The clinical significance of long non-coding RNAs MALAT1 and CASC2 in the diagnosis of HCV-related hepatocellular carcinoma.

BACKGROUND: Globally, hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death due to a lack of early predictive and/or diagnostic tools. Thus, research for a new biomarker is important. LncRNAs play a functional role in target gene regulation and their deregulation is associated with several pathological conditions including HCC. OBJECTIVE: This study aimed to explore the diagnostic potential of two LncRNAs MALAT1 and CASC2 in HCC compared to the routinely used diagnostic biomarker. MATERIALS AND METHODS: The current study is a case-control study carried out at Fayoum University Hospital and conducted on 89 individuals. The study included three groups of 36 HCC patients on top of HCV(HCC/HCV), 33 HCV patients, and 20 healthy volunteers as a control group. All study subjects were subjected to radiological examinations. The determination of CBC was performed by the automated counter and liver function tests by the enzymatic method were performed. In addition, HCV RNA quantification and the expression level of two LncRNAs (MALAT1 and CASC2) were performed by qRT-PCR. RESULTS: The results revealed a statistically significant difference between study groups regarding liver function tests with a higher mean in HCC/HCV group. Also, serum MALAT1 significantly up-regulated in HCV (11.2±2.8) and HCC/HCV (4.56±1.4) compared to the control group. Besides, serum CASC2 levels in the HCV group were significantly upregulated (14.9±3.6), while, downregulated in the HCC group (0.16± 0.03). Furthermore, The ROC analysis for diagnostic efficacy parameters indicated that CASC2 has higher accuracy (94.6%) and sensitivity (97.2%) for HCC diagnosis than AFP with an accuracy of (90.9%), sensitivity (69.4%), and MALAT1 showed an accuracy of (56.9%), sensitivity (72.2%). CONCLUSION: Our study results indicated that CASC2 is a promising biomarker and is considered better and could help in HCC diagnosis on top of HCV than MALAT1 and the routine biomarker AFP.

In Vitro and In Vivo Antidiabetic Activity, Phenolic Content and Microscopical Characterization of Terfezia claveryi.

Terfezia claveryi (T. claveryi) is used by traditional healers in the Middle East region to treat several diseases, including diabetes. The present study evaluated the total phenolic and investigated the blood-glucose-lowering potential of different aqueous extracts of this selected truffle using in vitro and in vivo models. The phytochemical profile was examined using UPLC-MS. The macerate and the microwave-assisted extract were the richest in phenolic compounds. All T. claveryi extracts exhibited a remarkable α-glucosidase inhibitory effect in vitro, with an IC50 of 2.43, 3.26, 5.18 and 3.31 mg/mL for the aqueous microwave-assisted extract macerate, infusion and decoction, respectively. On the other hand, in the high-fat diet alloxan-induced diabetic mice model, all tested crude aqueous extracts exhibited a significant antihyperglycemic activity (p < 0.05). Four hours after the administration of the 250 mg/kg dose, the macerate was able to induce a 29.4% blood-glucose-lowering effect compared to a 24.8% reduction induced by the infusion, which was sustained for a further two hours. The hypoglycemic effect (29.3% and 32.4%) was also recorded six hours after the administration of the single dose 500 mg/kg of the macerate and the infusion, respectively. Truffle extracts exhibited antidiabetic activity both in vitro and in vivo, providing a rationale for the traditional use as a natural hypoglycemic.

Comparative Phytochemical Profile and Biological Activity of Four Major Medicinal Halophytes from Qassim Flora.

Four halophytic plants, Lycium shawii, Anabasis articulata, Rumex vesicarius, and Zilla spinosa, growing in the central Qassim area, Saudi Arabia, were phytochemically and biologically investigated. Their hydroalcoholic extracts' UPLC-ESIQ-TOF analyses demonstrated the presence of 44 compounds of phenolic acids, flavonoids, saponins, carbohydrates, and fatty acids chemical classes. Among all the plants' extracts, L. shawii showed the highest quantities of total phenolics, and flavonoids contents (52.72 and 13.01 mg/gm of the gallic acid and quercetin equivalents, respectively), along with the antioxidant activity in the TAA (total antioxidant activity), FRAP (ferric reducing antioxidant power), and DPPH-SA (2,2-diphenyl-1-picryl-hydrazyl-scavenging activity) assays with 25.6, 56.68, and 19.76 mg/gm, respectively, as Trolox equivalents. The hydroalcoholic extract of the L. shawii also demonstrated the best chelating activity at 21.84 mg/gm EDTA equivalents. Among all the four halophytes, the hydroalcoholic extract of L. shawii exhibited the highest antiproliferative activity against MCF7 and K562 cell lines with IC50 values at 194.5 µg/mL and 464.9 µg/mL, respectively. The hydroalcoholic extract of A. articulata demonstrated better cytotoxic activity amongst all the tested plants' extracts against the human pancreatic cancer cell lines (PANC1) with an IC50 value of 998.5 µg/mL. The L. shawii induced apoptosis in the MCF7 cell lines, and the percentage of the necrotic cells changed to 28.1% and 36.5% for the IC50 and double-IC50 values at 22.9% compared with the untreated groups. The hydroalcoholic extract of L. shawii showed substantial antibacterial activity against Bacillus cereus ATCC 10876 with a MIC value of 12.5 mg/mL. By contrast, the A. articulata and Z. spinosa exhibited antifungal activities against Aspergillus niger ATCC 6275 with MIC values at 12.5 and 50 mg/mL, respectively. These findings suggested that the L. shawii is a potential halophyte with remarkable biological properties, attributed to its contents of phenolics and flavonoid classes of compounds in its extract.

Chemical Profile, Antioxidant, Antimicrobial, and Anticancer Activities of the Water-Ethanol Extract of Pulicaria undulata Growing in the Oasis of Central Saudi Arabian Desert.

Pulicaria undulata (L.) C. A. Mey has multiple uses as part of the traditional medicament, and several biological activities of the plant have been corroborated in the scientific literature. The current work evaluates the phytochemical constituents and biological properties of the water-ethanol extract of the P. undulata growing in Qassim, the central arid regions of the Kingdom of Saudi Arabia. Qualitative UPLC-ESIQ-TOF analysis identified 27 compounds belonging to the phenolics, flavonoids, triterpenes, coumarins, and of fatty acids chemical classes. The quantitative analysis exhibited 33.3 mg/g GAE (Gallic Acid Equivalents), and 10.8 mg/g QE (Quercetin Equivalents) of the phenolics and flavonoids in the plant's concentrated (to dryness) water-ethanol extract. The trace elements analysis of the plant's dry powder established the presence of copper (20.13 µg/kg), and zinc (68.2 µg/kg) in the higher levels of occurrences. In terms of the antioxidant potential of the plant's extract, the ferric-reducing, and free-radicals scavenging activities were recorded at 47.11 mg/g, and 19.13 mg/g equivalents of the concentrated to dryness water-ethanol extract of the plant. The water-ethanol extract of P. undulata also exhibited antimicrobial activity against the tested Gram-positive bacteria, while no activity was observed against the tested Gram-negative bacteria, or the fungi. The MIC (minimum inhibitory concentration) values were in the range of 49 to 1563 µg/mL, whereas the MBC (minimum bactericidal concentration) values ranged from 49 to 3125 µg/mL, against the tested Gram-positive bacteria. The P. undulata water-ethanol extract also exhibited potent cytotoxic effects with the IC50 value at 519.2 µg/mL against the MCF-7 breast cancer cell-lines, followed by the anticancer activity of erythroleukemic cell-lines, K562 at 1212 µg/mL, and pancreatic cell-lines, PANC-1, at 1535 µg/mL, as compared to the normal fibroblast cells (4048 µg/mL). The Annexin-V assay demonstrated that, as the P. undulata extract's dose increased from IC50 to twice of the IC50, the percentage of the necrosis was found to be increased in the late apoptosis stage of the cancer cells. These data confirmed the P. undulata extract's ability to inhibit several human cancer cell lines' growth in comparison to other local halophytes. The antimicrobial activity of the plant was also confirmed.

Charcot Arthropathy of Foot and Ankle: Radiographic and Clinical Patterns with Related Outcomes.

PURPOSE: Our aim is to retrospectively review and evaluate the patterns of affection of Charcot arthropathy of foot and ankle. METHODS: Two hundred twenty-eight patients (235 feet) with post-acute Charcot were reviewed and classified anatomically through plain radiographs into type I and type II based on single or multiple regions affected, respectively. Type I included ankle, Lisfranc (tarsometatarsal), naviculocuneiform, forefoot, and hindfoot which includes one of the following: talonavicular joint, calcaneocuboid joint, or calcaneus. Type II included peritalar, perinavicular, mid-tarsal Charcot, or any other combination. Both types were further classified into four stages (A, stable with no deformity; B, stable with deformity; C, unstable; and D, deformity/instability with associated mechanical ulcers). RESULTS: The most common type was type IIC (27.2%) followed by type IID (18.3%), while types IA and IIA represented the least common types (3.4% and 3.8%, respectively). Types IA and IIA were managed conservatively. All patients in types IC, ID, IIB, IIC, and IID and the majority of type IB received fusion surgery to achieve stability and correction of deformity. Type II D had the highest complication rate (30%). Five patients ended up with amputation, and all were stage IID. CONCLUSION: Affection of single region has better prognosis than affection of two or more regions. Stage A has the best prognosis and can be managed conservatively provided good diabetes control. Surgery is indicated in all cases of types IC, ID, IIB, IIC, and IID to achieve stability and correction of deformity and prevent complications. Mechanical ulcer (stage D) carries the worst prognosis and highest complication rate.

Phytochemical Analysis, Pharmacological and Safety Evaluations of Halophytic Plant, Salsola cyclophylla.

Salsola cyclophylla, an edible halophyte, is traditionally used for inflammation and pain. To confirm the claimed anti-inflammatory and analgesic properties, a detailed study on respective pharmacological actions was undertaken. The activities are contemplated to arise from its phytoconstituents. The LC-MS analysis of S. cyclophylla 95% aqueous-ethanolic extract revealed the presence of 52 compounds belonging to phenols, flavonoids, coumarins, and aliphatics class. A high concentration of Mn, Fe, and Zn was detected by atomic absorption spectroscopic analysis. The ethyl acetate extract showed the highest flavonoid contents (5.94 ± 0.04 mg/g, Quercetin Equivalents) and Fe2+-chelation (52%) potential with DPPH radicals-quenching IC50 at 1.35 ± 0.16 mg/mL, while the aqueous ethanolic extract exhibited maximum phenolics contents (136.08 ± 0.12 mg/g, gallic acid equivalents) with DPPH scavenging potential at IC50 0.615 ± 0.06 mg/mL. Aqueous ethanolic extract and standard quercetin DPPH radicals scavenging's were equal potent at 10 mg/mL concentrations. The aqueous ethanolic extract showed highest analgesic effect with pain reduction rates 89.86% (p = 0.03), 87.50% (p < 0.01), and 99.66% (p = 0.0004) after 60, 90, and 120 min, respectively. Additionally, aqueous ethanolic extract exhibited the highest anti-inflammation capacity at 41.07% (p < 0.0001), 34.51% (p < 0.0001), and 24.82% (p < 0.0001) after 2, 3, and 6 h of extract's administration, respectively. The phytochemical constituents, significant anti-oxidant potential, remarkable analgesic, and anti-inflammatory bioactivities of extracts supported the traditionally claimed anti-inflammatory and analgesic plant activities.

Anti-Microbial, Anti-Oxidant, and α-Amylase Inhibitory Activity of Traditionally-Used Medicinal Herbs: A Comparative Analyses of Pharmacology, and Phytoconstituents of Regional Halophytic Plants' Diaspora.

Halophytes are the category of plants growing under harsh conditions of super-salinity, and are wide-spread in the coastal Mediterranean climatic conditions and desert oasis. They are adept at surviving through maintaining excessive production of enzymatic, and non-enzymatic secondary metabolites, especially phenolics and flavonoids that primarily work as anti-oxidants and phytoalexins. Five major halophyte species growing in the kingdom's Qassim's high-salted desert regions were investigated for confirming their traditionally used biological activity of sugar-control and anti-infectious properties. In this context, the comparative presence of phenolics, and flavonoids together with anti-microbial, anti-oxidants, and the anti-diabetic potentials of the plants' extracts were investigated through the α-amylase inhibition method. The highest concentrations of phenolics and flavonoids were detected in Salsola imbricata (360 mg/g of the extract as Gallic-Acid-Equivalents/GAE, and 70.5 mg/g of the extract as Rutin-Equivalents/RE). In contrast, the lowest concentrations of phenolics and flavonoids were detected in Salsola cyclophylla (126.6 mg/g GAE, and 20.5 mg/g RE). The halophytes were found rich in trace elements, a factor for water-retention in high-salinity plants, wherein iron and zinc elements were found comparatively in higher concentrations in Aeluropus lagopoides (4113 µg/kg, and 40.1 µg/kg, respectively), while the copper was detected in higher concentration (11.1 µg/kg) in S. imbricata, analyzed through Inductively Coupled Plasma Optical Emission Spectrometric (ICP-OES) analysis. The anti-oxidant potentials and α-amylase enzyme inhibition-based anti-diabetic activity of S. imbricata was significantly higher than the other halophytes under study, wherein S. cyclophylla exhibited the lowest level of α-amylase inhibition. The maximum DPPH radicals' (52.47 mg/mL), and α-amylase inhibitions (IC50 22.98 µg/mL) were detected in A.lagopoides. The anti-microbial activity against the Methicillin-Resistant Staphylococcus aureus was strongly exhibited by Zygophyllum simplex (33 mm Inhibition Zone-Diameter, 50 µg/mL Minimum-Inhibitory-Concentration), while Escherichia coli, Enterococcus faecalis, and Candida albicans growths were moderately inhibited by Tamarix aphylla. The current findings exhibited significant differences among the locally distributed halophytic plants species with regards to their bioactivity levels, anti-oxidant potentials, and the presence of trace elements. The ongoing data corroborated the plants' traditional uses in infections and diabetic conditions. The enhanced local distribution of the plants' diaspora and higher density of occurrence of these plants species in this region, in comparison to their normal climatic condition's counterparts, seemed to be affected by humans' use of the species as part of the traditional and alternative medicine over a period of long time.

Diltiazem potentiates the cytotoxicity of gemcitabine and 5-fluorouracil in PANC-1 human pancreatic cancer cells through inhibition of P-glycoprotein.

AIM: Pancreatic cancer (PC) is one of the most aggressive tumors with dismal survival and a high death rate due to chemotherapeutic failure. P-glycoprotein (P-gp) plays a pivotal role in PC response to gemcitabine and 5-fluorouracil (5-FU). Diltiazem, a calcium channel blocker, is a P-gp inhibitor. In the current study, we investigated the hypothesis that targeting of P-gp by diltiazem can enhance the cytotoxicity of gemcitabine and 5-FU against human pancreatic cancer cells. MAIN METHODS: The cytotoxic effect of diltiazem, gemcitabine, and 5-FU in single and combined forms against PANC-1 and AsPC-1 cells were assayed by MTT. Flow cytometric analysis was used for the determination of cell cycle, apoptosis, and stemness markers in PC cells. Besides, immunoblotting was used for assessment of Bax, caspase 3, cyclin D1, and P-gp expressions. KEY FINDINGS: Diltiazem co-treatment, either with gemcitabine or 5-FU, synergistically reduced cell viability, induced apoptosis, and caused cell cycle arrest. In addition, diltiazem co-treatment decreased the expressions of stem cell markers CD24 and CD44, increased the expressions of Bax and cleaved caspase 3, enhanced DNA fragmentation, and attenuated cyclin D1 and P-gp expressions as compared to cells treated with either gemcitabine or 5-FU alone. SIGNIFICANCE: Our findings suggest that diltiazem may be potential neoadjuvant therapy to enhance the response of PC to gemcitabine or 5-FU treatment.

R-(-)-carvone Attenuated Doxorubicin Induced Cardiotoxicity In Vivo and Potentiated Its Anticancer Toxicity In Vitro

Background: Doxorubicin is one of the most potent broad-spectrum antitumor and chemotherapeutic agents. However, it produces cardiotoxicity. Aims: To investigate whether R-(-)-carvone exerts a cardioprotective effect against doxorubicin toxicity in vivo and in vitro. Study Design: Cell culture and animal experiment. Methods: The synergistic effect of R-(-)-carvone with doxorubicin was evaluated in the MCF 7 cancer cell line while its protective effect against doxorubicin toxicity was evaluated in the normal heart cell line (H9C2) and in vivo. Furthermore, the mechanism of its cardioprotective effect was studied. Results: R-(-)-carvone exerted cytotoxic action on the MCF 7 cancer cell line with an IC50 value of 14.22 µM and potentiated the cytotoxic action of doxorubicin, while it decreased the toxicity of doxorubicin on a normal heart cell line. In BALB/c mice, R-(-)-carvone protected the heart from the toxic action of doxorubicin, as was evident by biochemical and histological studies. The protective effect of R-(-)-carvone on the H9C2 heart cell line and on heart in vivo was due to an increase in catalase activity. Conclusion: R-(-)-carvone has synergistic anticancer action with doxorubicin on the MCF 7 cell line while decreasing its cardiotoxicity.

Hypolipidaemic and Insulin Secretagogue Activities of (R)-(-)-Carvone.

BACKGROUND: Dyslipidaemias are common in patients with diabetes mellitus. A high prevalence of type 2 diabetes in hyperlipidaemic patients also exists. The aim of this study was to find a treatment that lowers both blood glucose and lipid levels simultaneously. METHODS: The hypolipidaemic effect of (R)-(-)-carvone was investigated in a tyloxapol-induced hyperlipidaemia mice model. Furthermore, its effect on insulin secretion and proliferation of 1.1E7 human pancreatic ß-cells was studied. In addition, using molecular docking, the binding affinity of (R)-(-)-carvone against 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase was estimated. RESULTS: (R)-(-)-carvone (100 mg/kg) decreased plasma triglyceride, total cholesterol, low-density lipoprotein cholesterol (LDL-C) levels and atherogenic index by 90.6%, 49.3%, 56.6% and 70.3%, respectively, but it had no effect on high-density lipoprotein cholesterol (HDL-C). Furthermore, it increased hepatic triglyceride level and catalase activity by 79.6% and 59.6%, respectively. In-vitro, 500 µM (R)-(-)-carvone increased insulin secretion by 454.4% and proliferation of 1.1E7 cells with no cytotoxic effects up to a concentration of 100 µM. Molecular docking simulation demonstrated a good binding affinity with -5.03 Kcal/mol of (R)-(-)-carvone to HMG-CoA reductase. CONCLUSION: The hypolipidaemic effect of (R)-(-)-carvone is comparable to that of fenofibrate. (R)-(-)-carvone has the advantage over fenofibrate of not producing hypoglycaemia in animals. Furthermore, (R)-(-)-carvone increased proliferation and insulin secretion of human pancreatic ß-cells.

Gastroprotective activity of Loranthus acaciae flower extract in a rodent model of ethanol-induced ulcer.

Loranthus acaciae (Loranthaceae) is a perennial green semi-parasitic plant used in ethnopharmacological medicine for healing wounds. The protective effect of L. acaciae on gastric ulcer induced by ethanol was investigated in a rat model. Ulcer index and total glutathione level were measured and histological and immunohistochemical studies for the expression of cyclooxygenase-2 were performed. Furthermore, chemical constituents of the flower extract were analyzed. Ulcer index was significantly lowered in L. acaciae-treated groups. Protection ratios were 75.9%, 98.9%, and 70.7% for 250 mg/kg and 500 mg/kg of L. acaciae and 40 mg/kg of esomeprazole, respectively. Histological examination revealed fewer hemorrhage in mucosa and less edema in submucosa of L. acaciae-treated groups compared with control. In the esomeprazole-treated group, there was mild disruption in the surface epithelium and mild hemorrhage. However, edema and leucocytes infiltration in the submucosa layer were present. Immunohistochemical staining of stomach sections for cyclooxygenase-2 (COX-2) was negative in the control group as well as in the L. acaciae-treated groups. Total glutathione level in mucosa layer of the stomach was higher in L. acaciae-treated groups compared with control. Liquid chromatography-mass spectrometric analysis revealed the presence of loranthin and rutin as the major constituents. It can be concluded that L. acaciae imparted a gastroprotective action against ethanol-induced ulcer in rats. Novelty 500 mg/kg L. acaciae protected the stomach by 98.9% from ulcerogenic effect of ethanol. L. acaciae increased total glutathione level but not COX-2 expression in gastric mucosa. Loranthin and rutin were the major constituents in L. acaciae flower extract.

Randomized, double-blind, placebo-controlled, interventional phase IV investigation to assess the efficacy and safety of r-hirudin gel (1120I.U) in patients with hematomas.

BACKGROUND: Hirudin is the most potent direct thrombin inhibitor, and recombinant forms are routinely used in anticoagulation therapy. Recombinant hirudin gels are commercially available for the treatment of hematomas and associated symptoms. OBJECTIVES: To assess the efficacy and safety of a topically administered recombinant hirudin gel in patients with hematomas. PATIENTS/METHODS: This double-blind, placebo-controlled, phase IV investigation recruited patients presenting with at least one hematoma. Subjects were randomly assigned (1:1) recombinant hirudin gel (1120 IU/100 g) or a placebo, administered 2-3 times daily for 16 days. Changes in hematoma size, flare, and the proportion of patients achieving complete resolution of hematomas and associated edemas were investigated. RESULTS: By study end, a greater proportion of subjects in the treatment group achieved a complete resolution of hematomas versus placebo (98.0% vs 71.9%; P  < .001) and edemas (99% vs 50%; P  < .001). Patients in the recombinant hirudin group exhibited a marginally larger, yet significant, reduction in mean hematoma size versus placebo (99.9% vs 96.6%; P  < .001) and flare (93.6% vs 78.6%; P  < .001). Median time to hematoma resolution for the recombinant hirudin and placebo administered cohorts was 8 and 16 days, respectively (P  < .001). No adverse events were reported for the recombinant hirudin cohort. CONCLUSIONS: Topical recombinant hirudin is an effective, safe, and well tolerated intervention for the symptomatic treatment of hematomas. This trial was registered at http://www.clinicaltrials.gov as NCT01960569.

Functional pedal construct achieved by combined operative treatment in peritalar complex Charcot arthropathy: A prospective study of 38 feet.

BACKGROUND: Charcot arthropathy of the peritalar complex carries a high risk of amputation if not properly managed. Our aim is to assess the functional outcome of severe Charcot arthropathy of the peritalar complex following enblock resection of the ulcer, massive debridement and stabilizing all the elements of the peritalar complex. METHODS: We prospectively studied 38 feet in 35 patients with peritalar complex Charcot arthropathy. All Feet underwent intense debridement and fusion using a combination of (Ilizarov) external fixation, and (plate and locked nail) internal fixation. Thirty two feet were graded as Eichenholtz 2, and six feet were graded as Eichenholtz 3. The mean follow up was 35.9months. RESULTS: The mean AOFAS score was significantly elevated from 25.4±9.1 preoperatively to 67.6±5.7 at the most recent follow-up (p<0.001). Complete bony fusion was achieved in 28 feet. Unsound bony fusion occurred in 8 feet. Two feet required below knee amputation. CONCLUSION: Peritalar complex Charcot arthropathy is not uncommon variety. Such cases carry high risk of complications and amputation is not excluded. The proper timing of surgery is crucial. Massive debridement and rigid fixation with strict follow up is mandatory to achieve the ultimate goal of obtaining a plantigrade, stable, mechanically sound, painless and infection free pedal construct.

Triple management of cubitus valgus deformity complicating neglected nonunion of fractures of lateral humeral condyle in children: a case series.

BACKGROUND: Long standing nonunion of the lateral humeral condyle (LHC) usually results in elbow pain and instability with progressive cubitus valgus and tardy ulnar neuritis. Surgical treatment of long standing nonunion is still a controversial issue due to the reported complications, such as stiffness, loss of elbow motion, and avascular necrosis of the LHC fragment. In this study, we reported the outcomes of treatment of cubitus valgus deformity in long standing nonunion of the LHC in children treated with combined triple management (fixation of the nonunion site, dome corrective osteotomy, and anterior transposition of ulnar nerve) through a modified para-triceptal approach. METHODS: We evaluated ten patients with cubitus valgus deformity more than 20 degrees after neglected nonunion of the lateral humeral condyle more than 24 months. Only childern with post-operative follow up more than 24 months were included in this study. All patients were evaluated clinically, radio logically, and by pre- and post-operative functional evaluation using Mayo elbow performance score. For evaluation of ulnar nerve affection, the Akahori's system was used. RESULTS: There were six females and four males with the average age of 7.7 years at operation. The left elbow was affected in six patients and the right elbow was affected in four patients. The average time between fracture of the LHC and operation was 40.3 months with average post-operative follow up of 44.3 months. The average carrying angle of the healthy side was 5.5 degrees and pre-operative carrying angle of the affected side was 33.5 degrees. The average post-operative carrying angle of the affected side was 6.1 degrees. The improvement of the carrying angle at the last follow up was found statistically significant (p < 0.05). All six patients that had pre-operative various degrees of ulnar nerve affection had completely improved at last follow up. The osteotomy site united in an average time of 43 days, whereas the LHC nonunion site united in an average time of 77.2 days. The osteotomy site united in significantly less time than the LHC non-union site (p < 0.05). The correlation between time since injury and time of union of LHC non-union site was significant (p < 0.05). Post-operative elbow range of motion was not changed in five patients, slightly decreased in four patients, and increased in one patient. Three patients had an average 6.7 degrees (range; 5-10) loss of the last degrees of flexion. One patient developed extension lag of 10 degrees. The mean elbow range of motion (ROM) pre-operatively was 139 ± 4.6 degrees while the mean post-operative ROM was 138 ± 5.3 degrees. The difference was found to be statistically insignificant (p > 0.05). The mean pre-operative Mayo elbow performance score was poor 55 ± 9.7, four patients had fair score, and six had poor score. The mean post-operative Mayo elbow performance score was excellent 92.5 ± 10, six patients had excellent score, and four had good score. The improvement of the Mayo score at the last follow up was found to be statistically significant (p < 0.05). No intra-operative complications were recorded during any of the procedures and no patient developed a wound or pin track infection post-operatively. At the last follow up, none of the patients had developed avascular necrosis of the LHC. CONCLUSION: Preservation of the blood supply of the nonunited fragment is the key to successful management. This combined technique successfully addresses different aspects of the problem simultaneously and provides a durable solution without deterioration of the results over time. The para-triceptal approach provided excellent exposure of both sides of the elbow with minimal disruption of the triceps muscle.

Hybrid Fixation for Ankle Fusion in Diabetic Charcot Arthropathy.

BACKGROUND: Ankle fusion is difficult to achieve in the diabetic Charcot ankle Brodsky type 3a because of the poor quality of the bone and the inability to achieve a stable biomechanical construct. The aim of this study was to report the outcome of ankle fusion using a combination of an intramedullary nail and a circular external fixator in patients with diabetic Charcot arthropathy. METHODS: We prospectively studied 24 patients with diabetic Charcot arthropathy of the ankle who were treated by fusion of the tibiotalar joint using a combined retrograde intramedullary nail and Ilizarov external fixator. Their mean age was 50.7 ± 6.9 (range, 43-62) years. The mean follow-up after surgery was 36.4 ± 5.8 (range, 24-98) months. RESULTS: Twenty-two patients (92%) achieved clinical and radiographic solid bony fusion. No patients in this series needed amputation. All the patients were pain free, and the mean American Orthopaedic Foot & Ankle Society Score (AOFAS) improved significantly from 34.6 ± 6.8 to 66.4 ± 4.5 at the last follow-up. Two patients developed an ulcer over the heel due to a prominent nail. The ulcer healed after nail removal. Eight patients developed pin tract infection. CONCLUSION: We report a successful outcomes of ankle fusions using combined intramedullary nail locked only proximally and ring external fixator (hybrid fixation) in patients with diabetic Charcot arthropathy. LEVEL OF EVIDENCE: Level IV, case series.

The management of tibial pilon fractures with the Ilizarov fixator: The role of ankle arthroscopy.

BACKGROUND: Pilon fractures usually result from high energy trauma, and are commonly associated with extensive soft tissue damage which prevents the use of open reduction and internal fixation. PURPOSE: This study was designed to evaluate the use of the Ilizarov external fixator in the treatment of pilon fractures of the ankle, and to determine whether arthroscopy of the ankle could improve the outcome. METHODS: From February 2011 to May 2013 a total of 23 patients with unilateral closed pilon fractures were divided into two groups treated with and without arthroscopy during fixation with the Ilizarov external fixator. The fractures were classified according to the AO Rüdi and Allgower classification. Follow up ranged from 10 to 37 months with a mean of 18 months. RESULTS: All cases were evaluated at follow up by the AOFAS and the Bone et al. grading system. According to Bone et al. there were 3 cases excellent, 4 cases good, 2 cases fair, and 2 cases poor in Group A (without arthroscopy), whereas there were 4 cases excellent, 6 cases good, 2 cases fair in Group B (with arthroscopy). The AOFAS score for Group A was 77.8±5.8, and for Group B was 78.4±6.9. CONCLUSION: We concluded that the Ilizarov external fixator is an excellent method in treating pilon fractures as it minimizes the need for extensive surgery. We also conclude that the use of arthroscopy during pilon fracture fixation did not add statistically significant improvement to our results and it needs longer term investigation to assess its advantage - if any - to the final outcome. LEVEL OF EVIDENCE: level 2.