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.

The application of epiphenotyping approaches to DNA methylation array studies of the human placenta.

BACKGROUND: Genome-wide DNA methylation (DNAme) profiling of the placenta with Illumina Infinium Methylation bead arrays is often used to explore the connections between in utero exposures, placental pathology, and fetal development. However, many technical and biological factors can lead to signals of DNAme variation between samples and between cohorts, and understanding and accounting for these factors is essential to ensure meaningful and replicable data analysis. Recently, "epiphenotyping" approaches have been developed whereby DNAme data can be used to impute information about phenotypic variables such as gestational age, sex, cell composition, and ancestry. These epiphenotypes offer avenues to compare phenotypic data across cohorts, and to understand how phenotypic variables relate to DNAme variability. However, the relationships between placental epiphenotyping variables and other technical and biological variables, and their application to downstream epigenome analyses, have not been well studied. RESULTS: Using DNAme data from 204 placentas across three cohorts, we applied the PlaNET R package to estimate epiphenotypes gestational age, ancestry, and cell composition in these samples. PlaNET ancestry estimates were highly correlated with independent polymorphic ancestry-informative markers, and epigenetic gestational age, on average, was estimated within 4 days of reported gestational age, underscoring the accuracy of these tools. Cell composition estimates varied both within and between cohorts, as well as over very long placental processing times. Interestingly, the ratio of cytotrophoblast to syncytiotrophoblast proportion decreased with increasing gestational age, and differed slightly by both maternal ethnicity (lower in white vs. non-white) and genetic ancestry (lower in higher probability European ancestry). The cohort of origin and cytotrophoblast proportion were the largest drivers of DNAme variation in this dataset, based on their associations with the first principal component. CONCLUSIONS: This work confirms that cohort, array (technical) batch, cell type proportion, self-reported ethnicity, genetic ancestry, and biological sex are important variables to consider in any analyses of Illumina DNAme data. We further demonstrate the specific utility of epiphenotyping tools developed for use with placental DNAme data, and show that these variables (i) provide an independent check of clinically obtained data and (ii) provide a robust approach to compare variables across different datasets. Finally, we present a general framework for the processing and analysis of placental DNAme data, integrating the epiphenotype variables discussed here.

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.

Dedicated peri-operative pathway improved day case discharge rate for anterior cruciate ligament reconstructions.

The authors proposed that a well-developed peri-operative pathway for anterior cruciate ligament (ACL) reconstructions improve day case discharge rate with high patient satisfaction. A prospective observational study was undertaken at a district general hospital in UK between August 2017 and April 2018. A dedicated multidisciplinary peri-operative pathway was developed and introduced in January 2018. All primary ACL reconstructions using hamstring grafts in adult patients were included. Primary outcome measure was day case discharge and secondary outcome measures were visual analogue score for pain (VASP), nausea and vomiting scale (NVS), patient satisfaction and 30-day readmission. Patients who underwent surgery before and after introduction of the pathway were in group 1 and group 2, respectively. There were 19 and 22 patients each in group 1 and 2. Age and gender were similar in both groups. Day case discharge rate was significantly better in group 2 (68.4% vs 95.5%, p = 0.02). There were no significant differences in VASP or NVS on day 0, 1 or 3. Patient satisfaction rates were better in group 2 (85.7% vs 100%, p = 0.13). There were no readmissions in both groups. The VASP on day 1 and day 3 post-operatively was significantly better in those who were discharged on the same day (66.8 vs 41.3, p = 0.02; 60.5 vs 34.9, p = 0.03). A well-developed dedicated peri-operative pathway improved day case discharge rate for ACL reconstructions. The pathway was safe and had a higher patient satisfaction rate.

Management of rib fractures in traumatic flail chest: a meta-analysis of randomised controlled trials.

AIMS: Flail chest from a blunt injury to the thorax is associated with significant morbidity and mortality. Its management globally is predominantly non-operative; however, there are an increasing number of centres which undertake surgical stabilisation. The aim of this meta-analysis was to compare the efficacy of this approach with that of non-operative management. PATIENTS AND METHODS: A systematic search of the literature was carried out to identify randomised controlled trials (RCTs) which compared the clinical outcome of patients with a traumatic flail chest treated by surgical stabilisation of any kind with that of non-operative management. RESULTS: Of 1273 papers identified, three RCTs reported the results of 123 patients with a flail chest. Surgical stabilisation was associated with a two thirds reduction in the incidence of pneumonia when compared with non-operative management (risk ratio 0.36, 95% confidence interval (CI) 0.15 to 0.85, p = 0.02). The duration of mechanical ventilation (mean difference -6.30 days, 95% CI -12.16 to -0.43, p = 0.04) and length of stay in an intensive care unit (mean difference -6.46 days, 95% CI 9.73 to -3.19, p = 0.0001) were significantly shorter in the operative group, as was the overall length of stay in hospital (mean difference -11.39, 95% CI -12.39 to -10.38, p < 0.0001). CONCLUSION: Surgical stabilisation for a traumatic flail chest is associated with significant clinical benefits in this meta-analysis of three relatively small RCTs. Cite this article: Bone Joint J 2016;98-B:1119-25.

Management of the lower gastrointestinal system in burn: A comprehensive review.

BACKGROUND: Burn produces complex gastrointestinal (GI) responses. Treatment, including large volume fluid resuscitation and opioid analgesia, may exacerbate GI dysfunction. Complications include constipation and opioid-induced bowel dysfunction (OBD), acute colonic pseudo-obstruction (ACPO), bacterial translocation and sepsis, and abdominal compartment syndrome (ACS). Contamination of perineal burns contributes to delayed healing, skin graft failure and sepsis and may impact upon morbidity and mortality. The authors carried out a literature review on management of the lower GI system in burn. This study aimed to explain: current prevention and treatment modalities; drawbacks and complications associated with available treatments, and to provide direction for development of best practice guidelines. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis, to minimise and remove oedema. METHODS: A comprehensive search of English language literature was performed on PubMed, Medline and Embase. Both MeSH and keywords searches were used. RESULTS: Evidence available on the management of lower gastrointestinal system in burn is summarised. Levels of evidence available are generally low (level III-IV). CONCLUSION: Structured, graded interventions are required for prevention and treatment of constipation and OBD. Correction of electrolyte imbalance, adequate enteral intake and mobilisation are pre-requisites. Laxatives should be used according to World Gastroenterology Organisation recommendations. Resistant constipation may respond to changes in medication, but ACPO should be suspected and treated when present. Other complications, such as bacterial translocation and ACS are common in major burns. There is evidence that selective digestive tract decontamination reduces mortality and infectious episodes in major burns. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis. Surgery is reserved for non-responsive and severe cases. Perineal burns present challenges in wound and bowel management. Faecal management systems and negative pressure wound therapy (NPWT) may improve wound control and hygiene, but diversion colostomy will still be beneficial in some cases. There is a clear need for rigorous studies to guide practice more effectively in these challenging conditions.

Investigating spiritual care perceptions and practice patterns in Hong Kong nurses: results of a cluster analysis.

AIM: Nurses' spiritual care perceptions and practices are explored by identifying profiles of nurses studying in a part-time baccalaureate course in a local Hong Kong university. Relationships between nurses' spiritual care perceptions and their practices are explored. RESEARCH METHOD: Hundred and ninety three nurses completed a structured questionnaire. OUTCOME MEASURES: Spiritual care perceptions and practices. RESULTS: Two-step cluster analysis yielded three clusters. Clusters A, B, and C consisted of 15.0% (n = 29), 44.6% (n = 86), and 40.4% (n = 78), respectively. Cluster A nurses were characterized by relatively negative spiritual care perceptions and practices. Cluster C nurses reported positive perceptions, but negative practices; they mainly chose 'uncertain' for most items on both scales. Cluster B was a large group of nurses holding both positive spiritual care perceptions and practices. Significant differences towards spiritual care were found among clusters. Nurses' perceptions were significant positively correlated with practices (r = 0.62). High positive correlations were found between the two scales (r = 0.83) for nurses in Cluster A, for nurses in Clusters B and C, low positive correlations (r = 0.37) were found. CONCLUSION: Three clusters of Hong Kong nurses were differentiated. They showed differences in the level of their spiritual care perceptions and practices. Despite their level of spiritual care perceptions, nurses seldom incorporated spiritual care practices into their daily nursing care, and the level of spiritual care awareness of some nurses was low. Findings may be used to improve support of nurses, to ensure sensitive spiritual care in their daily practices, and to enhance nursing curricula.

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.