Measured distance from posterior tibia to popliteal artery increases with flexion and subluxation of the knee.

Purpose: Popliteal artery laceration is a devastating complication in total knee arthroplasty (TKA). Its anatomic position relative to the tibia has been studied using ultrasound or magnetic resonance imaging. This is the first study performed in a laboratory using radiographic measurements to determine if increased flexion and subluxation of the knee increase the distance between the tibia and popliteal artery. Methods: The femoral artery was infused with radiopaque dye in six cadavers. The knee was placed in two different degrees of flexion and three of subluxation. The radiographic distance between standardized markers in the posterior tibia and popliteal artery was measured. Results: The average distance from the tibial peg to the popliteal artery at 90° of flexion increased from 0% to 50% to 100% subluxation. The increase was statistically significant (Friedman test p = 0.016). The contrast between neutral and 100% subluxation was statistically significant (Sign test p = 0.031). At 115° flexion, average distance from the peg to popliteal artery significantly increased as subluxation increased (Friedman test p = 0.05). In three specimens, at 115° of flexion and 100% subluxation, a line perpendicular to the axis of the tibia, failed to intersect the popliteal artery. The measured distance increased from 90° to 115° of flexion at a given degree of subluxation, but this difference did not reach statistical significance. Conclusions: Increasing flexion and subluxation of the tibia results in increasing distance between the cut plane of the tibial plateau and popliteal artery and decreases risk of laceration. Level of Evidence: Not applicable.

Atlantoaxial subluxation and Down syndrome: A cross-sectional analysis.

Background: Atlantoaxial subluxation (AAS) is a diagnosis describing misalignment of the C1 vertebra relative to C2. Excessive translation of this joint, located adjacent to the medullary brain stem, can lead to devastating neurological consequences. A higher prevalence of AAS within the Down syndrome (DS) population has been well-established. This study aims to establish a prevalence rate of DS in patients hospitalized for AAS and compare outcomes between AAS patients with and without DS. Methods: This study utilized the National Inpatient Sample (NIS) provided by the Healthcare Cost and Utilization Project (HCUP). In accordance with HCUP 2023 Clinical Classifications Software Refined files, data were queried using the International Classification of Diseases 10th Edition codes for DS and AAS. Demographics, comorbidities, hospital course, and outcomes were examined and compared using binary and linear multivariate regression. IBM SPSS software was used for data analysis. Results: Of the 213,095 patients in the NIS database admitted between 2016 and 2020 with AAS as their primary diagnosis, 7.2% were DS patients. DS patients were significantly younger (26.56 ± 20.81 vs. 49.39 ± 27.63, P < 0.01), less likely to be female (33.30% vs. 52.10%), and had fewer comorbidities (diabetes mellitus, hypertension, and hyperlipidemia) than non-DS patients. There was no significant difference in likelihood to undergo surgical fusion between DS patients and non-DS patients with AAS. Conclusion: This large-scale study using NIS data determined that 7.2% of all patients admitted to hospitals for AAS are DS patients. The analysis of demographics, hospital course, and outcomes can influence the development of treatment protocols for AAS in the DS population.

[Transscleral fixation of intraocular lens in the treatment of lens subluxation in children]. / Transskleral'naya fiksatsiya intraokulyarnoi linzy v lechenii sublyuksatsii khrustalika u detei.

Congenital subluxation of the lens as a complication of Marfan syndrome, Weill-Marchesani syndrome, microspherophakia, etc. leads to the development of amblyopia and requires timely surgical treatment with removal of the subluxated lens and implantation of an artificial intraocular lens (IOL). IOL implantation in children with pathology of the ligamentous apparatus of the lens remains an urgent problem of ophthalmic surgery due to the lack of a consensus regarding the IOL fixation method among practitioners. PURPOSE: This study evaluated the effectiveness and safety of IOL implantation with transscleral fixation using the knotless Z-suture technique in pediatric patients with congenital lens subluxation. MATERIAL AND METHODS: The study included 24 children (36 eyes) with grade III congenital subluxation of the lens who underwent phacoaspiration of the subluxated lens with IOL implantation with transscleral fixation using the knotless Z-suture performed in the Kazakh Research Institute of Eye Diseases in Almaty in the period from 2017 to 2021. The average observation period was 31.7±11.3 months (2.0 to 4.5 years). The stability of the IOL position, the state of the intrascleral sutures, visual acuity after surgery, the presence and severity of complications in the long-term period were evaluated. RESULTS: All patients (100%) had a significant improvement in visual acuity after surgery. No intraoperative complications were registered in any of the cases. Postoperative complications were noted in 8.3% of cases (n=3). The final functional outcome of surgical treatment depended on the presence of concomitant pathology, the main cause of low vision was the development of refractive amblyopia due to refractive errors. CONCLUSIONS: The presented technique of transscleral fixation of IOL has proven to be reliable, which is especially important for pediatric patients considering their high physical activity and expected lifespan.

Sunrise in the eye: Bilateral superonasal lens subluxation in Marfan syndrome.

Aim: To describe the case of a patient with Marfan syndrome who had bilateral superonasal lens subluxation. Method: The case of a male patient, aged 18, who complained of having impaired vision in both eyes (BE) since he was a toddler, was presented. On examination of the patient, features suggestive of Marfan syndrome were revealed, as well as bilateral intraocular lens subluxation. Results: The patient was refracted and glasses were recommended, which improved his vision. The patient was referred to the cardiology, orthopedic, and dental departments for a multidisciplinary approach to prevent complications and further management. Discussion: Lens subluxation is frequently presented as a primary clinical manifestation of Marfan syndrome. It can vary from asymptomatic, which is seen only after pupillary dilation, to significant subluxation, in which the equator of the lens in the pupillary axis causes diplopia or decreased vision. Conclusion: This case underscored the importance of considering the rare feature of Marfan syndrome.

Arthroscopic Bankart Repair with Remplissage Yields Similar Outcomes to Open Latarjet for Primary and Revision Stabilization in The Setting of Subcritical Glenoid Bone Loss.

BACKGROUND: Management of patients with recurrent anterior glenohumeral instability in the setting of subcritical glenoid bone loss (GBL), defined in this study as 20% GBL or less, remains controversial. This study aimed to compare arthroscopic Bankart with remplissage (ABR+R) to open Latarjet for subcritical GBL in primary or revision procedures. We hypothesized that ABR+R would yield higher rates of recurrent instability and reoperation compared to Latarjet in both primary and revision settings. METHODS: A retrospective study was conducted on patients undergoing either arthroscopic ABR+R or an open Latarjet procedure. Patients with connective tissue disorders, critical GBL (>20%), < 2 year follow-up, or insufficient data were excluded. Recurrent instability and revision were the primary outcomes of interest. Additional outcomes of interest included subjective shoulder value (SSV), strength and range of motion (ROM) RESULTS: 108 patients (70 ABR+R, 38 Latarjet) were included with an average follow-up of 4.3 ±2.1 years. In the primary and revision settings, similar rates of recurrent instability (Primary: p=0.60; Revision: p=0.28) and reoperation (Primary: p=0.06; Revision: p=1.00) were observed between Latarjet and ABR+R. Primary ABR+R exhibited better SSV, active ROM, and internal rotation strength compared to primary open Latarjet. However, no differences were observed in the revision setting. CONCLUSION: Similar rates of recurrent instability and reoperation in addition to comparable outcomes with no differences in ROM were found for ABR+R and Latarjet in patients with subcritical GBL in both the primary and revision settings. ABR+R can be a safe and effective procedure in appropriately selected patients with less than 20% GBL for both primary and revision stabilization.

Anatomic total shoulder arthroplasty for posteriorly eccentric and concentric osteoarthritis: a comparison at minimum 5-year follow-up.

BACKGROUND: In patients with glenohumeral osteoarthritis and posteriorly eccentric wear patterns, the early to mid-term results of TSA using conservative glenoid reaming with no attempt at version correction have been favorable at early follow-up. The purpose of this study is to compare the clinical and radiographic outcomes of TSA using this technique for patients with and without eccentric wear patterns at a minimum 5-year follow-up. METHODS: Patients who underwent TSA with minimum 5-year follow-up were identified from an institutional registry. Preoperative and postoperative radiographs were used to determine humeroglenoid alignment (HGA-AP), humeroscapular alignment (HSA-AP), version, Walch classification and glenoid component seating. The outcome measures were the Simple Shoulder Test, glenoid component radiolucencies, and the occurrence of complications or revisions. RESULTS: Two hundred and ten patients were included in the study, of which 98 (47%) had posteriorly decentered humeral heads and 108 (51%) had centered humeral heads. There were 77 shoulders with Walch type A glenoids and 122 with Walch type B glenoids. At a mean 8-year follow-up, the final SST, change in SST and percentage of maximal improvement was not correlated with pre- and postoperative humeral head centering, Walch classification or glenoid version. There were no preoperative predictors of a low final SST. Two patients (1%) underwent open re-operations during the study period. In patients with Walch B1 and B2 glenoids (n=110), there were no differences in outcome measures between patients with postoperative retroversion of more and less than 15o. While 15 of 51 patients (29%) with minimum 5-year radiographs had glenoid radioluciences, these radiographic findings were not associated with inferior clinical outcomes. On multivariable analysis glenoid component radiolucencies were most strongly associated with incomplete component seating (OR 3.3, p = 0.082). CONCLUSION: The results of TSA with conservative glenoid reaming without attempt at version correction are favorable at minimum 5 year, mean 8-year follow-up. There were no differences in clinical and radiographic outcomes between patients with eccentric and concentric wear patterns. Incomplete glenoid component seating was the greatest predictor of glenoid component radiolucency, but these radiolucencies were not associated with inferior clinical outcomes.

Zonular fibre Insertion-to-Limbus Distance (ZLD): normative data to assess lens position and diagnose ectopia lentis.

PURPOSE: Subluxation of the crystalline lens (Ectopia Lentis, EL) can lead to significant visual impairment and serves as a diagnostic criterion for genetic disorders such as the Marfan syndrome. There is no established criterion to diagnose and quantify EL. We prospectively investigated the distance between the zonular fibre insertion and the limbus (ZLD) in healthy subjects as a parameter to assess the position of the lens, quantify EL and provide normative data. METHODS: This prospective, observational, cross-sectional study includes one-hundred-fifty eyes of 150 healthy participants (mean age 28 years, range 4-68). Pupils were dilated with tropicamide 0.5% and phenylephrine 2.5% eyedrops. ZLD was measured in mydriasis at the slit lamp as the distance between the most central visible insertions of the zonular fibres on the lens surface and the corneoscleral limbus. Vertical pupil diameter (PD) and refractive error were recorded. If zonular fibre insertions were not visible, the distance between limbus and the pupillary margin was recorded as ZLD. RESULTS: 145 right and 5 left eyes were examined. 93% of study subjects were Caucasian, 7% were Asian. In eyes with visible zonular fibre insertions (n = 76 eyes), ZLD was 1.30 ± 0.28 mm (mean ± SD, range 0.7-2.1) and PD was 8.79 ± 0.57 mm (7.5-9.8). In the remaining 74 eyes, ZLD was 1.38 ± 0.28 mm (0.7-2.1), and PD was 8.13 ± 0.58 mm (6.7-9.4). For all eyes, ZLD was 1.34 ± 0.29 mm (0.7-2.1), and PD was 8.47 ± 0.66 mm (6.7-9.8). Refractive error and sex did not significantly affect ZLD. Smaller PD and older age were associated with larger ZLD (P < 0.001 and P = 0.036, respectively). CONCLUSION: Average ZLD was 1.34 mm in eyes of healthy subjects. Older age correlated with larger ZLD. These normative data will aid in diagnosing and quantifying EL.

Physiotherapeutic Approach Towards Sensory and Motor Recovery in a Patient With Lateral Mass Fixation: A Report of a Rare Case.

Atlantoaxial dislocations (AAD) are a diverse set of C1-C2 rotatory subluxations that include the inferior and superior axial facet articulations. C1-C2 segments are both covered by cranial-cervical ligaments, indicating that AAD would damage both joints. Whenever the posterior elements are missing or impaired, lateral mass screw fixation has replaced alternative posterior cervical fixation procedures as the preferred treatment for securing the sub-axial cervical spine. An increase in muscle tone, hyperreflexia, pathological reflexes, digit/hand clumsiness, and gait deviations caused by spinal cord compression at the cervical level are the most common clinical features. A 23-year-old female patient came with the chief complaint of weakness, tingling sensation, and numbness in both upper and lower limbs along with imbalance while walking. She had a history of falls which was managed conservatively. As the symptoms progressed, an MRI, a CT scan, and an X-ray of the neck were done to rule out the level of injury which revealed AAD, and the patient was operated on for C1-C2 lateral mass fixation. Post-operatively, the patient was referred to the physiotherapy department for further management. The patient's quality of life and daily functioning were positively affected after undergoing early intervention as measured by the Functional Independence Measure, Neck Disability Index, Berg Balance Scale, and Dynamic Gait Index.

An investigation into the chiropractic practice and communication of routine repetitive radiographic imaging for the location of postural misalignments.

Many clinicians use radiological imaging in efforts to locate and diagnose the cause of their patient's pain, relying on X-rays as a leading tool in clinical evaluation. This is fundamentally flawed because an X-ray represents a "snapshot" of the structural appearance of the spine and gives no indication of the current function of the spine. The health and well-being of any system, including the spinal motion segments, depend on the inter-relationship between structure and function. Pain, tissue damage, and injury are not always directly correlated. Due to such a high incidence of abnormalities found in asymptomatic patients, the diagnostic validity of X-rays can be questioned, especially when used in isolation of history and/or proper clinical assessment. The utility of routine X-rays is, therefore, questionable. One may posit that their application promotes overdiagnosis, and unvalidated treatment of X-ray findings (such as changes in postural curvature), which may mislead patients into believing these changes are directly responsible for their pain. A substantial amount of research has shown that there is no association between pain and reversed cervical curves. Accuracy can also be questioned, as X-ray measurements can vary based on the patient's standing position, which research shows is influenced by an overwhelming number of factors, such as patient positioning, patient physical and morphological changes over time, doctor interreliability, stress, pain, the patient's previous night's sleep or physical activity, hydration, and/or emotional state. Furthermore, research has concluded that strong evidence links various potential harms with routine, repeated X-rays, such as altered treatment procedures, overdiagnosis, radiation exposure, and unnecessary costs. Over the past two decades, medical boards and health associations worldwide have made a substantial effort to communicate better "when" imaging is required, with most education around reducing radiographic imaging. In this review, we describe concerns relating to the high-frequency, routine use of spinal X-rays in the primary care setting for spine-related pain in the absence of red-flag clinical signs.

Nusinersen therapy changed the natural course of spinal muscular atrophy type 1: What about spine and hip?

Purpose: Spinal muscular atrophy type 1 has a devastating natural course and presents a severe course marked by scoliosis and hip subluxation in nonambulatory patients. Nusinersen, Food and Drug Administration-approved spinal muscular atrophy therapy, extends survival and enhances motor function. However, its influence on spinal and hip deformities remains unclear. Methods: In a retrospective study, 29 spinal muscular atrophy type 1 patients born between 2017 and 2021, confirmed by genetic testing, treated with intrathecal nusinersen, and had registered to the national electronic health database were included. Demographics, age at the first nusinersen dose, total administrations, and Children's of Philadelphia Infant Test of Neuromuscular Disorders scores were collected. Radiological assessments included parasol rib deformity, scoliosis, pelvic obliquity, and hip subluxation. Results: Mean age was 3.7 ± 1.1 (range, 2-6), and average number of intrathecal nusinersen administration was 8.9 ± 2.9 (range, 4-19). There was a significant correlation between Children's of Philadelphia Infant Test of Neuromuscular Disorders score and the number of nusinersen administration (r = 0.539, p = 0.05). The correlation between Children's of Philadelphia Infant Test of Neuromuscular Disorders score and patient age (r = 0.361) or the time of first nusinersen dose (r = 0.39) was not significant (p = 0.076 and p = 0.054, respectively). While 93.1% had scoliosis, 69% had pelvic obliquity, and 60.7% had hip subluxation, these conditions showed no significant association with patient age, total nusinersen administrations, age at the first dose, or Children's of Philadelphia Infant Test of Neuromuscular Disorders scores. Conclusion: Disease-modifying therapy provides significant improvements in overall survival and motor function in spinal muscular atrophy type 1. However, progressive spine deformity and hip subluxation still remain significant problems in the majority of cases which would potentially need to be addressed.

Latarjet procedure restores range of motion at six months postoperatively: a prospective cohort study utilizing motion capture analysis.

BACKGROUND: There is a common concern that range of motion (ROM) is negatively affected by the Latarjet procedure. We hypothesize that the Latarjet procedure results in full recuperation of ROM postoperatively and significantly improved patient reported outcome measures. METHODS: Patient data were prospectively collected from a randomized controlled trial to analyze outcomes after open Latarjet procedure. Inclusion criteria involved a minimum follow-up of six months and unilateral shoulder instability. Study outcome was assessed by postoperative ROM at six months postoperatively and compared to the preoperative ROM of the ipsilateral shoulder as well as the ROM of the unaffected contralateral shoulder. All ROM measurements were performed utilizing a motion capture system to ensure consistent and reliable measurements. RESULTS: The study included a total of 84 patients. ROM was measured in external rotation with the shoulder adducted (ER1), external rotation with the shoulder abducted 90 degrees (ER2), internal rotation with the arm abducted 90 degrees (IR2), and active forward elevation (AE). The average difference in ROM between the operated arm vs. the contralateral healthy arm at six months postoperatively was 3.4 degrees in ER1 (p=0.19), 4.2 degrees in ER2 (p=0.086), 2.2 degrees in IR2 (p=0.36), and 2.4 degrees in AE (p=0.045). Sub-analysis of patients with and without sling use revealed no significant difference in ROM between the operated shoulder and contralateral shoulder at six months in either group, with the exception of ER2 in the sling group. In this latter group, ROM was 71 degrees in the operated arm and 79 degrees in the contralateral arm (p=0.0094). Average preoperative pain score was 25.7 (21.4-30.1, 95%CI) vs. 13.0 postoperatively at six months (9.50-16.5, 95%CI) (p <0.00001). Average preoperative SANE instability was 42.9 (38.4-47.3, 95%CI) vs. 86.2 postoperatively at six months (83.6-88.7, 95%CI) (p <0.00001). Average preoperative Rowe score was 38.5 (34.3-42.7, 95%CI) vs. 84.3 at six postoperative months (81.1-87.4, 95%CI) (p<0.00001). CONCLUSIONS: Latarjet procedure performed for anterior instability utilizing a capsular repair result in complete ROM recovery in ER1, ER2, and IR2 at six months postoperatively, with only a slight discrepancy in active elevation. Sling use after the Latarjet procedure results in no benefit over postoperative recovery without the use of a sling. Sling use negatively affects the ROM in ER2, taking as reference the contralateral arm of the same patient, when compared to patients that did not use a sling postoperatively.

Operative Management of Extensor Carpi Ulnaris Instability: A Systematic Review.

Background Posttraumatic extensor carpi ulnaris (ECU) instability is an increasingly recognized cause of ulnar-sided wrist pain that occurs when the ECU subsheath is disrupted. Purpose The purpose of this systematic review was to assess outcomes of operatively treated posttraumatic ECU instability. Methods A systematic search of Medline, Embase, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed using "extensor carpi ulnaris" as the keyword. Studies were systematically screened and data extracted independently by two reviewers. Results Eight retrospective studies met the inclusion criteria with a total of 97 wrists. The mean age was 32 years (13-61). Patients underwent either primary repair (40%) using sutures and anchors, or reconstruction (60%) using extensor retinaculum flaps. One study performed deepening of the osseous ulnar groove. Two studies compared preoperative and postoperative values. They both reported a significant improvement in pain scores, functional scoring instruments, satisfaction, and grip strength. The rest of the studies reported similarly favorable outcomes across the same outcomes. Concomitant pathologies were identified in 66% of the study population. Complications occurred in 9% of the sample size, including ECU tendinitis, ulnar sensory nerve irritation, and reintervention for concomitant pathology. None of the studies reported recurrence or reruptures. However, five patients (6.7%) did not return to their previous activity level. Conclusion Patients can expect favorable outcomes with a potentially low complication rate. Nevertheless, the heterogeneity of the sample population, operative techniques, and outcome measures warrant further standardized studies. Level of Evidence IV.

Equine Talocalcaneal subluxation.

A Quarter horse filly was evaluated for a two-week old wound of the right hind cannon bone after the mare stepped on her. A sequestrum was noted radiographically and was surgically debrided. After continued follow-up a left hind varus deformity was noted and was corrected with a lateral transphyseal screw in the distal left tibia. After the varus deformity was improved, a lateromedial radiograph was taken of the distal left tibia and tarsus and talocalcaneal subluxation was seen. The same view was taken of the right tarsus and the same deformity was noted. After finding no case reports on the condition with information on treatment or surgical correction, humane euthanasia was elected. A few months later, the same owner brought a two-month-old colt out of the same mare to the hospital for an elective procedure. Tarsal radiographs were taken due to the owner's previous experience, although the colt had no clinical history or any traumatic incidents. A lateromedial view of the right tarsus revealed talocalcaneal subluxation.

Lens subluxation combined with parry-romberg syndrome: case report.

BACKGROUND: Parry-Romberg syndrome (PRS) is a rare progressive degenerative disorder of unknown etiology. Here we report a rare case of PRS combined with lens subluxation in Eye and ENT hospital of Fudan University, Shanghai. To our knowledge, it is the first reported case of PRS combined with lens subluxation that has been managed surgically with phacoemulsification and CTR placement and IOL implantation in Shanghai. CASE PRESENTATION: A 60-year-old woman was referred for "right visual blur for 2 years" and had persistent right facial paralysis of unknown etiology since the age 12. She had right facial muscle atrophy and paralysis. Eye examination also showed the right eyelid pseudoptosis, enophthalmos, age-related cataract combined with lens subluxation existed in the right eye. The patient was diagnosed as age-related cataract and lens subluxation in the right eye and progressive hemifacial atrophy (Parry-Romberg syndrome). We conducted a combined phacoemulsification, IOL and CTR implantation and pupilloplasty surgery for the patient under general anesthesia and the postoperative UCVA was 20/30 and remained for 1 year's follow up. CONCLUSIONS: Here we reported a rare case of PHA combined with lens subluxation in China. After appropriate eye surgery, the patient achieved satisfying vision result in the right eye.

Subluxación atlantoaxial en artritis reumatoidea. Resolución por odontoidectomía endonasal endoscópica y fusión e instrumentación por abordaje posterior. Reporte de caso

La subluxación atlantoaxial es la lesión más frecuente en la columna cervical causada por la artritis reumatoidea. Se manifiesta por rigidez de nuca, dolor cervical y déficit neurológico. El diagnóstico se realiza con tomografía computarizada e imágenes de resonancia magnética. El intervalo atlanto dental anterior mayor a 5mm indica inestabilidad atlantoaxial, el intervalo atlanto dental posterior menor a 14mm advierte riesgo neurológico. Las indicaciones más frecuentes de cirugía son: dolor cervical severo, inestabilidad y síntomas de mielopatía. Cuando existe compresión medular es necesaria la descompresión cervical alta sea por vía posterior o por vía anterior (odontoidectomía endonasal versus transoral). La línea rinopalatina nos indicará la factibilidad de una odontoidectomía endonasal endoscópica (OEE). El objetivo de la presentación del presente caso es compartir nuestra experiencia con la primera odontoidectomía endonasal endoscópica realizada en nuestro país y fomentar la utilización de la técnica. La cirugía fue realizada en un paciente con cuadriparesia espástica por subluxación atlantoaxial por artritis reumatoidea y que presentó excelente evolución pos operatoria, con recuperación casi completa. La OEE es una técnica operatoria mínimamente invasiva, ideal para pacientes con múltiples comorbilidades y que ofrece de buenos a excelentes resultados.

Atlantoaxial subluxation is the most common injury to the cervical spine caused by rheumatoid arthritis. It is manifested by neck stiffness, neck pain and neurological deficit. Diagnosis is made with computed tomography and magnetic resonance imaging. The anterior dental atlanto interval greater than 5mm indicates atlantoaxial instability, the posterior dental atlanto interval less than 14mm warns of neurological risk. The most frequent indications for surgery are: severe neck pain, instability and symptoms of myelopathy. When there is spinal cord compression, upper cervical decompression is necessary, either via a posterior or anterior approach (endonasal versus transoral odontoidectomy). The rhinopalatine line will indicate the feasibility of an endoscopic endonasal odontoidectomy (EEO). The objective of the presentation of this case is to share our experience with the first endoscopic endonasal odontoidectomy performed in our country and to promote the use of the technique. The surgery was performed on a patient with spastic quadriparesis due to atlantoaxial subluxation due to rheumatoid arthritis and who presented excellent postoperative evolution, with almost complete recovery. EEO is a minimally invasive surgical technique, ideal for patients with multiple comorbidities and offering good to excellent results.

Painful Peroneal Tendon Subluxation in a Patient With a Prior Ankle Fusion.

This case report describes a patient who underwent an ankle fusion using a lateral approach and fibular-onlay strut 14 years ago. She presented with increasing lateral ankle pain and giving way. Despite bracing and steroid injections, she had continued symptoms and surgery for hardware removal was recommended. While under anesthesia, she was found to have subluxation of her peroneal tendons. Operative findings included impingement of the peroneal brevis on the screw head from her fibular-onlay strut and a peroneal tendon tear. Hardware removal, a peroneal tenodesis, and reconstruction of the peroneal retinaculum were performed with a good clinical result.Level of Evidence: V (case report).

The enigma of a subluxated globe.

Spontaneous globe subluxation (SGS) is an uncommon condition wherein the equator of the globe protrudes anteriorly beyond the eyelid aperture causing severe lagophthalmos, proptosis and exposure keratopathy. SGS can lead to an emotional disturbance leading to anxiety and fear, thereby affecting one's quality of life. The patients might often be able to reduce the globe on their own, but permanent measures must be taken to prevent recurrence and vision-threatening sequelae of SGS. We present this case due to its rarity and to highlight the importance of a simple, cost-effective and cosmetically acceptable bilateral tarsorrhaphy in management of SGS.

A novel classification of intraoperative ulnar nerve instability to aid transposition surgery.

HYPOTHESIS: The purpose of this study was to compare inter- and intraobserver agreement of a novel intraoperative subluxation classification for patients undergoing ulnar nerve surgery at the elbow. We hypothesize there will be strong inter- and intraobserver agreement of the 4-category classification system, and reviewers will have substantial confidence while reviewing the classification system. METHODS: Four blinded fellowship-trained orthopedic hand surgeons reviewed 25 videos in total on 2 separate viewings, 21 days apart. Variables collected were ulnar subluxation classification (A, B, C, or D) and a confidence metric. Subsequent to primary data collection, classification grading was stratified into A/B or C/D subgroups for further analysis. Cohen κ scores were used to evaluate all variables collected in this study. The interpretation of κ scores included ≤0.0 as no agreement, 0.01-0.20 as none to slight, 0.21-0.40 as fair, 0.41-0.60 as moderate, 0.61-0.80 as substantial, and 0.81-1.0 as almost perfect agreement. RESULTS: Interobserver agreement of subluxation classification as a 4-category scale demonstrated a moderate agreement on first viewing, second viewing, and when both viewings were combined (κ = 0.51, 0.51, and 0.51 respectively). Seventy-five percent (3 of 4) of reviewers had moderate intraobserver agreement for ulnar nerve subluxation classification, whereas 1 reviewer had substantial intraobserver classification (κ = 0.72). Overall, there was high confidence in 65% of classification scores in the second round of viewing, which improved from 58% in the first viewing round. When ulnar subluxation classification selections were regrouped into classes A/B or C/D, 100% of reviewers had substantial interobserver (κ = 0.74-0.75) and substantial to almost perfect intraobserver (κ = 0.71-0.91) agreement. CONCLUSIONS: The 4-category classification was reproducible within and between reviewers. Agreement appeared to increase when simplifying the classification to 2 categories, which may provide guidance to surgical decision making. The validation of a reproducible classification scheme for intraoperative ulnar subluxation may aid with decision making and further postoperative outcomes research.

Vertebral Subluxation and Systems Biology: An Integrative Review Exploring the Salutogenic Influence of Chiropractic Care on the Neuroendocrine-Immune System.

In this paper we synthesize an expansive body of literature examining the multifaceted influence of chiropractic care on processes within and modulators of the neuroendocrine-immune (NEI) system, for the purpose of generating an inductive hypothesis regarding the potential impacts of chiropractic care on integrated physiology. Taking a broad, interdisciplinary, and integrative view of two decades of research-documented outcomes of chiropractic care, inclusive of reports ranging from systematic and meta-analysis and randomized and observational trials to case and cohort studies, this review encapsulates a rigorous analysis of research and suggests the appropriateness of a more integrative perspective on the impact of chiropractic care on systemic physiology. A novel perspective on the salutogenic, health-promoting effects of chiropractic adjustment is presented, focused on the improvement of physical indicators of well-being and adaptability such as blood pressure, heart rate variability, and sleep, potential benefits that may be facilitated through multiple neurologically mediated pathways. Our findings support the biological plausibility of complex benefits from chiropractic intervention that is not limited to simple neuromusculoskeletal outcomes and open new avenues for future research, specifically the exploration and mapping of the precise neural pathways and networks influenced by chiropractic adjustment.

Sutured scleral fixation of existing subluxated/dislocated acrylic one-piece intraocular lenses.

AIM: To evaluate the visual and refractive outcomes in cases after sutured scleral fixation of existing subluxated or dislocated acrylic one-piece intraocular lenses (IOLs). METHODS: This study retrospectively enrolled a consecutive series of patients who underwent a surgery of sutured existing subluxated or dislocated IOLs from October 2018 to June 2020. All patients underwent comprehensive preoperative and postoperative ophthalmologic examination, and data were collected including age, sex, surgical indications, best-corrected visual acuity, refractive error, intraocular pressure. Presence of intraoperative and postoperative surgical complications was documented. RESULTS: A total of 20 consecutive cases were enrolled for analysis with mean final follow-up period 9.8±5.3mo. Visual acuity improved from a mean of 0.35 (0.46±0.32 logMAR) preoperatively to 0.61 (0.21±0.18 logMAR) at the 3-month follow-up (P=0.002). The mean amount of preoperative keratometric astigmatism and total postoperative refractive astigmatism was -1.24±0.80 diopters (D) and -1.42±0.97 D, respectively. There was no statistically significant difference between preoperative and postoperative astigmatism (P=0.156). The mean IOL-induced astigmatism was -0.23±0.53 D. The mean spherical equivalent at the 3-month follow-up was -0.1±0.94 D. No major complications were noted during the follow-up period. CONCLUSION: Surgical techniques using sutured scleral fixation of existing subluxated or dislocated acrylic one-piece IOLs result in favorable visual and refractive outcomes without major complications.