A single-center, single-blinded, randomized, parallel-group, non-inferiority trial to compare the efficacy of a 22-gauge needle versus a 15 blade to perform an Achilles tendon tenotomy in 244 clubfeet-study protocol.

BACKGROUND: Achilles tendon tenotomy is an integral part of the Ponseti method, aimed at correcting residual equinus and lack of dorsiflexion after correction of the adductus deformity in clubfoot. Percutaneous tenotomy using a number 15 scalpel blade is considered the gold standard, resulting in excellent results with minimal complications. The use of a large-bore needle to perform Achilles tendon tenotomies has been described in literature, but a large-scale randomized controlled trial is currently lacking. In this trial, we aim to show the non-inferiority of the needle tenotomy technique compared to the gold standard blade tenotomy technique. METHODS: We will randomize 244 feet into group A: needle tenotomy or group B: blade tenotomy. Randomization will be done using a block randomization with random block sizes and applying a 1:1 allocation to achieve an intervention and control group of the exact same size. Children will be evaluated at 3 weeks and 3 months post-tenotomy for primary and secondary clinical outcomes. The primary clinical outcome will be the range of dorsiflexion obtained the secondary clinical outcomes will be frequency of minor and major complications and Pirani score. The non-inferiority margin was set at 4°, and thus, the null hypothesis of inferiority of the needle technique will be rejected if the mean difference between both techniques is less than 4°. The statistical analysis will use a multi-level mixed effects linear regression model for the primary outcomes and a multi-level mixed effects logistic regression model for the secondary clinical outcomes. The physician performing the evaluations post-tenotomy will be the only one blinded to group allocation. TRIAL REGISTRATION: This trial was registered prospectively with ClinicalTrials.gov registration number: NCT04897100 on 21 May 2021.

Percutaneous Achilles tendon tenotomy in clubfoot patients with a 22 gauge needle in a low-resource setting.

Ponseti treatment has been well-established as the gold standard for the treatment of idiopathic clubfoot in high-income countries and middle- and low-income countries (LMICs). The tenotomy is usually performed in the clinic using a scalpel blade under local anesthesia. However, we believe that by adapting the technique from Minkowitz et al. to a low-resource setting, we can help address some of the known barriers to Ponseti care. Using a needle instead of a blade makes the procedure less cumbersome easier to learn and easier to understand for the provider, family and the patient. We were able show that the needle tenotomy technique can be implemented in a low-resource setting like Pakistan, and can be performed using only one assistant and materials that are locally and readily available for the same cost This paper and its attached educational videos can help spread the technique among providers in low-resource settings.

Eight-year Review of a Clubfoot Treatment Program in Pakistan With Assessment of Outcomes Using the Ponseti Technique: A Retrospective Study of 988 Patients (1,458 Clubfeet) Aged 0 to 5 Years at Enrollment.

OBJECTIVE: To conduct an 8-year retrospective review of a clubfoot treatment program using the Ponseti technique with close monitoring of outcomes. METHODS: Between October 2011 and August 2019, 988 children with 1,458 idiopathic clubfeet were enrolled, ages ranging from new born up to 5 years. Ponseti treatment was used, and progress was monitored by comparing mean Pirani scores at enrollment (P1), initiation of bracing (P2), and end of treatment (P3) or most recent visit (P4) for children under treatment. RESULTS: A statistically significant reduction in Pirani scores was noted (P < 0.001) for all feet. For 320 feet completing treatment (213 children), the mean Pirani scores reduced from P1: 3.8 (±1.1) to P2: 1.1 (±0.6) and finally to P3: 0.6 (±0.3). Four hundred sixteen children are currently undergoing bracing. Higher education of the head of household and male sex of the child were markedly associated with improved outcomes in foot correction status. Correction was obtained with a mean of 5.8 casts per foot, the tenotomy rate was 68.2%, and the mean duration of bracing in children completing treatment was 3.6 years (±0.9). No surgical correction, other than tenotomy, was required. Relapse was noted in 12.1% of the total enrolled feet, and 32.0% children were lost to follow-up from the entire cohort of 988 children. CONCLUSION: Clubfoot treatment requires long-term follow-up. A dedicated clubfoot program is effective in maintaining continuity of care by encouraging adherence to treatment.

Wound closure after total knee replacement: Comparison between staples and sutures.

Background and Objective: Total Knee Arthroplasty is a commonly performed procedure for arthritic knees. Preventing complications is of utmost importance for good functional outcomes and preventing morbidity. Wound closure after the procedure is as important as the replacement aspect of surgery.The objective of this study was to provide subjective and objective evidence of better closure technique and material; we conducted the study so that the outcome of TKA can be further improved. Methods: We conducted a randomized trial at The Indus Hospital, Karachi, from December 2018 to June 2020. All patients from age 40 to 70 years who underwent total knee arthroplasty were included in the study. The wound of one knee was closed with Polypropylene (Prolene) sutures, and the other with staples. The wound was assessed independently by two assessors using Hollander's score; lower score means a worse outcome. All data was entered and analyzed using STATA version 16. Results: Thirty patients who underwent bilateral total knee replacement were included in the analysis, among which 71.8% were female. The average age of participants was 57.3 (± 7.5) years. The mean incision length on the right knee was 17.6 ± 1.1 cm, while on the left the incision length was 18.3 ± 1.2 cm. Overall, the mean Hollander score was significantly different among participants in the sutures and staples group in both the right (p-value=0.001) and left knees (p-value=0.001). The score was significantly higher in knees closed with sutures as compared to staples. Also, the mean Hollander score is significantly higher in females than males in both the right knee (B=0.56, p-value=0.049) and the left knee (B=0.38, p-value=0.044). Conclusion: The study has shown that Hollander's score was significantly higher in knees closed with sutures as compared to the patients in whom staples were used for wound closure.

Inter-observer variation of the Schatzker and Khan classification of Tibial plateau fractures: Cohort study.

OBJECTIVE: To compare the inter-observer reliability of Shatzker classification and Khan Classification of Tibial plateau fractures. METHODS: This retrospective cohort study was conducted at The Indus Hospital, Karachi, Pakistan. Radiographs of 50 patients who presented with tibial plateau fractures from March 2015 to November 2016 were collected. Two observers classified these cases independently according to Shatzker and Khan Classification. Gwet's AC1 statistics applied to assess inter-observer reliability of both the classification systems. RESULTS: Moderate inter-observer agreement for Schatzker classification (p<0.001) and slight inter-observer agreement on Khan Classification (p=0.738) was observed. CONCLUSIONS: Khan Classification is more comprehensive in classifying tibial plateau fractures and can be used for clinical research purpose, while Shatzker classification with better inter-observer reliability is applicable for routine clinical practice.

The triumvirate of NF-κB, inflammation and cytokine storm in COVID-19.

The coronavirus disease (COVID-19) has once again reminded us of the significance of host immune response and consequential havocs of the immune dysregulation. The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) inflicts severe complications to the infected host, including cough, dyspnoea, fever, septic shock, acute respiratory distress syndrome (ARDs), and multiple organ failure. These manifestations are the consequence of the dysregulated immune system, which gives rise to excessive and unattended production of pro-inflammatory mediators. Elevated circulatory cytokine and chemokine levels are accompanied by spontaneous haemorrhage, thrombocytopenia and systemic inflammation, which are the cardinal features of life-threatening cytokine storm syndrome in advanced COVID-19 diseases. Coronavirus hijacked NF-kappa B (NF-κB) is responsible for upregulating the expressions of inflammatory cytokine, chemokine, alarmins and inducible enzymes, which paves the pathway for cytokine storm. Given the scenario, the systemic approach of simultaneous inhibition of NF-κB offers an attractive therapeutic intervention. Targeted therapies with proteasome inhibitor (VL-01, bortezomib, carfilzomib and ixazomib), bruton tyrosine kinase inhibitor (acalabrutinib), nucleotide analogue (remdesivir), TNF-α monoclonal antibodies (infliximab and adalimumab), N-acetylcysteine and corticosteroids (dexamethasone), focusing the NF-κB inhibition have demonstrated effectiveness in terms of the significant decrease in morbidity and mortality in severe COVID-19 patients. Hence, this review highlights the activation, signal transduction and cross-talk of NF-κB with regard to cytokine storm in COVID-19. Moreover, the development of therapeutic strategies based on NF-κB inhibition are also discussed herein.

Flat Top Talus: Complication of Ponseti Method or Overcorrection?

Purpose Deformation of talus in idiopathic clubfoot is a common problem both surgically and after treatment with the Ponseti technique, although the cause of deformation and its clinical impact on the function of the ankle is not yet known. The goal of this research was to evaluate factors leading to talar dome deformation (flat-top talus) after the Ponseti technique Methods This was a single-center, cross-sectional study. Fifty patients with virgin idiopathic clubfoot were enrolled from our consecutive series of data from August 2017 to January 2018 from our clubfoot patients who completed their casting and bracing protocol. Weight-bearing lateral X-rays of the ankle were examined in patients to determine the flattening of the talus dome and its correlation with age, sex, BMI, number of casts, and casting period. In these patients, the frequency of tenotomy and its relationship to the flat top talus was also examined. Results The study included a total of 50 children, of which 36 (72%) were boys and 14 (28%) were girls. The mean age, height, weight, and BMI of the children were 5.06 ± 0.79 years, 101.6 ± 6.34 cm, and 19.7 ± 1.57 kg, respectively. No significant difference between the normal and flat top talus category was found in age and BMI (p=0.611 and 0.997, respectively). Whereas, relative to normal children, the children who had flat-top talus were on casts for a longer period of time (median: 9 vs. 6 weeks, p=0.026). In addition, a higher proportion of children with more than six casts developed flat-top talus than those with fewer than six casts (69.2% vs. 30.8%, p=0.005). After treatment, a total of 13 (26%) patients developed flat top talus, of which 11 (84.6%) were boys and two (15.4%) were girls (p=0.303). No substantial association between tenotomy and flat top talus (p=0.340) could be identified. Conclusion Flat top talus is a complication of improper manipulation specifically correlated with the number of Ponseti casts applied. Maintenance of cast treatment for more than three months may result in flat-top talus with no significant association with tenotomy of the tendoachilles.

Impact of metal crystallinity-related morphologies on the sensing performance of plasmonic nanohole arrays.

Plasmonic nanohole arrays for biosensing applications have attracted tremendous attention because of their flexibility in optical signature design, high multiplexing capabilities, simple optical alignment setup, and high sensitivity. The quality of the metal film, including metal crystallinity and surface roughness, plays an important role in determining the sensing performance because the interaction between free electrons in the metal and incident light is strongly influenced by the metal surface morphology. We systematically investigated the influence of metal crystallinity-related morphologies on the sensing performance of plasmonic nanohole arrays after different metal deposition processes. We utilised several non-destructive nanoscale surface characterisation techniques to perform a quantitative and comparative analysis of the Au quality of the fabricated sensor. We found empirically how the surface roughness and grain sizes influence the permittivity of the Au film and thus the sensitivity of the fabricated sensor. Finally we confirmed that the deposition conditions that provide both low surface roughness and large metal grain sizes improve the sensitivity of the plasmonic sensor.

Nottingham Hip Fracture Score as a predictor of 3 months postoperative mortality in patients undergoing surgical fixation of hip fractures: A prospective study.

OBJECTIVE: Nottingham Hip Fracture Score was utilized to evaluate its efficacy to identify high risk pateints interms of 3 months postoperative mortality.NHFS comprises of seven independent predictors that were incorporated into a risk score to identify patients who were high risk for post-operative mortality with hip fracture.. METHODS: NHFS was prospectively calculated for 88 patients who underwent surgeries for hip fracture from 25th December 2014 to 25th June 2015 at the Indus Hospital Karachi. Both neck of femur and Intertrochanteric fracture were included. NHFS of ≤4 was considered as low risk and a score of ≥5 as high risk for mortality. RESULTS: The 3 months post-operative mortality was 22%. Increase in number of mortality was observed in patients who belonged to the high risk (NHFS ≥5) group, with statistically significant relationship when compared with the low risk (NHFS ≤4) group (p=0.01). CONCLUSIONS: NHFS can be used to predict the risk of 3 months postoperative mortality in patients undergoing hip fracture surgery.

Slipped capital femoral epiphysis after treatment of femoral neck fracture.

Slipped capital femoral epiphysis (SCFE) in children after treatment of femoral neck fracture is a very rare condition. This complication should be recognized promptly and treated urgently. The risk of development of this complication can be minimized by anatomical reduction of the fracture and stable internal fixation of the fracture. Five years old male child sustained right sided femur neck fracture and was treated with closed reduction and Hip spica cast application. The fracture healed with a varus deformity. After 7 months, he developed slip of femoral epiphysis with a coxa vara deformity of proximal femur, which was treated with in situ fixation with Cannulated screws. His subsequent course remained uneventful up to five months. Slipped capital femoral epiphysis (SCFE) after treatment of femoral neck fracture in children is a rare complication that should be recognized and treated promptly. The onset of SCFE may show inadequate reduction or fixation of the fracture. Anatomic reduction and stable internal fixation for femoral neck fracture in children provides best outcomes. Postoperative care and delayed weight bearing are also equally important to avoid complications.

Time-driven activity-based costing of total knee replacements in Karachi, Pakistan.

INTRODUCTION: Osteoarthritis of the knee has been identified as the most common disability in Pakistan. Total knee replacement (TKR) surgery is the curative treatment for advanced osteoarthritis of the knee; however, cost remains one of the barriers to effective and timely service delivery. OBJECTIVE: We conducted a time-driven activity-based costing (TDABC) analysis of TKR to identify major cost drivers and areas for process improvement. METHODS AND ANALYSIS: We performed a prospective TDABC analysis of patients who underwent bilateral TKR at The Indus Hospital (TIH) during a 14-month period from October 2015 to December 2016. Detailed process maps were developed for each phase of the care cycle. Time durations and costs were allocated to each resource utilised and aggregated across the care cycle, including personnel, direct and indirect costs. RESULTS: We identified seven care phases for a complete TKR care cycle and created their detailed process maps. Major time contributors were ward stay and discharge (20 160 min), TKR surgery (563 min) and surgical admission (333 min). Overall, 92.10% of time is spent during the ward stay and discharge phase of care. Patients remain hospitalised for an average of 14 days postoperatively. Overall institutional cost of a TKR at TIH was US$4360.51 (Pakistani rupees 456 981.17) per bilateral TKR surgery. The overall primary cost drivers for the full bundle of care were consumables used during TKR surgery itself, consumables utilised in the wards and personnel costs contributing 57.64%, 27.45% and 12.03% of total costs, respectively. CONCLUSION: Utilising TDABC allowed us to obtain a granular analysis of time and cost that was subsequently used to inform quality process improvement initiatives. In low-resource settings, such as Pakistan, TDABC has the potential to be a useful tool to guide resource allocation and process improvement.

The frequency of Deep Vein Thrombosis in patients with hip fractures.

OBJECTIVE: To find out the frequency of deep vein thrombosis in hip fracture patients. Methods: The prospective, cross-sectional study Was conducted at Indus Hospital, Karachi, from November 2016 to September 2017, and comprised patients with hip fractures who were scanned for the presence of deep vein thrombosis on both lower limbs preoperatively at the time of presentation and postoperatively on post-op day 3 and day 28. No thrombo-prophylaxis was provided to the patients. Risk factors for deep vein thrombosis were also assessed. Data was analysed using SPSS 21.. Results: Of the 109 patients, 50(46%) were male and 59(64%) were females. The overall mean age was 64.59 ± 9.82 years. Deep vein thrombosis was found in 4(3.66%) patients; 2(50%) preoperatively and 2(50%) in the early postoperative period. No deep vein thrombosis was found in any patient on postop day 28.. Conclusion: The frequency of deep vein thrombosis in Pakistani geriatric patients with hip fractures was found to be low compared to the western population.

Non-destructive analysis on nano-textured surface of the vertical LED for light enhancement.

In this work, the nano-textured surface of a GaN-based vertical light emitting diode (VLED) is characterized using a unified framework of non-destructive techniques (NDT) incorporating scanning electron microscopy (SEM), atomic force microscopy (AFM), Raman spectroscopy, Photoluminescence (PL), and X-ray diffraction (XRD) to optimize the light output efficiency. The surface roughness of ∼300 nm is revealed by AFM. Compressive stress-state of 0.667 GPa in the GaN surface is indicated by the E2(high) and A1(LO) phonon peak values at 569 cm-1 and 736 cm-1, respectively, in Raman spectrum and the wavelength at 442 nm rather 450 nm in PL spectrum. Without damaging the LED, surface analysis by NDT helps to advance the understanding of the optimized angular light redistribution subject to the high-roughness surface and the negative impacts of the stress induced at the top GaN layer, which leads to the optical efficiency degradation of the VLED. Furthermore, the impact of texturing on underneath n-GaN and MQWs layers is investigated via SEM-based transmission Kikuchi diffraction (TKD) and aberration-corrected scanning transmission electron microscopy (AC-STEM) and revealed a smooth surface morphology and good crystalline quality, indicating that the etch-induced damage by texture engineering does not impair the active region of the VLED. Accordingly, prospective optimizations are suggested in the context of surface engineering for light enhancement in VLEDs.

Vasopressin vs noradrenaline: Have we found the perfect recipe to improve outcome in septic shock?

PURPOSE: The metabolic and circulatory disturbances in patients with septic shock results in a high mortality rate. There is a lack of high-level evidence on the optimal approach. We present a meta-analysis elucidating the outcomes of regimes with only noradrenaline versus a combination of noradrenaline and vasopressin in managing septic shock. METHODS: A literature search of studies comparing the use of noradrenaline and vasopressin in septic shock was conducted, using MEDLINE and EMBASE databases. The primary outcome evaluated was mortality rate. Subgroup analysis of secondary measures was also conducted using Review Manager 5.3 software. RESULTS: Four RCTs of 1039 patients were included. There is good evidence supporting a comparable mortality rate (RR: 0.92, 95% CI: 0.78, 1.08, p = .32, I2 = 0%), and moderate evidence supporting an equivalent length of ICU stay (MD: 0.14, 95% CI: -1.37, 1.65, p = .86, I2 = 46%) and occurrence of adverse events (RR: 1.19, 95% CI: 0.83, 1.70, p = .35, I2 = 13%) between the two cohorts. CONCLUSION: The two regimes have equivalent outcomes, but vasopressin has a role in selected patients experiencing less severe septic shock beyond a 36-h period. Further work will make definitive clinical recommendations for optimal strategy of vasopressin or noradrenaline usage.

Significance Of Pirani Score at Bracing-Implications for Recognizing A Corrected Clubfoot.

BACKGROUND: The aim of clubfoot treatment by Ponseti method is to achieve a corrected foot, with at least 15° dorsiflexion and 70° abduction, and fit comfortably into a brace at the recommended setting. This study aimed to acknowledge the validity and reliability of the Pirani scoring system, while investigating if a corrected clubfoot has a Pirani score of zero. The study hypothesized that a corrected clubfoot may or may not have a Pirani score of zero. METHODS: 706 patients with clubfoot were treated by Ponseti's method of weekly manipulations and casting, from November 2011 to May 2016, at a tertiary care hospital, making a total of 1055 feet. All data was entered into the International Clubfoot Network Database, along with Pirani scoring. Tenotomy was performed in eligible patients. RESULTS: The mean Pirani score at the end of treatment phase of casting and initiation of the maintenance phase of bracing for the right foot was 1.1 (SD=0.55) and left foot was 1.2 (SD=0.58). These feet not only fit the criteria of a corrected clubfoot, 70° abduction and 15° dorsiflexion, but also fit well in a foot abduction brace. Of the 1055 diagnosed Clubfeet, 643 required tenotomy (60.9%). CONCLUSION: The study shows that the affected foot does not need to have a Pirani score of zero to be considered a corrected foot. Pirani score is an excellent tool used over the years to evaluate clubfoot. Pirani score does not assess adequately the transition from the treatment phase of casting to the maintenance phase of bracing. The use of the International Clubfoot Database-Treatment visit form, including all components of clubfoot and the Pirani score, provides a clear understanding of whether the patient has achieved foot correction or not. Level of Evidence: Level IV.

Insights into the Silver Reflection Layer of a Vertical LED for Light Emission Optimization.

In this work, Ag as a highly reflective mirror layer of gallium nitride (GaN)-based blue vertical light-emitting diodes (VLEDs) has been systematically investigated by correlating scanning electron microscopy/energy dispersive X-ray spectroscopy/transmission Kikuchi diffraction/electron backscatter diffraction, aberration-corrected scanning transmission electron microscopy, and atomic force microscopy techniques. In the context of high-efficiency lighting, three critical aspects have been scrutinized on the nanoscale: (1) chemical diffusion, (2) grain morphology, and (3) surface topography of the Ag layer. We found that nanoscale inhomogeneous distribution of In in InGaN/GaN quantum wells (QWs), interfacial diffusion (In/Ga out-diffusion into the Ag layer and diffusion of Ag into p-GaN and QWs), and Ag agglomeration deteriorate the light reflectivity, which account for the decreased luminous efficiency in VLEDs. Meanwhile, the surface morphology and topographical analyses revealed the nanomorphology of the Ag layer, where a nanograin size of ∼300 nm with special nanotwinned boundaries and an extremely smooth surface of ∼3-4 nm are strongly desired for better reflectivity. Further, on the basis of these microscopy results, suggestions on light extraction optimization are given to improve the performance of GaN-based blue VLEDs. Our findings enable fresh and deep understanding of performance-microstructure correlation of LEDs on the nanoscale, providing guidance to the design and manufacture of high-performance LED devices.

Intra-operative implantation errors during Austin Moore Hemiarthroplasty.

Austin Moore hemiarthroplasty is an established treatment in elderly patients with neck of femur fractures. Being commonly performed, it is also associated with several technical errors of implantation which results in complications and failure requiring revision surgery. This retrospective pre- and post-operative radiographic study to determine the frequency of technical errors was conducted at the Indus Hospital, Karachi, and comprised data of 50 patients who underwent Austin Moore hemiarthroplasty between January and November 2016. Of the total, 29(58%%) patients had no error of implantation. Overhanging of prosthesis was observed in 21(42%) patients, followed by inadequate length of the neck remnant in 18(36%). Moreover, 8(16%) patients sustained intra-operative periprosthetic fractures managed with cerclage wire. Also, 33(66%) patients had a Dorr type-Afemur morphologic pattern. Hemiarthroplasty was found to be a technically demanding procedure associated with avoidable intra-operative implantation errors by proper preoperative planning, careful patient selection, proper training of surgeons, hence avoiding failure.

Blunt splenic injury: use of a multidetector CT-based splenic injury grading system and clinical parameters for triage of patients at admission.

PURPOSE: To assess the use of a dual-phase multidetector computed tomography (CT)-based grading system alone and in combination with assessment of clinical parameters at triage of patients with blunt splenic injury for determination of appropriate treatment (observation, splenic artery embolization [SAE], or splenic surgery). MATERIALS AND METHODS: This HIPAA-compliant retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. Between January 2009 and July 2011, 171 hemodynamically stable patients with blunt splenic injury underwent multidetector CT at admission to the hospital. Images were reviewed by applying a multidetector CT-based grading system, and the amount of hemoperitoneum was quantified. Demographic data, vital signs, laboratory values, injury severity score, abbreviated injury severity, final treatment decision, and success of nonsurgical treatment were reviewed. Receiver operating characteristic curves and stepwise logistic regression analyses were performed to determine the optimal parameters for effective triage of patients. RESULTS: One hundred seventy one patients with splenic injury underwent multidetector CT. At triage, clinical treatment decisions were made, and patients received either observation (85 of 171 [50%]) or splenic intervention (surgery, 19 of 171 [11%] or splenic angiography, 67 of 171 [39%]). Four patients underwent SAE after unsuccessful observation. Six of 171 (3.5%) other patients received unsuccessful nonsurgical treatment with SAE. No patients who received observation required splenectomy. Areas under the receiver operating characteristic curve (AUCs) showed that the CT grading system was the best individual predictor of successful observation (AUC, 0.95), and stepwise logistic regression analysis results showed that multidetector CT grade and the abbreviated injury scale score (AUC, 0.97; P = .02) were the best combination of variables for selection of patients for observation versus splenic intervention. The combination of abbreviated injury scale score, systolic blood pressure reading, and serum glucose level was the best triage model for decision making between splenectomy and SAE (AUC, 0.84). CONCLUSION: The best individual predictor of successful observation in patients with blunt splenic injury was the CT-based grading system. Multidetector CT grade and abbreviated injury scale score were the best combination of variables for selection of patients for observation versus splenic intervention.