant improvement from pre-injection value of 67.77 (63.03-72.55) to 31.18 (13-60) at week-2 stage, and further improved to 24.20 (15.73-32.67) at the final follow-up (p < 0.0001). The mean improvement from pre-injection to the final follow up was 43.57 (34.25-52.90). No adverse effects for injections were recorded.

CONCLUSION

This small series suggests an encouraging response of a single injection of HA as an effective and safe option for non-insertional Achilles tendinopathy.

Outcomes and Return to Sports Following the Ankle Lateral Ligament Reconstruction in Professional Athletes: A Systematic Review of the Literature

INTRODUCTION

The literature on the early reconstruction of severe acute lateral ligament injuries in professional athletes suggests earlier rehabilitation and reduced incidence of recurrent instability. Predicted time to return to training and sports is important to both the athlete and the club and has not previously been reported.

AIMS AND OBJECTIVES

The primary aim was to establish the best treatment options available for lateral ligament injury in professional athletes and assess the average time to return to physical training and return to play (RTP). Secondary aims were to find out the rate of return to the pre-injury level of competitive sports and the reasons for delayed recovery.

MATERIALS AND METHODS

We performed a systematic review according to PRISMA guidelines to evaluate the demographics, clinical profile, management, and treatment outcomes. Electronic searches of the MEDLINE, EMBASE, and Cochrane databases were performed. Studies conducted between Jan 2000 and Dec 2020 with articles reporting the ankle lateral ligament reconstruction in professional athletes were included.

MAIN RESULTS

After initial screening, 982 articles were identified, of which, 10 articles evaluating 343 athletes met the criteria and were included for final review. The combined mean age was 23 years with an average follow-up of 58.4 months. After surgery 308 (89%) returned to their pre-injury level of sports, 7 (2%) patients returned to a lower-level sport while the remaining 28 (9%) never returned to play.

CONCLUSION

Our results provide a guide to predict the expected time to return to play (RTP) after surgical repair of lateral ligament injuries along with associated injuries leading to delayed rehabilitation. Lateral ligament reconstruction is a safe and effective treatment for severe ruptures providing a stable ankle with a mean time of 16 weeks to return to sports. The available studies vary considerably in their metrics used for measuring patient-reported outcomes.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00532-0.

Litigations in trauma and orthopaedic surgery: analysis and outcomes of medicolegal claims during the last 10 years in the United Kingdom National Health Service

This study analyses the outcomes of litigation claims in trauma and orthopaedic surgery between 2008/2009 and 2018/2019.

Utilizing a formal request to the NHS Resolution under the Freedom of Information Act, the data related to claims against orthopaedic surgery were obtained. A total of 8548 claims were analysed and re-grouped to perform a meaningful analysis for the type of claims and the type of injuries.

The total pay-out cost for the settled claims was over £1.2 billion. The most common types of claims were related to mismanagement (39.0%), diagnostic issues (17.6%), perioperative issues (15.9%) and alleged incompetence (10.2%). The most common primary causes for claims were patients’ dissatisfaction (52.2%), damage to the limbs (19.0%) and neurological injuries (9.2%).

The highest amounts of damages paid out were related to patients’ dissatisfaction (37.7%), burns and bruising (31.0%), neurological injuries (24.5%) and damage to the limbs (22.3%). The number of claims and the pay-out cost were found to be steadily increasing; however, there was a slightly declining trend observed during the last two years.

The cost of litigation continues to have a significant financial impact on the NHS. The recent declining trend is encouraging; however, surgeons need to take consistent diligent steps to avoid preventable causes that lead to litigation claims.

The proposed change in the coding system of claims in the NHS Resolution will not only help to formulate a clear classification system but will also improve the learning from previous experience.

Cite this article: EFORT Open Rev 2021;6:152-159. DOI: 10.1302/2058-5241.6.200100

Clinical and patient-reported outcomes following Low Intensity Pulsed Ultrasound (LIPUS, Exogen) for established post-traumatic and post-surgical nonunion in the foot and ankle

BACKGROUND

Biophysical methods including Low Intensity Pulsed Ultrasound (LIPUS) are emerging as potential alternatives to revision surgery for treating established nonunions. We aim to prospectively review the clinical and patient-reported outcomes of patients treated with LIPUS following post-traumatic and post-surgical nonunions in the foot and ankle.

METHODS

Forty-seven consecutive patients underwent Exogen treatment. Patient-reported outcome scores included MOXFQ, EQ-5D and VAS. Patients were divided in to 3 groups: fractures (A), hindfoot procedures (B) and midfoot/forefoot procedures (C).

RESULTS

Thirty-seven patients (78.7%) clinically united, 4 patients (8.5%) noticed no significant improvement but did not want further intervention and 6 patients (12.8%) underwent revision surgery. The mean duration of Exogen treatment was 6 months. Union rates of 93%, 67% and 78% were noted in the three groups. Significant improvement in functional outcomes and potential cost savings were observed.

CONCLUSIONS

Exogen for established nonunion in the foot and ankle is a safe, valuable and economically viable clinical option as an alternative to revision surgery. We observed better results in the fracture and midfoot/forefoot groups and relatively poorer results in the hindfoot fusion group.

Oncology care in the era of pandemics

Since the declaration by the World Health Organization on 11 March 2020 of a global pandemic from sars-cov-2, the public health impact on broader society has been unprecedented. [...]

Fatal myocarditis and rhabdomyositis in a patient with stage IV melanoma treated with combined ipilimumab and nivolumab

Combination immune checkpoint blockade with concurrent administration of the anti-ctla4 antibody ipilimumab and the anti-PD-1 antibody nivolumab has demonstrated impressive responses in patients with advanced melanoma and other diseases. That combination has also been associated with increased toxicity, including rare immune-related adverse events. Here we describe a case of fatal steroid-refractory myocarditis and panmyositis associated with the use of this combination in a patient with metastatic melanoma. Correlative studies indicated increased levels of serum interleukin 6 in this patient at the onset of toxicity, suggesting a possible role for anti-interleukin 6 receptor antibodies in the treatment of subsequent cases of this rare, but fatal, toxicity.

Silastic replacement of the first metatarsophalangeal joint: historical evolution, modern concepts and a systematic review of the literature

Silastic implants for the first metatarsophalangeal joint (MTPJ) have been in use for over 50 years. Initial reports were associated with high failure rates leading to development of new designs that are currently in use.The aim of this article is to review the historical evolution and the outcomes of silastic implants for the treatment of end-stage OA of the first MTPJ. Databases were searched for studies reporting the outcomes of silastic implants for the first MTPJ. Various relevant search terminologies were used. Studies reporting the outcomes of metallic implants or arthrodesis were excluded.The literature search revealed 522 studies, of which 28 were included. Eight studies used single-stemmed implants and 20 used double-stemmed implants for their patients. Twenty-eight studies had a total of 2354 feet with silastic replacements in 1884 patients (1968 to 2003) with an average age of 53 years and the average follow-up was 85.3 months. There were a total of 5.3% (124 feet) failed prostheses. Improvement in pain was reported in 76.6% (1804 feet) with an average patient satisfaction rate of 84%. Radiological changes around the implants were found to be significantly higher with single-stemmed implants (30.3%) compared to the double-stemmed implants (14.7%) (p < 0.05).Significantly more single-stemmed implants failed (11%) than the double-stemmed implants (3.6%) (p < 0.05). Despite the initial reports of failed implants and complications, first- and second-generation silastic implants were associated with high patient satisfaction and pain improvement. Current literature lacks long-term outcomes of implants currently in use. Cite this article: EFORT Open Rev 2019;4:77-84. DOI: 10.1302/2058-5241.4.180055.

Survivorship and long-term outcome of a consecutive series of 200 Scandinavian Total Ankle Replacement (STAR) implants

AIMS

We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.

PATIENTS AND METHODS

Between November 1993 and February 2000, 200 consecutive STAR prostheses were implanted in 184 patients by a single surgeon. Demographic and clinical data were collected prospectively and the last available status was recorded for further survival analysis. All surviving patients underwent regular clinical and radiological review. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot scoring system. The principal endpoint of the study was failure of the implant requiring revision of one or all of the components. Kaplan-Meier survival curves were generated with 95% confidence intervals and the rate of failure calculated for each year.

RESULTS

A total of 84 patients (87 ankles) were alive by the end of this study. Of the surviving 84 patients (87 ankles; rheumatoid arthritis (RA), n = 40; OA, n = 47), 45 were women and 39 were men, with a mean age of 54 years (18 to 72 years) at the time of surgery. A total of 32 implants failed (16%), requiring revision surgery. The mean time to revision was 80 months (2 to 257). The implant survival at 15.8 years, using revision as an endpoint, was 76.16% (95% confidence interval (CI) 64.41 to 87.91). We found a steady but low decrease in survival over the study period. The mean AOFAS score improved from 28 (10 to 52) preoperatively to 61 (20 to 90) at long-term follow-up.

CONCLUSION

STAR prostheses in the United Kingdom have now been largely superseded by newer design TAAs, potentially with improved characteristics and surgical techniques. The long-term survivorship for the STAR prosthesis can provide a benchmark for these later designs of ankle arthroplasty.

Effect on Hospital Length of Stay of Tourniquet Use During Internal Fixation of Ankle Fractures: Randomized Controlled Trial

Approximately 50% of ankle fractures require internal fixation. A tourniquet is often used to create a bloodless operative field, but its effect on hospital length of stay (LOS) is unclear. This article reports a parallel-group observer-blinded randomized trial of the effect of tourniquet use on LOS. One hundred eighty-eight adult patients requiring internal fixation of ankle fracture were randomized to surgery with or without a tourniquet. LOS was analyzed on intention-to-treat principles using Poisson regression. As a secondary outcome, duration of operation was analyzed by analysis of covariance. Mean LOS was 1.79 ± 1.50 days in the tourniquet group and 1.65 ± 1.11 days in the no-tourniquet group. The covariate-adjusted rate ratio for LOS (reference group: no tourniquet) was 1.084 (95% confidence interval 0.871, 1.348; p = .470). Sensitivity analyses (unadjusted intention-to-treat analysis and as-treated analysis) gave similar nonsignificant results. The covariate-adjusted mean difference in duration of operation was 3.03 minutes (95% confidence interval -4.96, 11.02; p = .455), favoring the tourniquet group; sensitivity analyses again gave similar results. Adverse events did not differ significantly between groups. In conclusion, the use of a tourniquet during internal fixation does not significantly influence hospital LOS, of which preinjury medical condition of the patient appears to be the most important determinant.

Total ankle arthroplasty: what are the risks?: a guide to surgical consent and a review of the literature

AIMS

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

PATIENTS AND METHODS

A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants.

RESULTS

There were wound-healing problems in nine ankles (3.2%), superficial infection in 20 ankles (7.2%), and deep infection in six ankles (2.2%). Intraoperative fractures occurred in medial malleoli in 27 ankles (9.7%) and in lateral malleoli in four ankles (1.4%). Aseptic loosening and osteolysis were seen 16 ankles (5.8%). Fracture of the polyethylene component occurred in one ankle (0.4%) and edge-loading in seven ankles (2.5%). We observed medial gutter pain in 31 ankles (11.1%). The incidence of thromboembolism occurred in two ankles (0.7%). The results were found to be comparable to the previously reported complications of total ankle arthroplasty in the literature.

CONCLUSION

Total ankle arthroplasty continues to evolve and improve the ankle function. Despite high overall complication rates with TAA surgery, most complications appear to be minor and do not affect final clinical outcome. Our results and literature review will help in the consent process and provide detailed complication rates for an informed consent. Cite this article: Bone Joint J 2018;100-B:1352-8.

Minimally invasive reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular calcaneal fractures: A systematic review of the literature

The aim of this article is to systematically identify and analyse research evidence available to compare the outcomes of minimally invasive reduction and percutaneous fixation (MIRPF) versus open reduction and internal fixation (ORIF) for displaced intra-articular calcaneal fractures.

Articles from 2000 to 2016 were searched through MEDLINE (PubMed), Cochrane Library, Embase, ScienceDirect, Scopus and ISI Web of Knowledge using Boolean logic and text words. Of the 570 articles identified initially, nine were selected including three randomized controlled trials and six retrospective comparative studies.

All nine studies had a total of 1031 patients with 1102 displaced intra-articular calcaneal fractures. Mean follow-up was 33 months. Of these, 602 (54.6%) were treated with MIRPF and 500 (45.4%) were treated with ORIF.

Overall incidence of wound-related complications in patients treated with MIRPF was 4.3% (0% to 13%) compared with 21.2% (11.7% to 35%) in the ORIF group

Functional outcomes were reported to be better in the minimally invasive group in all studies; however, the results did not reach statistical significance in some studies. All the studies had methodological flaws that put them at either ‘unclear’ or ‘high’ risk of bias for multiple domains.

Overall quality of the available evidence is poor in support of either surgical technique due to small sample size, flaws in study designs and high risk of bias for various elements. Individual studies have reported minimally invasive techniques to be an effective alternative with lower risk of wound complications and better functional outcomes.

Cite this article: EFORT Open Rev 2018;3:418-425. DOI: 10.1302/2058-5241.3.170043

Talar process fractures: An overview and update of the literature

Fractures of the lateral and the posterior processes of the talus are uncommon and frequently missed because of a low level of suspicion and difficulty in interpretation on plain radiographs. Missed fractures can lead to persistent pain and reduced function.

Lateral process fractures are usually a consequence of forced dorsiflexion and inversion of fixed pronated foot. These are also commonly known as snowboarder’s fractures.

The posterior process of the talus is composed of medial and lateral tubercles, separated by the groove for the flexor hallucis longus tendon.

The usual mechanism of injury is forced hyperplantarflexion and inversion causing direct compression of the posterior talus, or an avulsion fracture caused by the posterior talofibular ligament. CT scans are helpful in cases of high clinical suspicion.

There is a lack of consensus regarding optimal management of these fractures; however, management depends on the size, location and displacement of the fragment, the degree of cartilage damage and instability of the subtalar joint. Non-operative treatment includes immobilization and protected weight-bearing for six weeks. Surgical treatment includes open reduction and internal fixation or excision of the fragments, depending on the size.

Fractures of the lateral and the posterior processes of the talus are uncommon but important injuries that may result in significant disability in cases of missed diagnosis or delayed or inadequate treatment. Early diagnosis and timely management of these fractures help to avoid long-term complications, including malunion, nonunion or severe subtalar joint osteoarthritis.

Cite this article: EFORT Open Rev 2018;3:85-92. DOI: 10.1302/2058-5241.3.170040

Abstract P3-12-04: Efficacy of extended adjuvant aromatase inhibitors in subgroups of women with early breast cancer

Background: Randomized trials (RCTs) have reported improvements in breast cancer outcomes from extending treatment with aromatase inhibitors (AIs) beyond the initial 5 years after diagnosis. It is uncertain whether this effect is consistent in different subgroups.

Methods: We identified RCTs that compared extended AIs to placebo or no treatment using a systematic search of MEDLINE. The search was supplemented by a review of abstracts from the American Society of Clinical Oncology and San Antonio Breast Cancer Symposium meetings between 2013 and 2016. Hazard ratios (HRs) and 95% confidence intervals (CI) for disease-free survival (DFS) were extracted or estimated from forest plots and included in a meta-analysis using generic inverse variance and random effects modelling. Pre-specified subgroups included age (&lt;60 ± 5 years vs. ≥60 ± 5 years), tumor size (≤2 cm vs. &gt;2 cm), nodal status (positive vs. negative), hormone receptor status (estrogen [ER] and progesterone receptor [PR] positive vs. ER or PR positive) and administration of adjuvant chemotherapy (yes vs. no).

Results: Seven trials comprising 16,349 patients were analyzed. Studies designs and prior endocrine therapy are shown in Table 1

Table 1: Characteristics of included studies.TrialTreatment ArmsSample sizePrior endocrine treatmentABCSG 6aAnastrozole 3 years vs. none387/ 469Tamoxifen± aminoglutethimide: 100%, 5 yearsMA 17Letrozole 5 years vs. placebo2572/ 2577Tamoxifen: 100%, ∼5 yearsNSABP B-33Exemestane 5 years vs. placebo783/ 779Tamoxifen: 100%, ∼5 yearsDutch DATAAnastrozole 6 years vs,. anastrozole 3 years827/ 833Tamoxifen: 100%, 2-3 yearsIDEALLetrozole 5 years vs. letrozole 2.5 years903/ 898Any endocrine treatment (tamoxifen/AIs/sequence of tamoxifen+ AIs): 100%, 5 yearsMA.17RLetrozole 5 years vs. placebo959/ 959AIs: 100%, ∼5 years Prior tamoxifen: 79.3%NSABP B-42Letrozole 5 years vs. placebo1959/ 1964Any endocrine treatment (AIs/sequence of tamoxifen+ AIs): 100%, 5 years

. The pooled effect of prolonged treatment with AIs in different subgroups is shown in the Table 2.

Table 2: Intra-subgroup comparison of longer AIs treatment effect by subgroupsSubgroup ASubgroup BHR (95% CI) Subgroup AHR (95% CI) Subgroup BP for differenceAge &lt;60 ± 5Age ≥60 ± 50.83 (0.70-0.99)0.85 (0.74-0.97)0.64T &gt;2 cmT ≤2 cm0.77 (0.55-1.06)0.88 (0.68-1.13)0.44N positiveN negative0.72 (0.63-0.83)0.83 (0.64-1.08)0.22ER and PR positiveER or PR positive0.68 (0.44-1.04)1.03 (0.53-2.02)0.27Adjuvant chemotherapyNone0.71 (0.59-0.86)0.80 (0.65-0.98)0.51

Overall, the effect of prolonged AIs was similar in all subgroups. However, non-significantly greater effect sizes were seen in patient with larger tumors, nodal involvement, presence of both ER and PR expression and those treated with adjuvant chemotherapy.

Conclusions: Extended treatment with adjuvant AIs is associated with similar relative improvements in DFS in all subgroups analyzed. The greater effect size seen in node positive and large tumor subgroups and the higher baseline risk of recurrence will likely translate to a higher absolute benefit from extended AIs in these groups.

Citation Format: Goldvaser H, Algorashi I, Ribnikar D, Majeed H, Ocana A, Seruga B, Templeton AJ, Amir E. Efficacy of extended adjuvant aromatase inhibitors in subgroups of women with early breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-12-04.

Amplification of the Atlantic Multidecadal Oscillation associated with the onset of the industrial-era warming

North Atlantic sea surface temperatures experience variability with a periodicity of 60–80 years that is known as the Atlantic Multidecadal Oscillation (AMO). It has a profound imprint on the global climate system that results in a number of high value societal impacts. However the industrial period, i.e. the middle of the 19th century onwards, contains only two full cycles of the AMO making it difficult to fully characterize this oscillation and its impact on the climate system. As a result, there is a clear need to identify paleoclimate records extending into the pre-industrial period that contain an expression of the AMO. This is especially true for extratropical marine paleoclimate proxies where such expressions are currently unavailable. Here we present an annually resolved coralline algal time series from the northwest Atlantic Ocean that exhibits multidecadal variability extending back six centuries. The time series contains a statistically significant trend towards higher values, i.e. warmer conditions, beginning in the 19th century that coincided with an increase in the time series’ multidecadal power. We argue that these changes are associated with a regional climate reorganization involving an amplification of the AMO that coincided with onset of the industrial-era warming.

Large ossification mass causing groin pain and limited hip function

Acute avulsion fractures to the anterior inferior iliac spine are unusual, yet well documented injuries, especially in the adolescent skeleton. To our knowledge, chronic avulsion fracture to the anterior inferior iliac spine has not been reported. This report presents a case of chronic avulsion fracture to the anterior inferior iliac spine leading to a large ossification mass resulting in a late presentation of hip with limited function. Surgical excision followed by physiotherapy led to satisfactory resolution of pain and significantly improved the range of flexion.

Multiple intratendinous ossified deposits of the Achilles tendon: Case report of an unusual pattern of ossification

True ossification of the Achilles tendon is a rare condition as compared to calcification. The etiology of ossification is multifactorial, however, previous surgery, trauma and degenerative changes have been attributed to be the major causes. Three different patterns of ossification have been described within the Achilles tendon based on their location. We present a case of multiple discrete deposits of ossification within the main substance of the Achilles tendon in a young male with a previous history of clubfoot surgery in childhood. The pattern of ossification was different than all the previously reported cases. Pain was the predominant symptom. He was investigated by using plain radiographs, ultrasonography, computed tomography and magnetic resonance imaging. Surgical excision of all the bony lumps lead to satisfactory outcome without any complications.

Failure of meniscal repair association with late anterior cruciate ligament reconstruction

INTRODUCTION

Meniscus injury is associated with ACL (anterior cruciate ligament) injury. It would be ideal to repair all meniscus tears but failure rate is high.

AIM

Our objective was to assess the success of meniscus repair.

METHOD

All consecutive patients between Jan 2009 to Dec 2013 were retrospectively analysed.

RESULTS

85 meniscus repairs were performed: 64 patients presented after 3 months (Group 1) and 21 patients had meniscus repair within 2 weeks. The failure rate group 1 was 23%-4.8% group 2 at a mean follow up of 11 months.

CONCLUSION

Early meniscal repair had a higher success rate. Level III evidence.

Cement augmentation for vertebral fractures in patients with multiple myeloma

Objective of our study was to assess the outcome of cement augmentation in patients with multiple myeloma. We reviewed 12 patients with 48 vertebral fractures. Mean age was 62.5 years. Average length of follow-up was 27.5 months. Expected survival was less than 12 months in 2 patients and more than 12 months in the remaining patients. After surgery mean survival was 32.5 months. Mean correction in vertebral angle was 3.6°. Karnofsky score was more than 70 in 5 patients, 50-70 in 6 and less than 50 in 1 patient preoperatively, while it was more than 70 in all patients postoperatively. Preoperative mean ODI was 72%. After surgery it was 46% at 6 weeks and 14% at 12 months. All patients reported improvement in their pain status after surgery. Cement augmentation is a safe and effective way of treating symptoms of multiple myeloma, which occur due to vertebral metastases. It results in excellent pain control and improvement in quality of life.

Prepatellar continuation rupture: Report of an unusual case

In anatomical studies the deepest soft tissue layer, related to the deep rectus femoris tendinous fibers, has been described as the "prepatellar quadriceps continuation". We present an unusual case of an isolated prepatellar continuation rupture, which to our knowledge is the first described case in the literature. Injuries to the extensor mechanism may include isolated rupture of the prepatellar continuation with intact quadriceps and patellar tendons. Diagnosis may be difficult with ultrasound scan and requires MRI scan for confirmation. Appropriate clinical assessment and regular physiotherapy lead to a full functional recovery.

Tertiary syphilis in the cervical spine: a case report and review of the literature

As the prevalence of syphilis rises, an increase in tertiary syphilis with spinal involvement is predicted. We report what we believe to be the first case of compressive cervical spine syphilitic gummata, with central cord compression signs. We also review the relevant literature to date. The diagnosis of syphilis in the spine relies on the physician to be aware of it as part of the differential diagnosis. Treponemal laboratory tests are an important aid in establishing a diagnosis.

Accuracy of prognostic scores in decision making and predicting outcomes in metastatic spine disease

INTRODUCTION

Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease.

METHODS

Retrospectively, four years of data were collected (2007-2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction.

RESULTS

A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32-87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1-39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age.

CONCLUSIONS

The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.

Accuracy of prognostic scores in decision making and predicting outcomes in metastatic spine disease

INTRODUCTION

Management of metastatic spinal disease has changed significantly over the last few years. Different prognostic scores are used in clinical practice for predicting survival. The aim of this study was to assess the accuracy of prognostic scores and the role of delayed presentation in predicting the outcome in patients with metastatic spine disease.

METHODS

Retrospectively, four years of data were collected (2007-2010). Medical records review included type of tumour, duration of symptoms, expected survival and functional status. The Karnofsky performance score was used for functional assessment. Modified Tokuhashi and Tomita scores were used for survival prediction.

RESULTS

A total of 55 patients who underwent surgical stabilisation were reviewed. The mean age was 63 years (range: 32-87 years). The main primary sources of tumours included myeloma, breast cancer, lymphoma, lung cancer, renal cell cancer and prostate cancer. Of the cases studied, 29 patients had posterior instrumented stabilisation alone, 10 patients had an anterior procedure alone and 16 patients (with an expected survival of more than one year) had both anterior and posterior procedures performed. Twenty-three patients presented with spinal cord compression. The mean follow-up duration was 9 months (range: 1-39 months). Patients who were treated within one week of referral survived longer than anticipated. Patients were divided into three groups based on their expected survival. Actual survival was better in all three groups after surgery. Discrepancies in scores were prominent in patients with myeloma, breast and prostate cancers. Functional outcome was better in patients under 65 years of age.

CONCLUSIONS

The prognostic scoring systems are not uniformly effective in all types of primary tumours. However, they are useful in decision making for surgical intervention, taking other factors into account, in particular the age of the patient, the type and stage of the primary tumour and general health.

Early results after vertebral body stenting for fractures of the anterior column of the thoracolumbar spine

INTRODUCTION

Vertebroplasty and balloon kyphoplasty have shown to improve pain and functional outcome in cases with symptomatic vertebral fractures. Although restoration of the vertebral body height and kyphosis seemed to be easier with balloon kyphoplasty, it became clear that some of the correction achieved by the balloon is lost once it was deflated. Vertebral body stent was developed to eliminate this phenomenon. To our knowledge this is the first study in describing this technique in clinical settings.

MATERIALS AND METHODS

Seventeen patients with 20 fractured vertebral bodies were included. All fractures were Type A1.3 or A3.1 (incomplete burst). Information about pain (visual analogue scale-VAS) and function (Oswestry disability index-ODI) and vertebral body deformity (vertebral angle-VA) was recorded in a prospective way at regular intervals. Patients were classified into osteoporotic group (7 patients) and traumatic groups (10 patients, younger than 60 years).

RESULTS

There were 6 male and 11 female patients with mean age of 58.1 years (31-88 years). Mean follow up was 12 months. The preoperative pain level showed a mean VAS score of 8.9 in osteoporotic group and 9.7 in traumatic group. Postoperatively, in osteoporotic group, mean VAS was 4.8 at 6 weeks, 4.0 at 6 months and 2.5 at 12 months compared with traumatic fracture group where it was 2.7 at 6 weeks, 2.2 at 6 months and 1.6 at 12 months. Mean ODI in osteoporotic group was 41.7% (14-58%) and in traumatic group it was 20.4% (6-33%). Mean vertebral body angle prior to surgery in osteoporotic group was 9.7 whilst postoperatively it was 5.2°; so the mean correction achieved was 4.5°. In traumatic group preoperative VA was 13° whilst postoperatively it was 5.7°; therefore the mean correction achieved was 7.3°. None of the patients lost reduction at their last follow up.

CONCLUSION

Vertebral body stenting leads to satisfactory improvement in pain, function and kyphosis correction in the treatment of osteoporotic and traumatic fractures. Anterior spinal column, especially the fragmented superior endplate is nicely reconstructed by the stent provided it is inserted accurately. With addition of posterior transpedicular instrumentation, indications for this technique may be wider covering some Type B and C fractures with similar vertebral body damage.

Clinical results and motion analysis following arthroscopic anterior stabilization of the shoulder using bioknotless anchors

Purpose:

Traumatic anterior dislocation of the shoulder is a common occurrence increasingly being treated arthroscopically. This study aims to determine the outcome of arthroscopic anterior stabilization using bioknotless anchors and analyze the motion in a subset of these patients.

Materials and Methods:

The outcome of 20 patients who underwent arthroscopic anterior stabilization using the bioknotless system was studied (average follow-up 26 months). Four of these patients underwent motion analysis of their shoulder pre- and post-operatively.

Results:

15% were dissatisfied following surgery and the recurrence of instability was also 15%. Those who were dissatisfied or suffered recurrent symptoms had statistically significant lower constant scores at the final follow up. Pre-operative motion analysis showed a disordered rhythm of shoulder rotation which was corrected following surgery with minimal loss of range of motion.

Conclusions:

Our success rate was comparable to similar arthroscopic techniques and results published in the literature. Patient satisfaction depended more on return to usual activities than recurrence of symptoms. There was very little reduction in range of movement following surgery and the rhythm of shoulder motion, particularly external rotation in abduction was improved.

Level of Evidence:

Four retrospective series.

Fc24-01 - Ego defense mechanisms in pakistani medical students: a cross sectional analysis

Background

Ego defense mechanisms, defined by Freud as unconscious resources used by the ego to reduce conflict between the id and superego, are a reflection of how an individual deals with conflict and stress. Vaillants’ proposed Hierarchy of Defenses states that mature defenses are associated with better adaptive functioning and health, as opposed to immature defense which are correlated negatively with measures of adaptive adult functioning.

Objectives

This study assesses the prevalence of various ego defense mechanisms employed by medical students of Karachi, which is a group with higher stress levels than the general population.

Methods

A questionnaire based cross-sectional study was conducted on 682 students from five major medical colleges of Karachi in November 2006. Ego defense mechanisms were assessed using the Defense Style Questionnaire(DSQ-40) individually and as grouped under Mature, Immature, and Neurotic factors.

Results

Neurotic defenses had a higher mean score(5.62) than Mature(5.60) and Immature(4.78) mechanisms. Immature mechanisms were more commonly employed by males whereas females employed more Neurotic mechanisms than males. Neurotic and Immature defenses were significantly more prevalent in first and second year students. Mature mechanisms were significantly higher in students enrolled in Government colleges than Private institutions (p< 0.05).

Conclusions

Neurotic mechanisms are more commonly encountered than Mature or Immature mechanisms among medical students of Karachi, and this could reflect greater stress levels than the general population. Employment of these mechanisms was associated with female gender, enrollment in a private medical college, and students enrolled in the first 2 years of medical school.

Prediction of the warfarin maintenance dose after completion of the 10 mg initiation nomogram: do we really need genotyping?

INTRODUCTION

Initiation of warfarin therapy is complicated by its narrow therapeutic index and inter-patient dose-effect variability. A '10-mg nomogram' warfarin initiation protocol permits safe therapeutic anticoagulation in outpatients started on warfarin. We aimed to develop a safe and effective warfarin maintenance dose prediction tool in these patients.

METHODS

Baseline potential predictor variables were collected on a retrospective cohort of outpatients initiated on warfarin for venous thromboembolism treatment. The primary outcome was the warfarin maintenance dose, defined as mean warfarin dose over the last 10 days of the first month of warfarin treatment. Univariate and multivariate analyses were performed to determine which baseline variables were warfarin maintenance dose predictors. An independent cohort of patients validated the derived warfarin maintenance dose prediction rule.

RESULTS

Patient's age and weight, cumulative dose of warfarin over the first week of induction and international normalized ratio (INR) on days 3, 5 and 8 were statistically significant predictors of the warfarin maintenance dose. Our final prediction rule reads: maintenance dose (in mg) = 2.5 + 10% of the first week cumulative dose - INR value at day 8 + 1.5 if INR was below 2.0 at day 5. In the validation cohort, the predicted dose was strongly correlated with the actual maintenance dose (r = 0.88, P < 0.0001). The mean difference between observed and predicted dose was not clinically significant: -0.1 +/- 1.1 mg.

CONCLUSION

In outpatients initiated on warfarin using a '10-mg nomogram', a simple prediction rule can accurately predict warfarin maintenance dose. Prospective studies employing the rule are indicated.

Sensitivity pattern and beta-lactamase production in clinical isolates of Aeromonas strains

Of the 43 Aeromonas spp. isolated from various clinical samples 94% isolates were Beta-lactamase producers. The isolates were tested for sensitivity by disc diffusion method which is commonly used in Pakistan. MIC was determined by using Epsilometer test (E-test) method. More than 80% isolates were sensitive to cephalosporins and quinolones. However, resistance to commonly used antibiotics was very high, 94% isolates were resistant to ampicillin which corresponds to the betalactamase production. More than 60% of the isolates were resistant to cotrimoxazole and 40% to chloramphenicol, hence quinolones and cephalosporins appear to be the drugs of choice for treating serious Aeromonas infections. The MIC range of Aeromonas was best for cefotaxime < 0.06 - 1.0 ug/ml. MIC 90 for cefotaxime was 0.50 ug/ml, for imipenem 0.25 ug/ml and for ciprofloxacin 2.0 ug/ml.

Antibodies to a streptococcal cell wall adjuvant structure persist in patient with chronic rheumatic heart disease

Sera from 50 patients with chronic rheumatic heart disease were analysed by an enzyme linked immunosorbent assay for the presence of antibodies to the streptococcal minimal adjuvant moiety, muramyl dipeptide (MDP). The T-cell responsiveness to this structure was also studied in vitro, using the lymphocyte transformation test. Fifty four percent of the patients possessed anti-MDP antibodies in their sera when examined 5 to 25 years after the initial rheumatic attack. Such antibodies were found only in 5 to 6% of sera from healthy controls or from patients with cardiac disease of non-rheumatic origin. There was neither antigenic nor mitogenic stimulation by MDP of the T-cells from peripheral blood of chronic rheumatic heart disease patients or controls. The results point to a lifetime persistence of anti-MDP antibodies in rheumatic fever and rheumatic heart disease. Possible mechanisms by which detectable levels of such antibodies are maintained in rheumatic heart disease are discussed.