Lower Limb Malrotation following Minimally Invasive Plating in Distal Tibia Fractures

Introduction

Minimally invasive percutaneousosteosynthesis (MIPO) plating techniques havedemonstrated good outcomes in the treatment of distal tibia fractures. Early arthritis and functional impairment mayoccur if length and rotation are not restored. This study aims to determine the incidence and severity of tibia malrotation following MIPO plating of isolated unilateral distal tibia fractures, defined as torsional difference of greater than 10° as compared to the contralateral limb and whether the degree of malrotation affects functional outcomes scores.

Materials and methods

This was a level 2 prospective cohort study. All patients with fractures of the distal tibia who underwent surgical fixation with the exclusion ofpatients with polytrauma, neurovascular injuries or pre-existing disabilities were recruited. Patients underwent MIPO plating followed by a post-operative ComputedTomography (CT) scan of bilateral lower limbs. AOFAS ankle-hindfoot score was recorded at six months and one year follow-up.

Results

A total of 24 patients (28 to 83 years old) were recruited. Nineteen patients obtained CT scans. Nine of the 19 patients (47.3%) had tibia malrotation. The mean tibia malrotation angle was 10.3° (0° - 45°). The average AOFAS scores was 82.4 and 84.3 at 6 months and 1 year follow-up. Degree of CT malrotation was not significantly associated with AOFAS scores at 6 month (spearman rho -0.386) and 1 year (spearman rho -0.343).

Conclusions

Tibia malrotation following MIPO plating of distal tibia fractures is common, with an incidence of 47.3% and an average malrotation angle of 10.3°. The degree of malrotation does not appear to have significant mid-term functional impact on the patient.

Functional Outcomes Following Posterior Cruciate Ligament and Posterolateral Corner Reconstructions. A Three-year Experience in Seremban, Malaysia

Introduction:

This study was conducted to evaluate the demographics, causes and outcomes of patients who underwent Posterior Cruciate Ligament (PCL) reconstruction and/or Posterolateral Corner (PLC) reconstruction performed at our institution over the last three years. Sub-analysis was performed to assess the impact of delay from injury to surgery and how this affected outcomes.

Material and Methods:

From an initial number of 10 patients, seven were contactable and available for analysis. All patients underwent PCL and/or PLC reconstruction (modified Larson’s procedure) between 2017 and 2019. The mean age of our cohort was 31.4±9.6 years (range, 21 to 46). Assessment of functional outcomes pre- and post-operatively were done using the Lysholm knee scoring scale, the Knee injury and Osteoarthritis Outcome Score (KOOS) and visual analogue scale (VAS). The mean follow-up from operation at time of reporting was seven months (range, 2 to 12 months).

Results:

There were four combined PCL and PLCs, two isolated PLCs and one patient who underwent an isolated PCL reconstruction. There were significant improvements between pre-operative and post-operative in all functional outcome scores utilised following PCL reconstruction and/or modified Larson’s reconstruction. Lysholm knee scoring scale improved from pre-operative to post-operative at 41.14±12.32 to 74.86±13.52 (p=0.0001), KOOS from 49.71±11.19 to 71.43±13.84 (p=0.001), and VAS from 5.71±2.06 to 2.86±2.48 (p=0.001). Our sub-analysis showed that higher functional outcomes were present when surgery was done less than six months from the time of index injury. There were no complications (eg. Infections, revisions) in this cohort at the time of reporting.

Conclusion:

Reconstructive surgery for PCL and/or PLC injury is successful in increasing the functional outcomes of patients post-operatively. Delays from injury to surgery remains a problem in the public setting as patients may need to await appropriate imaging and approval of funding. Increased awareness for early surgical intervention may improve overall outcomes of PCL and/or PLC reconstruction in Malaysia.

The first pilot study of expanded newborn screening for inborn errors of metabolism and survey of related knowledge and opinions of health care professionals in Hong Kong

INTRODUCTION

Newborn screening is important for early diagnosis and effective treatment of inborn errors of metabolism (IEM). In response to a 2008 coroners' report of a 14-year-old boy who died of an undiagnosed IEM, the OPathPaed service model was proposed. In the present study, we investigated the feasibility of the OPathPaed model for delivering expanded newborn screening in Hong Kong. In addition, health care professionals were surveyed on their knowledge and opinions of newborn screening for IEM.

METHODS

The present prospective study involving three regional hospitals was conducted in phases, from 1 October 2012 to 31 August 2014. The 10 steps of the OPathPaed model were evaluated: parental education, consent, sampling, sample dispatch, dried blood spot preparation and testing, reporting, recall and counselling, confirmation test, treatment and monitoring, and cost-benefit analysis. A fully automated online extraction system for dried blood spot analysis was also evaluated. A questionnaire was distributed to 430 health care professionals by convenience sampling.

RESULTS

In total, 2440 neonates were recruited for newborn screening; no true-positive cases were found. Completed questionnaires were received from 210 respondents. Health care professionals supported implementation of an expanded newborn screening for IEM. In addition, there is a substantial need of more education for health care professionals. The majority of respondents supported implementing the expanded newborn screening for IEM immediately or within 3 years.

CONCLUSION

The feasibility of OPathPaed model has been confirmed. It is significant and timely that when this pilot study was completed, a government-led initiative to study the feasibility of newborn screening for IEM in the public health care system on a larger scale was announced in the Hong Kong Special Administrative Region Chief Executive Policy Address of 2015.

Some personal thoughts on plagiarism

Some personal thoughts on plagiarism

J. W. T. Ng, Department of Surgery, Yan Chai Hospital, 7–11 Yan Chai Street, Tsuen Wan, Hong Kong

Prospective study of safety, patient satisfaction and leg ulcer healing following saphenous and subfascial endoscopic perforator surgery

C. Recek, Mantlergasse 24, A-1130 Vienna, Austria

Author's reply O. Nelzén, Centre for Leg Ulcer Research, Vascular Surgical Unit, Department of Surgery, Skaraborg Hospital, S-541 85 Skovde, Sweden

Outcome measures after lower extremity bypass surgery: there is more than just patency

S. Caeiro, Unidad de Angiología y Cirugía Vascular, Complexo Hospitalario de Ourense, C/Ramón Puga 54, Ourense, Spain

Author's reply I. Dawson, Department of Surgery, IJsselland Ziekenhuis, Prins Constantijnweg 2, 2908 ZC Capelle aan de Ijssel and J. H. van Bockel, Department of Surgery, Leiden University Medical Centre, Rijnsburgerweg 10, 2333 AA Leiden, The Netherlands

Laparoscopic vagotomy and open pyloroplasty for bleeding duodenal ulcer not controlled endoscopically

The majority of our patients with bleeding duodenal ulcer responded to endoscopic injection treatment. However, in six patients admitted during a 2 1/2-year period, we were forced to do emergency surgery to control the hemorrhage (three with failed injection and persisting exsanguination from a brisk bleeder and three rebled soon after apparent initial hemostasis). We performed an innovative procedure: pyloroplasty was done after oversewing the arterial bleeder in the duodenum through a small transverse wound in the right upper quadrant. The wound was then closed around a 10-mm trocar sheath. With the addition of three more ports, a truncal vagotomy was completed laparoscopically. Recovery was rapid and uneventful in all six cases; postoperative pain was minimal. The mean operative time was 85 minutes. We believe that, in a selected group of patients, laparoscopic vagotomy and open pyloroplasty through an essentially extended port wound (as described in detail) is an expedient and effective procedure in the emergency setting.

The technique of endoscopic exploration for parathyroid adenoma of the neck

BACKGROUND

The technical details of endoscopic exploration of parathyroid adenoma are described here, thereby drawing attention to the enormous potential of this new modality of minimal-access surgery.

METHODS

Four patients with a parathyroid adenoma that was clearly demonstrated by pre-operative localization imaging techniques were subject to endoscopic exploration using one 11 mm and two 5 mm ports: a technique heretofore undescribed.

RESULTS

An adenoma was successfully localized endoscopically in each case and was removed. The postoperative outcome proved most encouraging: no analgesics were required, the hypercalcaemia rapidly corrected and the patients were pleased with the smallness of scars.

CONCLUSIONS

The described endoscopic approach is a viable and promising alternative to open surgery for parathyroid adenoma; further study would be fruitful.

Laparoscopic orchidopexy for persistent müllerian duct syndrome

Persistent müllerian duct syndrome, characterized by the presence of a uterus and fallopian tubes in a phenotypic male, frequently presents as undescended testis, either intra-abdominal or within a hernial sac. We report the first two postpubertal cases successfully managed by a one-stage laparoscopic-assisted orchidopexy. The first had one and the second had two intra-abdominal testes. All testes were brought to the scrotum after dividing the spermatic vessels while the collateral circulation was carefully preserved. The two cardinal therapeutic goals, intrascrotal placement of well-vascularized testes and normal hormonal function, were achieved. Laparoscopic surgical techniques for this condition are discussed.

Isolated duplications of the cystic duct: case report and implications in laparoscopic cholecystectomy

During laparoscopic cholecystectomy on an elderly patient, we were alarmed to find another "cystic" duct after division of the cystic duct, and the operation was converted to open laparotomy. This is the first documented case in the English literature of duplication of a cystic duct with two ducts joining the common hepatic duct at the same level. This and other anatomic variations are important considerations in the safe performance of laparoscopic cholecystectomy.

Murine B7-2, an alternative CTLA4 counter-receptor that costimulates T cell proliferation and interleukin 2 production

The B7-1 molecule, expressed on antigen presenting cells (APC), provides a crucial costimulatory signal for T cell activation. Recent studies demonstrate the existence of alternative, non-B7-1 CTLA4 counter-receptors in mice and humans. Here, we describe the molecular cloning and demonstrate costimulatory function of the murine B7-2 (mB7-2) gene. Murine B7-2 cDNA encodes a member of the Ig supergene family that binds CTLA4-Ig and stains with the GL1 but not anti-mB7-1 mAb. Murine B7-2 costimulates the proliferation and interleukin 2 production of CD4+ T cells and this costimulation can be inhibited by either CTLA4-Ig or GL1 mAb. Identification of the B7-2 molecule will permit further manipulation of the B7:CD28/CTLA4 costimulatory pathway which has been shown to be involved in the prevention of tolerance, induction of tumor immunity, and most recently, in the pathogenesis of autoimmunity.

Cloning of B7-2: a CTLA-4 counter-receptor that costimulates human T cell proliferation

Although presentation of antigen to the T cell receptor is necessary for the initiation of an immune response, additional molecules expressed on antigen-presenting cells deliver essential costimulatory signals. T cell activation, in the absence of costimulation, results in T cell anergy. The B7-1 protein is a costimulator molecule that regulates interleukin-2 (IL-2) secretion by signaling through the pathway that uses CD28 and CTLA-4 (hereafter referred to as the CD28 pathway). We have cloned a counter-receptor of CD28 and CTLA-4, termed B7-2. Although only 26 percent identical to B7-1, B7-2 also costimulates IL-2 production and T cell proliferation. Unlike B7-1, B7-2 messenger RNA is constitutively expressed in unstimulated B cells. It is likely that B7-2 provides a critical early costimulatory signal determining if the T cell will contribute to an immune response or become anergic.

Intestinal obstruction due to axial twisting of bowel in transmesenteric hernia

A baby, born with gastroschisis, had an unrepaired large aperture in the mesocolon close to a short segment of colon. One day, the entire length of bowel proximal to the defect traversed the rent. The free segment of colon was affected by the resulting twist along the long axis of the bowel and became obstructed. A large mesenteric defect, albeit too wide to strangulate the bowel, is not totally innocuous and should always be closed.

Severe hemorrhage from cytomegalovirus rectal ulcers in a burned adult

Clinically evident gastrointestinal involvement by cytomegalovirus has been amply documented in various immunocompromised states with the notable exception of burns. A 44-yr-old man, having sustained 40% burn, who developed severe bleeding from rectal ulcers at the time of a primary cytomegalovirus infection is described. Evidence is provided, implicating cytomegalovirus as the responsible pathogen. We suggest that cytomegalovirus infection should be included in the differential diagnosis of gastrointestinal bleeding occurring in a burned patient. In that case, bleeding can occur from any part of the gastrointestinal tract.