Acquired Brown Syndrome in Head Trauma: Does Fixation of Associated Nasal and Frontal Bone Fractures Provide a Cure?

A 43-year-old gentleman presented with vertical double vision following nasal and frontal bone fractures resulting from blunt trauma to the glabella. Orthoptic assessment revealed a diagnosis of traumatic Brown syndrome affecting the right eye. The fractures were fixed with open reduction internal fixation via a coronal flap nine days after the injury was sustained. Evidence of resolution of the syndrome became apparent clinically within 15 days following surgery, which was confirmed with a later orthoptic evaluation. This case demonstrates that prompt surgical intervention of fractures associated with traumatic Brown syndrome may lead to resolution without the need to resort to extraocular muscle surgery.

OpenWorm: overview and recent advances in integrative biological simulation of Caenorhabditis elegans.

The adoption of powerful software tools and computational methods from the software industry by the scientific research community has resulted in a renewed interest in integrative, large-scale biological simulations. These typically involve the development of computational platforms to combine diverse, process-specific models into a coherent whole. The OpenWorm Foundation is an independent research organization working towards an integrative simulation of the nematode Caenorhabditis elegans, with the aim of providing a powerful new tool to understand how the organism's behaviour arises from its fundamental biology. In this perspective, we give an overview of the history and philosophy of OpenWorm, descriptions of the constituent sub-projects and corresponding open-science management practices, and discuss current achievements of the project and future directions.This article is part of a discussion meeting issue 'Connectome to behaviour: modelling C. elegans at cellular resolution'.

Non-dependence of nuclear decay rates of 123I and 99mTc on Earth-Sun distance.

Recently published studies have suggested an annual fluctuation of the decay rate of several radionuclides, in particular 32Si and 226Ra. Variation of solar neutrino flux caused by variation of Earth-Sun distance has been proposed as the mechanism of this fluctuation. In this study we prospectively look at two radionuclides which have not previously been studied for annual variation, 123I and 99mTc. Half-lives of samples of these radionuclides were measured approximately weekly and semiweekly respectively over a period of 2 years. Spectral analysis using the Lomb-Scargle method demonstrated no significant periodicity, and in particular, no evidence for a period of 1 year.

Unit testing, model validation, and biological simulation.

The growth of the software industry has gone hand in hand with the development of tools and cultural practices for ensuring the reliability of complex pieces of software. These tools and practices are now acknowledged to be essential to the management of modern software. As computational models and methods have become increasingly common in the biological sciences, it is important to examine how these practices can accelerate biological software development and improve research quality. In this article, we give a focused case study of our experience with the practices of unit testing and test-driven development in OpenWorm, an open-science project aimed at modeling Caenorhabditis elegans. We identify and discuss the challenges of incorporating test-driven development into a heterogeneous, data-driven project, as well as the role of model validation tests, a category of tests unique to software which expresses scientific models.

Hip flexor muscle size, strength and recruitment pattern in patients with acetabular labral tears compared to healthy controls.

Acetabular labral tears are a source of hip pain and are considered to be a precursor to hip osteoarthritis. Hip flexor muscles contribute to hip joint stability and function but it is unknown if their size and function is altered in the presence of labral pathology. This study aimed to investigate hip flexor muscle size, strength and recruitment pattern in patients with hip labral pathology compared to control subjects. 12 subjects diagnosed with an unilateral acetabular labral tear were compared to 12 control subjects matched for age and gender. All subjects underwent magnetic resonance imaging (MRI) of their lumbo-pelvic region. Average muscle cross-sectional area (CSA) of the iliacus, psoas, iliopsoas, sartorius, tensor fascia latae and rectus femoris muscles were measured. Hip flexion strength was measured by an externally fixed dynamometer. Individual muscle recruitment pattern during a resisted hip flexion exercise task was measured by muscle functional MRI. Hip flexor muscle strength was found to be decreased in patients with labral pathology compared to control subjects (p < 0.01). No difference between groups or sides was found for hip flexor muscle size (all p > 0.17) and recruitment pattern (all p > 0.53). Decreased hip flexor muscle strength may affect physical function in patients with hip labral pathology by contributing to altered gait patterns and functional tasks. Clinical rehabilitation of these patients may need to include strengthening exercises for the hip flexor muscles.

Corneal protection during general anesthesia for nonocular surgery.

Corneal abrasion is the most common ophthalmologic complication that occurs during general anesthesia for nonocular surgery. Such abrasions can be caused by a variety of mechanisms and can lead to sight-threatening microbial keratitis and permanent scarring. There is no standard mode of protecting the cornea during general anesthesia for nonocular surgery. Methods described in the literature are not entirely effective and may be associated with unwanted side effects. Taping alone provides protection that is equivalent or superior to other interventions and has fewer side effects. Petroleum gel is flammable and is best avoided when electrocautery and open oxygen are to be used around the face. Preservative-free eye ointment is preferred, as preservative can cause corneal epithelial sloughing and conjunctival hyperemia. Recently, the application of Geliperm and bio-occlusive dressings has been advocated. Geliperm may be particularly useful during endonasal surgery when continuous perioperative observation of the eye is required. In this article, the literature on the etiology of perioperative corneal abrasions is reviewed and various protection strategies are compared in order to identify the best methods to prevent corneal abrasions during general anesthesia.

Knee arthroplasty: a cross-sectional study assessing energy expenditure and activity.

BACKGROUND: What has been missing from current assessment tools post knee arthroplasty is a means by which a patient's mobility and activity levels can be objectively measured over time in a real world setting. The Intelligent Device for Energy Expenditure and Activity (Minisun, Fresno, USA) (IDEEA) is one such device that meets these criteria. It quantifies activity by measuring energy expenditure and records the type of activity performed. The purposes of this study were to (i) determine if there were differences in energy expenditure in different groups of patients at various time points pre- and post-surgery and (ii) determine the correlations between energy expenditure and each of the subjective International Knee Documentation Committee (IKDC), Oxford and Tegner scoring systems. METHODS: Sixty-five total knee arthroplasty (TKA) patients were recruited into a cross-sectional study to collect energy expenditure and activity data using the IDEEA. Data were collected preoperatively and post-operatively at 6-week, 3-month, 6-month and 12-month time intervals. RESULTS: Energy expenditure and type of activity did not significantly change over the five recording periods. The patients spent <5% of the recording time walking, stepping or in transitions between movements. Energy expenditure showed a low to moderate correlation with the subjective IKDC, Oxford and Tegner questionnaires. CONCLUSIONS: Current evaluation questionnaires may not accurately record activity levels and TKA patients spend less time walking than the normal population. We believe the IDEEA is an effective tool for objectively measuring activity and energy expenditure following knee arthroplasty.

Repair of radial tears and posterior horn detachments of the lateral meniscus: minimum 2-year follow-up.

PURPOSE: The aim of this study was to show that repair of posterior radial tears and horn detachments of the lateral meniscus is possible and to assess the outcomes. METHODS: A retrospective review of 24 patients who had repair of a posterior defunctioning tear of the lateral meniscus combined with anterior cruciate ligament reconstruction was undertaken. Patients completed a follow-up postal questionnaire that included Lysholm, subjective International Knee Documentation Committee (IKDC), and Tegner scoring systems. RESULTS: Eight patients had suture repair of a lateral meniscal radial tear. The mean Lysholm, IKDC, and Tegner scores were 86.9 (SD, 11.6), 81.6 (SD, 13.9), and 5.8 (SD, 2.7), respectively, at a mean follow-up of 70.5 months (range, 29.0 to 168.0 months). Subsequent arthroscopy in 2 patients confirmed meniscal healing. Sixteen patients underwent a posterior horn reattachment. The mean Lysholm, subjective IKDC, and Tegner scores were 86.1 (SD, 13.3), 84.3 (SD, 17.0), and 6.5 (SD, 2.1), respectively, at a mean follow-up of 53.6 months (range, 26.0 to 116.0 months). Three patients had subsequent magnetic resonance imaging and/or arthroscopy that indicated meniscal healing. Two further patients had reinjury, and magnetic resonance imaging and/or arthroscopy showed that their repairs had failed. CONCLUSIONS: Posterior radial tears that extend to the capsule and posterior horn detachments of the lateral meniscus are frequently amenable to repair. In this study 22 of 24 repairs functioned successfully over a mean follow-up of 58.6 months (range, 26.0 to 168.0 months). LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Cutaneous larva migrans with optic disc edema: a case report.

INTRODUCTION: A rare case of optic disc edema associated with cutaneous larva migrans is presented. To the best of our knowledge, this has not been previously reported in literature. Joint management by ophthalmology and tropical medicine teams proved most beneficial for our patient, facilitating correct diagnosis, appropriate investigations and instigation of suitable treatment. CASE PRESENTATION: A 45-year-old Caucasian man, a naturalist, from the UK developed cutaneous larva migrans while in Kenya and presented to us with visual disturbance secondary to unilateral optic disc edema. This resolved after receiving a single dose of ivermectin and visual acuity reverted to normal. CONCLUSION: To the best of our knowledge, optic disc edema associated with cutaneous larva migrans has not been previously reported. This case highlights the importance of taking relevant history of recent travel to endemic areas affected by the nematodes in patients presenting with optic disc edema, and pertinent questioning regarding non-ocular symptoms, including skin lesions. In this case, a history of recent foreign travel and treatment for skin lesions was crucial.

Femoral nerve block vs fascia iliaca block for total knee arthroplasty postoperative pain control: a prospective, randomized controlled trial.

Femoral nerve block (FNB) is an accepted mode of analgesia for lower limb procedures but has a documented complication rate. This study compared femoral nerve and fascia iliaca regional anesthesia for total knee arthroplasty (TKA), using fentanyl consumption as the primary outcome measure. Ninety-eight primary unilateral TKA patients were blinded and randomized into fascia iliaca block (FIB) (n = 51) or FNB (n = 47) groups. No significant differences were found in analgesia use (fentanyl and tramadol) at 12 and 36 hours in pain, nausea and range of motion between the groups. There was one case of paresthesia in the femoral nerve in the FNB group. Fascia iliaca block is as effective as FNB as part of a multimodal anesthetic regimen for TKA.

Jessner's lymphocytic infiltrate: a rare cause of lid ectropion.

Ectropion is a condition in which the lower eyelid turns outwards from the globe. It is commonly due to age related involutional laxity of the lid tissue. Ectropion may also be secondary to scarring or contracture of the periorbital skin and underlying tissues which pulls the eyelids outwards. Jessner's lymphocytic infiltrate is a rare and enigmatic dermatological condition which is uncommon in the elderly. We describe a case of recurrent ectropion following redo lid surgery in which Jessner's lymphocytic infiltrate was fortuitously diagnosed on skin biopsy. We are unaware of any report in the literature describing recurrent cicatrical ectropion due to this condition.

Impairment and disability following limb salvage procedures for bone sarcoma.

Bone sarcomas are the fourth most common cancer in individuals under 25 years. Limb salvage procedures are popular for the treatment of osteosarcomas as they have functional and physiological benefits over traditional amputative procedures. The objective of this study was to apply disease specific measures to a group of intra-articular knee osteosarcoma patients and to evaluate structural and treatment variables predictive of the functional outcome scores. Twenty patients (10 female, 10 male) treated with tumour resection and endoprosthetic knee arthroplasty took part in the study. The Musculoskeletal Tumour Society (MSTS) rating scale and the Toronto Extremity Salvage Score (TESS) were used to assess impairment and disability respectively. Impairment was recorded as 83% and disability was recorded as 86% suggesting moderate to high function following limb salvage surgery. Task difficulty was shown to increase for activities requiring large knee flexion angles, presumably due to increased patellofemoral forces. Bivariate correlations revealed that loss of quadriceps musculature, knee extension strength and knee flexion range of motion were parameters moderately associated with the assessment instruments. ANOVA revealed no significant differences in impairment (P=0.962) or disability (P=0.411) between the differing types of prostheses. In conclusion clinicians and therapists should emphasise restoration of post-surgical range of motion and strength in order to enhance functional recovery.

Meniscal repair in the elite athlete: results of 45 repairs with a minimum 5-year follow-up.

BACKGROUND: The preservation of meniscal tissue is important to protect joint surfaces. PURPOSE: We have an aggressive approach to meniscal repair, including repairing tears other than those classically suited to repair. Here we present the medium- to long-term outcome of meniscal repair (inside-out) in elite athletes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Forty-two elite athletes underwent 45 meniscal repairs. All repairs were performed using an arthroscopically assisted inside-out technique. Eighty-three percent of these athletes had ACL reconstruction at the same time. Patients returned a completed questionnaire (including Lysholm and International Knee Documentation Committee [IKDC] scores). Mean follow-up was 8.5 years. Failure was defined by patients developing symptoms of joint line pain and/or locking or swelling requiring repeat arthroscopy and partial meniscectomy. RESULTS: The average Lysholm and subjective IKDC scores were 89.6 and 85.4, respectively. Eighty-one percent of patients returned to their main sport and most to a similar level at a mean time of 10.4 months after repair, reflecting the high level of ACL reconstruction in this group. We identified 11 definite failures, 10 medial and 1 lateral meniscus, that required excision; this represents a 24% failure rate. We identified 1 further patient who had possible failed repairs, giving a worst-case failure rate of 26.7% at a mean of 42 months after surgery. However, 7 of these failures were associated with a further injury. Therefore, the atraumatic failure rate was 11%. Age and size and location of the tears were not associated with a higher failure rate. Medial meniscal repairs were significantly more likely to fail than lateral meniscal repairs, with a failure rate of 36.4% and 5.6%, respectively (P < .05). CONCLUSION: Meniscal repair and healing are possible, and most elite athletes can return to their preinjury level of activity.

Bioabsorbable versus titanium interference screws with hamstring autograft in anterior cruciate ligament reconstruction: a prospective randomized trial with 2-year follow-up.

PURPOSE: The purpose of this study was to prospectively assess the outcome of hamstring autograft anterior cruciate ligament (ACL) reconstruction by use of identically shaped bioabsorbable and titanium interference screws in a randomized trial. METHODS: One hundred patients were randomized to have either bioabsorbable or titanium interference screws used for graft tunnel fixation in hamstring autograft ACL reconstruction. Patients were objectively and subjectively assessed preoperatively and 3, 6, 12, and 24 months postoperatively. Radiographs at 12 months postoperatively were also assessed for tunnel width. RESULTS: There were no differences in clinical outcome by use of Lysholm and International Knee Documentation Committee scores between the 2 groups at any stage of follow-up to 2 years. Tibial tunnel widths were the same between the 2 groups. There was slightly more tunnel widening in the femur when bioabsorbable interference screws were used. CONCLUSIONS: Identically shaped bioabsorbable interference screws and titanium interference screws used for hamstring autograft ACL reconstruction are equally successful up to 2 years postoperatively. LEVEL OF EVIDENCE: Level I, prospective randomized trial with more than 80% follow-up.

Pupil dilation using a pledget sponge: a randomized controlled trial.

BACKGROUND: To show that a pledget soaked in mydriatics and placed in the lower conjunctival fornix is as effective as drops in providing mydriasis for cataract surgery. METHODS: A randomized, masked, controlled trial of 56 patients assigned to either a pledget group (n=25) or a control eye drops group (n=31) was carried out. Controls had the routine practice of repeated topical mydriatic drops: tropicamide, phenylepherine and atropine. The trial group had a 3-mm pledget trimmed, soaked in mydriatics and placed in the inferior fornix for 20 min. Pupil diameter was measured using a photographic technique with a standard scale shown in each picture. Two masked observers measured the pupils using the scale of the ruler in the developed photograph. All patients completed a 0-10 stinging score prior to surgery. RESULTS: There were no complications. The mean pupil diameter in the control group was 7.23 (6.91-7.94 95% confidence intervals [CI]) and 7.44 (6.96-7.92 95% CI) in the pledget group. There was no statistically significant difference in pupil diameter between the two groups: difference between means 0.21 (-0.32 to 0.75 95% CI) and Student's t-test of the difference between means (t=0.8 and two-tailed) probability P=0.43. There was no significant difference in the stinging scores: Mann-Whitney test P=0.69. CONCLUSION: The use of a pledget cellulose sponge to deliver mydriatics prior to cataract surgery is as effective as the conventional method of repeated drop administration and was not associated with any adverse effects.

Central versus peripheral tibial screw placement in hamstring anterior cruciate ligament reconstruction: in vitro biomechanics.

PURPOSE: To determine whether a cone-shaped interference screw positioned centrally during tibial fixation in hamstring anterior cruciate ligament (ACL) reconstruction was equal to or better than a peripheral position in terms of stiffness, yield load, ultimate load, and mode of failure. TYPE OF STUDY: Randomized matched-pair biomechanical pullout study. METHODS: One of each of 7 matched pairs of human cadaveric tendon in porcine tibia with titanium cone-shaped screws were randomly allocated to either the peripheral or central group. Bone tunnels were drilled 45 degrees to the long axis of the tibia, akin to standard ACL reconstruction. Tunnel diameter was matched to tendon diameter and a screw 1 mm larger than tunnel diameter was inserted. A Universal Materials Testing Machine (Hounsfield Testing Equipment, Horsham, PA) was used to pull in the line of the tendon. Tendons were inspected after construct disassembly. RESULTS: The central screw configuration showed significantly higher stiffness (P = .0085), yield load (P = .0135), and ultimate load (P = .0075). The mode of failure in the peripheral screw position was slippage at the screw-tendon interface in all cases. In the central group, 87.5% of cases had a breakage in the tendon and 12.5% had slippage at the tendon-bone interface. CONCLUSIONS: Central interference screw fixation of soft-tissue ACL reconstruction offers superior fixation strength and stiffness in single pullout mode when compared with peripheral interference screw fixation. Failure in the central group was mostly by tendon breakage, suggesting that a larger difference may be exhibited by the central over the peripheral fixation than demonstrated in this study. CLINICAL RELEVANCE: Central interference screw fixation compared with peripheral fixation may allow greater confidence in early rehabilitation and reduced clinical failure rates in the long term.