Posterior Tibial Slope in Anterior Cruciate Ligament Surgery: A Systematic Review.

Background: While the literature suggests a correlation between posterior tibial slope and sagittal stability of the knee, there is a lack of consensus relating to how to measure the slope, what a normal slope value would be, and which critical values should guide extra surgical treatment. We performed a systematic literature review looking at the posterior tibial slope and cruciate ligament surgery. Our aims were to define a gold standard measurement technique of posterior tibial slope, as well as determining its normal range and the important values for consideration of adjuncts during cruciate ligament surgery. Methods: Electronic searches of MEDLINE (PubMed), CINAHL, Cochrane, Embase, ScienceDirect, and NICE in June 2020 were completed. Inclusion criteria were original studies in peer-reviewed English language journals. A quality assessment of included studies was completed using the Methodological Index for Non-Randomized Studies (MINORS) Criteria. Results: Two-hundred and twenty-one papers were identified; following exclusions 34 papers were included for data collection. The mean MINORS score was 13.8 for non-comparative studies and 20.4 for comparative studies, both indicating fair to good quality studies. A large variation in the posterior tibial slope measurement technique was identified, resulting in a wide range of values reported. A significant variation in slope value also existed between different races, ages and genders. Conclusion: Cautiously, the authors suggest a normal range of 6-12º, using the proximal tibial axis at 5 and 15 cms below the joint. We suggest 12º as a cut-off value for slope-reducing osteotomy as an adjunct to revision ligament reconstruction.

Radiofrequency ablation (Rafaelo Procedure) for the treatment of hemorrhoids: a case series in the United Kingdom.

PURPOSE: Hemorrhoidal disease remains a common condition that can have a significant effect on a patient's quality of life. Various methods have been introduced over the years; however, their overall success rates remain low. Although the traditional Milligan Morgan technique is effective, the associated pain level prevents it from being an attractive form of treatment. This study was devised to assess the safety and efficacy associated with a novel minimally invasive approach, radiofrequency ablation (RFA). METHODS: Forty-two patients underwent RFA at a single center, by 1 of 2 surgeons. This was performed under local anesthetic and sedation. Outcomes including postoperative pain levels, recurrence rates, and patient satisfaction scores were recorded and analyzed using medians and interquartile ranges. RESULTS: The median postoperative pain score was 2.5/10 (interquartile range [IQR], 0-4.5) and the overall patient satisfaction score was 9 out of 10 (IQR, 6.5-10). Recurrence rates (6-12 months following the procedure) were low at 12% and all patients reported milder symptoms at recurrence. There were no serious adverse complications. CONCLUSION: The results from this case series supports other limited data in concluding that RFA is a safe and effective method in the treatment of hemorrhoids and patients report a high level of satisfaction following.

Patellotrochlea Index in Normal Healthy Knees.

Patella alta is a common and significant abnormality responsible for many patellofemoral joint-related conditions. Many methods of patella height measurements are described; however, patellotrochear index (PTI) is the most logical method as it measures the direct relation between patella and trochlea. The aim of this study is to investigate PTI in normal healthy asymptomatic volunteers to understand the patellofemoral relation in normal knees. Twenty-five healthy volunteers underwent magnetic resonance imaging (MRI) scans of both knees. Two observers independently measured PTI on two different occasions at 6-week interval. Statistical analysis was performed to identify intra- and interobserver correlation between two observers and the mean value of PTI. Agreement analysis was performed according to Bland and Altman. Comparisons of means were made using paired t-tests. The mean age of 25 healthy volunteers was 21.28 years (19-23) with a male:female ratio of 14:11. The overall mean PTI value of all observations was 36.8% and pooled standard deviation (SD) 11.5%. Intraclass correlation (ICC) testing showed "good" interobserver ICC between two observers for PTI for both first (0.80) and second (0.84) set of measurements. There was "excellent" intraobserver correlation for two sets of measurements of PTI made by each first (0.96) and second (0.91) observer. Intraobserver repeatability for PTI was ± 0.07 and ± 0.1, respectively, for the first and second observer. Interobserver repeatability for PTI was ± 0.159 and ± 0.133, respectively, for the first and second set of measurements. Analysis of individual measurements of patella and trochlear articular cartilage revealed that the largest repeatability values were for trochlea measurements. The study reports that the average PTI in asymptomatic healthy knee utilizing current clinical MRI scanning conditions is 36.8%. This provides surgeons with a gold standard normal PTI value, which can serve as a target value in clinical diagnosis as well as surgical correction of patella height. There is good to excellent intra- and interobserver correlation with limited variability in assessing patella height using PTI on MRI scan.

Characterization and treatment of immune thrombocytopenia in Europe: a qualitative observational study.

BACKGROUND: Immune thrombocytopenia (ITP) is a rare disease, characterized by increased platelet destruction/suboptimal platelet production, leading to thrombocytopenia and risk of severe bleeding events. METHODS: Interviews with 23 physicians and 12 payors, a survey with 113 physicians and validation using published data were used to define the current treatment paradigm and healthcare resource utilization and to determine the costs associated with managing acute bleeds in six European countries (Germany, Spain, France, Italy, Netherlands, UK). The study estimated a prevalence of 9 to 10 per 100,000 adults in 2020 across all six countries (disease severity split: 34% mild, 32% moderate, 33% severe (due to rounding up some values might not sum up to 100%). RESULTS: Physician feedback showed that most patients with ITP (60%) received first-line treatment or were monitored by their physician; ∼75% of patients relapsed within 3-4 months. Thrombopoietin-receptor agonists (TPO-RAs) and rituximab were used to achieve disease stabilization in patients who relapse; patients could switch to an alternative TPO-RA to control symptoms, manage side-effects or improve adherence. The costs of rescue therapies and hospital services (e.g. surgery and admissions) accounted for the majority of healthcare resources to manage bleeding events. CONCLUSION: Physicians would welcome earlier use of TPO-RAs to help maintain long-term control of ITP bleeds and potentially reduce both hospitalization and therapy costs.

A new qualitative RT-PCR assay detecting SARS-CoV-2.

The world is facing an exceptional pandemic caused by SARS-CoV-2. To allow the diagnosis of COVID-19 infections, several assays based on the real-time PCR technique have been proposed. The requests for diagnosis are such that it was immediately clear that the choice of the most suitable method for each microbiology laboratory had to be based, on the one hand, on the availability of materials, and on the other hand, on the personnel and training priorities for this activity. Unfortunately, due to high demand, the shortage of commercial diagnostic kits has also become a major problem. To overcome these critical issues, we have developed a new qualitative RT-PCR probe. Our system detects three genes-RNA-dependent RNA polymerase (RdRp), envelope (E) and nucleocapsid (N)-and uses the ß-actin gene as an endogenous internal control. The results from our assay are in complete agreement with the results obtained using a commercially available kit, except for two samples that did not pass the endogenous internal control. The coincidence rate was 0.96. The LoD of our assay was 140 cp/reaction for N and 14 cp/reaction for RdRp and E. Our kit was designed to be open, either for the nucleic acid extraction step or for the RT-PCR assay, and to be carried out on several instruments. Therefore, it is free from the industrial production logics of closed systems, and conversely, it is hypothetically available for distribution in large quantities to any microbiological laboratory. The kit is currently distributed worldwide (called MOLgen-COVID-19; Adaltis). A new version of the kit for detecting the S gene is also available.

Complex Regional Pain Syndrome after Total Knee Arthroplasty is Rare and Misdiagnosis Potentially Hazardous-Prospective Study of the New Diagnostic Criteria in 100 Patients with No Cases Identified.

Previous studies suggest that complex regional pain syndrome (CRPS) occurs in up to 21% of patients following total knee arthroplasty (TKA). However, this diagnosis has a substantial impact on the patient's management if it is incorrect. We aimed to identify cases, using updated internationally accepted criteria, while investigating potential causes of misdiagnosis.We prospectively studied a consecutive series of 100 primary TKA patients. Each patient was assessed 6-week post-TKA. Pain levels were recorded with the presence of symptoms and signs of CRPS (Budapest Diagnostic Criteria) assessed in those with excessive pain. An alternative diagnosis was sought, in these patients, including the presence of neuropathic pain.We found no cases of CRPS (no patients had symptoms or signs in greater than two of four subgroups). Seventeen patients had excessive pain levels (nine had an alternative diagnosis explaining this). The commonest signs were sensory and sudomotor, whereas motor/trophic changes were not seen. Using a previous definition (Orlando Criteria), eight patients may have been diagnosed with CRPS. Over half of the patients with unexplained excessive pain had evidence of neuropathic pain.CRPS is a rare diagnosis following TKA using modern criteria. Isolated signs and symptoms may lead to the overdiagnosis of CRPS in the presence of unexplained pain following TKA. New diagnostic criteria, with strict definitions and treatment algorithms, are now accepted. Delays in managing more common causes (such as neuropathic pain) may negatively affect the patient's outcome.

Acrometastasis following colorectal cancer: A case report and review of literature.

INTRODUCTION: Colorectal cancer commonly metastasises to the liver, peritoneum and lungs. Bony metastases are uncommon in colorectal cancer and in particular metastases to the hands or feet (acrometastasis) are an extremely rare occurrence. CASE PRESENTATION: A 65-year-old male with a colonic malignancy underwent elective anterior resection. Intra-operatively he was found to have a pelvic collection necessitating an end colostomy. Histology confirmed complete Dukes B tumour excision with no evidence of lymph node metastases. The patient underwent chemo-radiotherapy but was unsuitable for reversal of Hartmann's due to elevated CEA levels and asymmetrical thickening of the rectal stump with a solitary lung nodule identified at a one-year surveillance CT. The lung nodule was resected revealing metastatic adenocarcinoma and biopsies from the rectal stump showed chronic inflammatory changes. The patient was offered further chemotherapy. However, six years after his original surgery the patient presented with an acutely painful left foot with radiographic appearances of an infiltrative sclerotic and lucent lesion confirmed as a calcaneal acrometastasis on Magnetic Resonance Imaging (MRI). DISCUSSION: Diagnosis of acrometastasis is challenging and generally constitutes a wider metastatic process with poor prognosis. Patients are often asymptomatic or present with symptoms mimicking benign lesions such as arthritis, infection or ligamentous sprains of the hands or feet. Therefore, there should be a high index of suspicion and prompt radiological investigation is warranted in order to exclude disease recurrence. CONCLUSION: Although acrometastasis may indicate a poor prognosis, timely diagnosis and intervention may facilitate improvement of long-term survival and symptomatic management.

De Garengeot's hernia: our experience of three cases and literature review.

Groin hernia is a common surgical presentation and nearly half of the femoral hernias present acutely with strangulation. The hernia sac usually contains omentum or small bowel. Rarely, the appendix can herniate into the femoral canal. De Garengeot's hernia is the term used to describe the presence of appendicitis in the femoral hernia. Hernia explorations are performed by surgical trainees and encountering a De Garengeot's hernia can be challenging to manage. We report our experience of three cases of this rare entity and a literature review to improve our understanding for optimum management.

Actinomyces infection causing acute right iliac fossa pain.

This is a case of a 75-year-old man being admitted to the on-call surgical department with acute abdominal pain. On arrival he was clinically dehydrated and shocked with localised pain over McBurney's point and examination findings were suggestive of appendiceal or other colonic pathology. Full blood testing revealed a white cell count of 38×10(9)/L and a C reactive protein (CRP) of 278 mg/L. A CT scan revealed a gallbladder empyema that extended into the right iliac fossa. This case highlights the potential for a hyperdistended gallbladder empyema to present as acute right iliac fossa pain with blood tests suggestive of complicated disease. Further analysis confirmed Actinomyces infection as the underlying aetiology prior to a laparoscopic subtotal cholecystectomy. This case serves to remind clinicians of this as a rare potential cause of atypical gallbladder pathology.

Patient reported outcome measures in military patients with shoulder instability.

OBJECTIVES: The Oxford Shoulder Instability Score (OSIS) is a measure of functional impairment of the upper limb, but it is unclear how it translates into military patients where lower scores, implying higher function, may still be insufficient to meet the increased demands of military service and necessitating surgery. This study aimed to compare OSIS in military and civilian patients undergoing shoulder stabilisation surgery. METHODS: We undertook a prospective, blinded cohort-controlled study with a null hypothesis that there was no difference in the Oxford Instability Scores between military and civilian patient groups. 40 patients were required in each group. A prospective clinical data base (iParrot, ByResults, Oxford, UK) was interrogated for consecutive patients undergoing shoulder stabilisation surgery at a single centre. The senior author-blinded to the outcome score-matched patients according to age, gender and diagnosis. Statistical analysis showed the data to be normally distributed and a paired samples t test was used to compare the two groups. RESULTS: 110 patients were required to provide a matched cohort of 40 in each group (70 male, 10 female subjects). Age distribution was 16-19 years (n=6); 20-24 years (n=28); 25-29 (n=16); 30-34 (n=12); 35-49 (n=12); and 40-44 (n=6). 72 patients (90%) had polar group 1 instability and eight patients (10%) had polar group 2 instability. The mean OSIS in the civilian group was 17.25 and in the military group 18.25. There was no statistical difference between the two groups (p=0.395). CONCLUSIONS: This study supports the use of the OSIS to assess military patients with shoulder instability and monitor the progress of their condition.

Doppler-guided haemorrhoidal artery ligation with recto anal repair: a new technique for the treatment of symptomatic haemorrhoids.

PURPOSE: Doppler-guided haemorrhoidal artery ligation (DGHAL) is a minimally invasive surgical technique used to treat symptomatic haemorrhoids. In 2005, the DGHAL proctoscope was redesigned to incorporate a window through which a recto anal repair (RAR) could be performed to improve the outcome in patients with significant prolapse symptoms. The aim of this study was to observe the outcome of a series of consecutive DGHAL-RAR procedures. METHOD: Seventy-seven consecutive patients (49 male) underwent DGHAL-RAR for symptomatic haemorrhoids and were reviewed for a minimum of 6 months post-surgery. RESULTS: Fifty-seven (74%) of patients presented with both prolapse and bleeding symptoms. The median number of DGHALs performed was six, and the median number of RARs was two. Most (96%) patients were discharged the same day. At follow-up, 11 patients complained of recurrent symptoms, five of prolapse, four of bleeding and two of pruritus. Eight patients suffered with post-operative anal fissures. The procedure is recommended by 84.4% of patients 6 weeks post-surgery. CONCLUSION: DGHAL-RAR is safe, effective and well tolerated. It reduces the need for potentially dangerous excisional procedures. The RAR component is an effective addition to DGHAL in the short term for the treatment of prolapse, but longer follow-up will be required to demonstrate durability of the technique.

Identification of New World monkey MHC-DRB alleles using PCR, DGGE and direct sequencing.

Identification of New World monkey MHC-DRB alleles has previously relied upon labor-intensive cloning and sequencing techniques. Here we describe a rapid and unambiguous way to distinguish DRB alleles in New World monkeys using the polymerase chain reaction (PCR), denaturing gradient gel electrophoresis (DGGE), and direct sequencing. The highly variable second exon of New World monkey DRB alleles was amplified using generic DRB primers and alleles were separated by DGGE. DNA was then reamplified from plugs removed from the gel and alleles were determined using fluorescent-based sequencing. The validity of this typing procedure was confirmed by the identification of all DRB alleles previously characterized by cloning and sequencing techniques from an individual cotton-top tamarin. Importantly, our analysis revealed DRB alleles not previously identified in this reference animal. Following validation of our technique, the protocol was employed for the characterization of MHC-DRB alleles in four other species of New World monkey: the pygmy marmoset, white-faced saki monkey, long-haired spider monkey and owl monkey. Using this technique, we identified five alleles from the cotton-top tamarin, five alleles from the owl monkey, three alleles from the long-haired spider monkey, three alleles from the white-faced saki monkey and two alleles from the pygmy marmoset. On the basis of phylogenetic tree analyses, 13 new DRB alleles were assigned to eight different MHC-DRB lineages. Whereas traditional DRB typing via cloning and sequencing provides limited information, our new technique provides a simple and relatively rapid way of identifying New World monkey MHC-DRB alleles.

Stepwise progression of familial adenomatous polyposis-associated desmoid precursor lesions demonstrated by a novel CT scoring system.

INTRODUCTION: Desmoids are rare, locally aggressive but nonmetastasizing clonal proliferations of fibroblasts that occur both sporadically and in association with familial adenomatous polyposis. Most occur in intra-abdominal sites, where they may lead to major morbidity and mortality. A proposed desmoid precursor lesion occurs in the mesentery of one-third of patients with familial adenomatous polyposis, and postoperative mesenteric fibromatosis has been identified in 20 percent of such patients. True desmoids occur in 10 percent, which suggests a model of development in which the phenotype becomes increasingly severe in a manner analogous to the adenoma-carcinoma sequence. This work aimed to confirm such a progression. METHODS: A five-point CT scoring system for mesenteric fibromatosis and desmoids was devised and validated, and in doing so, their incidence was observed. In the second part of the study, seven patients known to have a precursor lesion underwent abdominal CT a median of 27.5 months after the surgery that identified the lesion. Scans were assessed by the scoring system and compared with those of a matched control group of familial adenomatous polyposis patients. RESULTS: The CT scoring system was reliable and reproducible. Of 103 scans of asymptomatic patients with familial adenomatous polyposis, mesenteric fibromatosis and desmoid tumors were identified in 21 and 2 percent, respectively. In the follow-up of patients with desmoid precursor lesions, those in the precursor lesion group had a significantly greater degree of mesenteric fibromatosis and desmoid formation than their corresponding controls (P = 0.009, Mann-Whitney U test). CONCLUSION: A reliable CT scoring system for mesenteric fibromatosis and desmoid tumors in familial adenomatous polyposis is presented. Results with this system provide further evidence for a stepwise progression in the development of desmoids.