Cachexia in tuberculosis in South-East Asian and African regions: knowledge gaps and untapped opportunities.

Tuberculosis (TB) and cachexia are clinical entities that have a defined relationship, making them often found together. TB can lead to cachexia, while cachexia is a risk factor for TB. This article reviews cachexia in Tuberculosis patients in Southeast Asian and African regions by conducting a comprehensive literature search across electronic databases such as PubMed, Google Scholar, and Research Gate between 2013 and 2024 using keywords including 'Africa', 'cachexia', 'prevalence', 'implications', 'tuberculosis', and 'Southeast Asia. This article utilized only studies that satisfied the inclusion criteria, revealing knowledge gaps and untapped opportunities for cachexia in TB across Southeast Asian and African regions. Many Southeast Asian and Western Pacific patients initially receive a tuberculosis diagnosis. Sub-Saharan African countries are among the 30 high TB burden nations, according to the WHO. Food inadequacy and heightened energy expenditure can impair the immune system, leading to latent TB and subsequently, active infection. Symptoms needing attention: shortness of breath, productive cough, hyponatremia at 131 mmol/l, hypoalbuminemia at 2.1 g/dl, elevated aspartate transaminase at 75 U/l, increased lactate dehydrogenase at 654, and normocytic anemia. Comorbidities, such as kidney disease, cardiovascular disease, and asthma, can influence the nutritional status of individuals with TB. While efforts like screening, contact tracing, and utilizing gene Xpert to detect TB cases were implemented, only a few proved effective. It is essential to conduct further studies, including RCTs, in Southeast Asia and Africa to evaluate and manage cachexia in TB patients.

Analysis of the outcomes of postdiverticulitis investigations: a multicentre cohort study including 1,120 patients.

INTRODUCTION: The aim of this study was to assess the yield of the endoscopic investigations performed following the resolution of acute diverticulitis. METHODS: A retrospective multicentre study included patients with multislice computed tomography (MSCT)-proven diverticulitis, in four NHS hospitals, between January 2016 and April 2023. The primary outcome was the rate of colonic cancer in the diseased segment. Secondary outcomes included the rate of malignancy in the nondiseased colonic segments, the benign colonic polyp detection rate, the rate of malignancy in the resected surgical specimens in patients who underwent an emergency surgery on the index admission and the rate of complications in the investigated group. RESULTS: A total of 1,120 patients were included in the study, out of which 604 were females, with a median age of 61 years; 731 patients (65%) had uncomplicated diverticulitis (Hinchey 1A) while 389 (35%) had complicated diverticulitis (Hinchey 1B-4). Following the acute episode, 757 (74%) patients had subsequent endoscopic evaluation. The incidence of colorectal cancer (CRC) or advanced adenomas (AA) in patients with uncomplicated diverticulitis was 0.14%. In the complicated diverticulitis group, the incidence of CRC/AA in patients with Hinchey 1b and Hinchey 2 was 1.4% and 5.4%, respectively. Out of the 102 patients who underwent emergency colonic resection for suspected perforated diverticulitis, 18 (17.6%) had histological evidence of colonic malignancy. CONCLUSIONS: Endoscopic investigations following uncomplicated diverticulitis have a low yield for sinister colonic pathology. Colonoscopy should be planned following complicated diverticulitis and in patients with uncomplicated diverticulitis with suspicious radiological finding on index imaging or in patients with ongoing clinical manifestations. In patients who undergo emergency surgery, oncological principles should be applied whenever possible.

Efficacy of Intrawound Vancomycin in Prevention of Periprosthetic Joint Infection After Primary Total Knee Arthroplasty: A Prospective Double-Blinded Randomized Control Trial.

BACKGROUND: Periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a devastating complication. Intrawound vancomycin powder has been shown to reduce infection rates in spine surgery, but its role in arthroplasty remains controversial. This prospective randomized control trial aimed to evaluate the efficacy of intrawound vancomycin in preventing PJI after primary TKA. METHODS: A total of 1,022 patients were randomized to the study group (n = 507, who received 2 grams intrawound vancomycin powder before arthrotomy closure) or to the control group (n = 515, no local vancomycin) with a minimum follow-up of 12-months. The primary outcome was the incidence of PJI or surgical site infection (SSI). Secondary outcomes included associated minor complications such as stitch abscess, persistent wound drainage, and delayed stitch removal. Other parameters evaluated include reoperation rates and incidences of nephrotoxicity. RESULTS: The overall infection rate in 1,022 patients was 0.66%. There was no significant difference in PJI rate in the study group (N = 1; 0.2%) versus the control group (N = 3; 0.58%), P = .264. Reoperation rates in the study group (N = 4; 0.78%) and control (N = 5; 0.97%), and SSI rates in the study (N = 1; 0.2%) and control groups (N = 2; 0.38%) were comparable. The Vancomycin cohort, however, demonstrated a significantly higher number of minor wound complications (n = 67; 13.2%) compared to the control group (n = 39; 7.56%, P < .05). Subgroup analysis showed diabetics in the study group to also have a higher incidence of minor wound complications (24 [14.1%] versus 10 [6.2%]; P < 05]. Multivariate analyses found that vancomycin use (odds ratio = 1.64) and smoking (odds ratio = 1.85) were associated with an increased risk of developing minor wound complications. No cases of nephrotoxicity were reported. CONCLUSIONS: Intrawound vancomycin powder does not appear to reduce PJI/SSI rate in primary total knee arthroplasties, including high-risk groups. Although safe from a renal perspective, intrawound vancomycin was associated with an increase in postoperative aseptic wound complications. Intrawound vancomycin may not be effective in reducing the rate of PJI in primary TKA.

Operating room efficiency for a high-volume surgeon in simultaneous bilateral robotic-assisted total knee arthroplasty: a prospective cohort study.

Robotic-assisted total knee arthroplasty (RATKA) has been shown to achieve more accurate component positioning and target alignment than conventional jig-based instrumentation; however, concerns remain regarding its adoption since it is associated with steep learning curves, higher operational costs, and increased surgical time. This study aims to compare the operating times of three cohorts of patients undergoing simultaneous bilateral TKA, i.e., first 50 RATKA, last 50 RATKA (at the end of 1 year), and 50 conventional TKA. This prospective cohort study was conducted at a single high-volume tertiary care center by a single experienced surgeon on 150 patients (300 knees), who were allotted into three equal cohorts of 50, between February 2020 and December 2021. Simultaneous bilateral TKAs were done in all three groups and operative times recorded. We describe the technique for optimizing the surgical time of SB-RATKA for efficient operative room logistics. The operating times of the two robotic-assisted TKA cohorts were compared with the operating times of the conventional SB-TKA cohort. The mean age of the study population was 59(±6.2) years with the majority of females (82%). The mean coronal deformity was comparable between the cohorts. The mean operating time in the conventional CTKA, initial 50 RATKA, and final 50 RATKA cohorts were 115.56 (±10.7), 127.8 (±26), and 91.66 (±13.5) min, respectively, all of which showed a statistically significant difference (p < 0.001). The mean operating times of the final 50 RATKA at the end of 1 year improved by about 36 min with all the SB-RATKA cases being completed in under 120 min. The efficiency of SB-RATKA improved significantly with time and experience, resulting in shorter operational times within a year, revealing the potential of robotic-assisted surgery to surpass conventional approaches in TKA in terms of operating room efficiency.

Infrared thermal images using PCSAN-Net-DBOA: An approach of breast cancer classification.

This manuscript proposes thermal images using PCSAN-Net-DBOA Initially, the input images are engaged from the database for mastology research with infrared image (DMR-IR) dataset for breast cancer classification. The adaptive distorted Gaussian matched-filter (ADGMF) was used in removing noise and increasing the quality of infrared thermal images. Next, these preprocessed images are given into one-dimensional quantum integer wavelet S-transform (OQIWST) for extracting Grayscale statistic features like standard deviation, mean, variance, entropy, kurtosis, and skewness. The extracted features are given into the pyramidal convolution shuffle attention neural network (PCSANN) for categorization. In general, PCSANN does not show any adaption optimization techniques to determine the optimal parameter to offer precise breast cancer categorization. This research proposes the dung beetle optimization algorithm (DBOA) to optimize the PCSANN classifier that accurately diagnoses breast cancer. The BCD-PCSANN-DBO method is implemented using Python. To classify breast cancer, performance metrics including accuracy, precision, recall, F1 score, error rate, RoC, and computational time are considered. Performance of the BCD-PCSANN-DBO approach attains 29.87%, 28.95%, and 27.92% lower computation time and 13.29%, 14.35%, and 20.54% greater RoC compared with existing methods like breast cancer diagnosis utilizing thermal infrared imaging and machine learning approaches(BCD-CNN), breast cancer classification from thermal images utilizing Grunwald-Letnikov assisted dragonfly algorithm-based deep feature selection (BCD-VGG16) and Breast cancer detection in thermograms using deep selection based on genetic algorithm and Gray Wolf Optimizer (BCD-SqueezeNet), respectively. RESEARCH HIGHLIGHTS: The input images are engaged from the breast cancer dataset for breast cancer classification. The ADQMF was used in removing noise and increasing the quality of infrared thermal images. The extracted features are given into the PCSANN for categorization. DBOA is proposed to optimize PCSANN classifier that classifies breast cancer precisely. The proposed BCD-PCSANN-DBO method is implemented using Python.

Improved intra-operative decision making in RA-TKR with the help of pre-operative CT scan.

Background: Robotic-assisted total knee replacement (RA-TKR) is a significant advancement in orthopedic surgery, but intra-operative decision-making remains challenging. Pre-operative imaging techniques, particularly CT scans, have gained momentum, providing insights into the patient's anatomy, improving implant positioning and alignment. However, further research is needed to explore their influence on RA-TKR planning and execution. Materials and methods: The hospital based cross-sectional study was conducted in Orthopedics department of Sparsh Speciality Hospital, Bangalore & Sunshine Hospital, Hyderabad. A total of 1020 participants in the age group over 50 years during the study period were included based on convenient sampling. The axial CT images were taken preoperatively and RA-TKA was done for all the patients. Results: The study participant's average age was 64.01 ± 7.13. Out of 1020 patients 259 (24.4%) were males and 761 (74.6%) were females. The median femoral, tibia and Polyethylene predicted and the actual component were same with the side of surgery and BMI. The median femoral predicted actual component was significantly higher among the age category of more than 80 years when compared to other age groups. The median femoral, tibia and Polyethylene predicted was higher in males when compared to females. Conclusion: Pre-operative CT scans enhance RA-TKR procedures by providing precise anatomical insights, enhancing implant placement, and identifying potential issues, improving surgical outcomes and patient satisfaction.

Impact of Hepatitis B on Complications and Functional Outcomes in Patients Undergoing TKR.

Background: In India, infected patients with hepatitis B virus (HBV) undergoing total knee replacement (TKA) are increasing. It is recognized that patients with HBV infection are more susceptible to complications after surgery. To evaluate the effect of HBV infection on complications and functional outcome after TKA was the aim of this study. Methods: This is the retrospective observation analysis of patients who underwent primary total knee replacement in our hospital from 2017 to 2019. A total of 92 patients were included in the study, of which 46 patients were asymptomatic HBV-positive, and these 46 patients were compared with a matched cohort of another 46 patients who were non-HBV. Results: A total of 92 patients were analyzed (asymptomatic HBV n = 46, non-HBV n = 46). The incidence rate of total complications in patients undergoing TKA with asymptomatic HBV was 19.57% compared to 4.3% in non-HBV (p < 0.001). Applied with regression models, patients with HBV had an 8.6% increased risk of surgical complication which included one peri-prosthetic joint infection, three wound dehiscence compared with the non-HBV group which had 2.17% surgical complications (one wound dehiscence). Medical complications were higher in asymptomatic HBV group with 10.87% (which includes one pulmonary embolism, two DVT, and two strokes). In comparison with the non-HBV group which had 2.17% medical complications (one DVT), asymptomatic HBV group had 5.35-fold (95% CI 1.09-26.33; p < 0.01) increase in overall complications. Post-TKA surgical complications are 4.29-fold (95% CI 0.46-39.91; p < 0.01) higher compared to non-HBV group. Conclusion: Our study showed asymptomatic hepatitis B patients are at an increased risk of complications (peri-prosthetic joint infections and wound dehiscence) compared to normal patients. In hepatitis B and non-hepatitis B patients, functional outcomes in terms of OKS are comparable.

Expression of anti - Apoptotic survivin in odontogenic keratocyst, adenomatoid odontogenic tumor and ameloblastoma.

Background: The process of odontogenesis is complex involving epithelial-mesenchymal interactions, along with the molecular signalling pathways triggering the initiating process. The triggering factors and cells precisely involved in the pathogenesis of odontogenic cysts and tumors are unknown. There is a vast array of biomarkers used to stain different sites, thereby helpful in diagnosing and evaluating the prognosis of these cysts and tumors. In the following study, Anti Apoptotic survivin expression patterns were assessed quantitatively in 48 samples (12 each) of Reduced Enamel Epithelium, Adenomatoid Odontogenic Tumor, Odontogenic Keratocyst and Ameloblastoma. Aim: The Aim of this study is to assess the anti-apoptotic survivin expression in Reduced Enamel Epithelium, Adenomatoid odontogenic tumour, Odontogenic Keratocyst and Ameloblastoma. Materials and Methods: The present study is carried out with 12 samples in each group. Routine hematoxylin and eosin staining was performed for confirmatory diagnosis. Later Immunohistochemistry was performed using survivin antibody. Survivin protein expression was analyzed using the parameters like location, intensity, percentage of cells positivity with survivin protein and extent of staining. With the help of Olympus BX 43 microscope, with ProgRes microscope camera, the 48 slides obtained were examined. The region of interest was selected in each slide and number of cells positively stained was counted. Data was analyzed using SPSS software version 23. Descriptive for scale data, results were analysed by using ANOVA with Chi-square test for intergroup comparison. Results: The results showed significant P value <0.05. Expression of survivin was highest in Ameloblastoma, followed by Odontogenic keratocyst, Adenomatoid odontogenic tumor, and Reduced Enamel Epithelium. Conclusion: Survivin was involved in the inhibition of apoptosis as well as the detailed understanding of the biological behaviour of odontogenic cysts and tumours, thereby increasing therapeutic approaches.

Relationship between femoral component placement and patient-specific anatomical rotational landmarks in robotic arm assisted total knee Arthroplasty- a multicentric study.

Introduction: Osteoarthritis of the knee is a common problem in the elderly, leading to severe morbidity. Total Knee Arthroplasty (TKA) is a widely validated surgery to provide a remarkable extent of knee function and simultaneously alleviates pain for knee osteoarthritis (OA). It is clearly understood that precision of the rotational alignment and accuracy of the technique in the placement of the femoral component is a prerequisite for excellent and successful outcomes of TKA. Advanced technology has now allowed surgeons to understand patient-specific variabilities in anatomical reference landmarks and the relationship of component positioning in relation to the reference landmarks to achieve accurate gap balancing with minimal soft tissue release.14 Robotic Arm Assisted-Total Knee Arthroplasty (RAA-TKA) is a semi-automated system that enables us in replicating the same. Using this technology, the bony resections, component positions, probable component sizing and gap balancing can be tentatively planned preoperatively with CT Scan Analysis and executed intraoperatively. Hence this study was undertaken to estimate the relationship between femoral component placement to normal rotational landmarks such as the Posterior Condylar Axis (PCA) and to quantitatively evaluate coronal and sagittal plane correction obtained. Also, we aimed to use the data to detect any anatomical variations in the study population and evaluate the accuracy of predicted component sizing, including gender-based evaluation. Materials and methods: A Prospective Observational Study of 1073 knees of patients of either sex above 50 years of age with Kellgren Lawrence Grade 4 Osteoarthritis of the knee which were confirmed with X-Ray undergoing RAA-TKA using MAKO Robotic System using Stryker Triathlon (Cruciate Substituting) CS Knee was conducted during the period between 2022 and 2023 in two South Indian hospitals specializing in joint replacement surgeries. Results: We found a statistically significant difference between the native Posterior Condylar Axis (PCA) (4.82 ± 2.15°) and final femoral component external rotation (3.24 ± 1.29°) with a p-value of <0.001 at 95% confidence interval. The accuracy of component size prediction was 99.8%. Also, analysis in our study has shown the most common implant sizes to be 4 in males and 2 in females. We also found no statistically significant difference based on age, size, laterality, or primary varus deformity. Conclusions: RAA-TKA provides patient-specific alignment/restricted kinematic alignment which might further enhance the outcome for the patient. Reliable deformity correction in coronal and sagittal planes can be achieved. Accurate flexion and extension gap balancing can be done through component placement and with minimal soft tissue dissection. Irrespective of all the advantages noted in RAA-TKA, further follow-up and long-term outcome studies are required to properly gauge and analyze this new technology.

Unveiling Scapular Pseudo-winging: A Case Report on Ventral Osteochondroma of the Scapula in a 21-year-old.

Introduction: Scapular pseudo-winging caused by ventral osteochondromas is a rare condition that has been reported in only a handful of cases. This case report describes a 21-year-old male patient with scapular pseudo-winging due to ventral osteochondromas of the scapula. This report adds to the limited literature on this topic and highlights the importance of considering ventral osteochondromas as a possible cause of scapular pseudo-winging. Case Report: A 21-year-old male presented with a swelling on his left upper back that had gradually increased in size over the past 10 years. Physical examination revealed a bony hard swelling arising from the medial border of the scapula, with associated scapular pseudo-winging. Diagnostic imaging confirmed the presence of two ventral osteochondromas located on the body of the scapula. Surgical excision was performed to address the patient's cosmetic concerns. Conclusion: This case report highlights the importance of considering ventral osteochondromas as a possible cause of scapular pseudo-winging. It contributes to the existing literature by documenting a rare presentation and providing insights into the clinical course, diagnostic imaging, and surgical management of this condition. By raising awareness among tumor surgeons and orthopedic surgeons, this report may aid in early recognition and appropriate management of scapular pseudo-winging cases caused by ventral osteochondromas. Furthermore, this report expands our understanding of the etiology and treatment options for scapular pseudo-winging, potentially benefiting patients across various clinical specialties. Categories: Oncology, orthopedics.

Calcaneal Osteosarcoma: A Rare Instance in Adolescent Patient.

Introduction: Calcaneal osteosarcoma is extremely uncommon, accounting for <1% of all osteosarcomas. They typically exhibit swelling and chronic heel pain and are frequently clinically misdiagnosed as traumatic or inflammatory process. Case Report: We report a case of a 19-year-old girl with calcaneal osteosarcoma who initially complained of heel pain that was refractory to analgesic medications over a period of 4 months. Conclusion: The case highlights the importance of early diagnosis and management of osteosarcoma in patients with chronic heel pain and also highlights the importance of considering osteosarcoma as a differential diagnosis in adolescents who present with chronic heel pain, despite the rarity of the condition.

Mid-resection Workflow for Robotic-assisted Total Knee Arthroplasty in a Stiff Knee.

Introduction: With the growing prevalence of robotic-assisted total knee arthroplasty (RATKA), the significance of effectively addressing complex deformities using this approach is gaining widespread recognition. This article underscores the importance of a novel mid-resection workflow specifically tailored for RATKA in cases with complex deformities. Case Report: A 58-year-old female patient diagnosed with severe osteoarthritis in both knees and a stiff left knee underwent RATKA utilizing a mid-resection workflow. The surgery resulted in favorable intraoperative stability and achieved a satisfactory range of motion. Follow-up at the 1-year post-operative mark demonstrated a range of movement of 110° and a positive functional outcome for the patient. Conclusion: Severe knee arthritis with flexion deformity represents a common condition encountered in surgical practice. The advent of RATKA has provided us with an opportunity to assess and establish the effectiveness of mid-resection workflow in managing such cases.

Functional alignment is associated with increased incidence of pre-balance, reduced soft-tissue release, and post-operative pain compared to mechanical alignment in patients undergoing simultaneous bilateral robotic-assisted TKA.

This study aimed to compare two alignment strategies in the same patient undergoing simultaneous bilateral robotic-assisted TKA (SB-RATKA): mechanical alignment (MA), the gold-standard, and functional alignment (FA), a balance-driven, personalized alignment strategy. The outcome measures included quantitative assessment of soft-tissue release, incidence of knee balance, and post-operative pain. This was a prospective, self-controlled, randomized-controlled trial involving 72 patients who underwent SB-RATKA using the MAKO® robotic system with comparable grades of deformity and pain in both knees. 65 patients were finally included with one alignment strategy done per knee, with the patients blinded to the strategy used. The study recorded the additional soft-tissue releases required, incidence of pre-balance, and daily post-operative VAS pain scores. The mean age of the study population was 57.95 years, with a female preponderance (N = 53, 81.6%). MA group had significantly more medial compartment tightness in both flexion (MA-15.6 ± 1.8; FA-17 ± 1.3) and extension (MA-14.9 ± 1.9; FA-17 ± 1.1) (p < 0.0001) compared to the FA group after dynamic balancing. 66% of knees in the FA group (N = 43) achieved pre-balance compared to 32.3% in the MA group (N = 21) (p < 0.0001). VAS scores showed a significant reduction in pain in the FA group up to 72 h post-surgery (p < 0.0001). The requirement for posteromedial release (PM), posterior capsular (PC) release, tibial reduction osteotomy (TRO), and superficial MCL pie crusting (sMCL) were significantly lower in FA (PM-22, PC-13, TRO-8, sMCL-2) compared to MA (PM-44, PC-29, TRO-18, sMCL-8). Functional alignment strategy consistently resulted in a higher incidence of knee balance with a significant reduction in soft-tissue releases and immediate post-operative pain when compared to MA in the same patient undergoing SB-RATKA. Therapeutic Level 1.

Percutaneous Management of Aneurysmal bone Cyst of Axis Vertebrae in a 12-year-old Child: A Case Report.

Introduction: Aneurysmal bone cyst (ABC) of cervical spine is rare in the pediatric age groups. It brings along a gamut of problems in management such as growth disturbances, instability, deformities, and neurological deficiencies. We report a case that was successfully managed by intralesional injection, making it safe and reproducible. Case Report: A 12-year-old girl presented with pain and swelling around the nape of neck that increased in size over 1 year. Imaging and biopsy were suggestive of ABC. She was managed with selective embolization and percutaneous injection of methylprednisolone and calcitonin. Injections were given twice over 2 months period. At 1½ year follow-up, the patient was asymptomatic and swelling had shrunk in size and lesions ossified. Conclusion: ABC'S are rare lesions that can create therapeutic dilemma in the pediatric population. Intralesional injection of calcitonin and methylprednisolone can prove to be a safer and efficacious treatment modality.

Is it worth the risk? Frailty transition and complications following robotic total knee arthroplasty: A retrospective observational study.

BACKGROUND: Frailty is an underutilized prognostic parameter in the geriatric population. Our study aimed to analyse the frailty incidence, its transition over 1 year and its influence on complication rate in patients undergoing elective robotic-assisted total knee arthroplasty (TKA). METHODS: This was a retrospective study wherein an accumulation of deficits model was used to evaluate frailty of 435 consecutive patients undergoing primary unilateral Mako-assisted cemented TKA between January 2020 and July 2021. Based upon the preoperative values, participants were divided into three groups; non-frail (FI < 0.11), vulnerable (0.11-0.20) and frail (FI > 0.20) states and were followed up for 1 year for change in frailty class, complications, re-admissions and mortality. RESULTS: A total of 435 patients were divided into three groups, non-frail (178), vulnerable (208) and frail (49). Improvement in mean frailty scores was seen in all three groups (P < 0.0001); 21.63% of the vulnerable and 48.97% of the frail participants improved by one frailty class. Multivariate analysis showed the co-relation of change in frailty index (ΔFI) with preoperative FI (r = 0.083) and Knee Society Score (KSS) (r = 0.742). The frail group had a significantly higher re-admission rate over 1 year. When compared with the vulnerable group, the frail group had a higher hazard ratio for readmission (3.12 vs. 0.96) and complications (1.62 vs. 1.26). CONCLUSION: Although frail individuals are at a higher risk for readmissions and perioperative complications, TKA significantly improves the mobility and frailty status of elderly individuals. With explained higher risk of complications, surgeons should not refrain from offering TKA to elderly frail individuals disabled with knee pain.

Intraoperative Periprosthetic Fractures during primary Total knee arthroplasty: Experience from an Asian high-volume arthroplasty centre.

BACKGROUND: Intraoperative periprosthetic fracture (IF) is an under-reported complication in primary total knee arthroplasty (TKA). This study aimed to audit the outcomes and complication rates in patients encountering IF during primary TKA and propose a new classification for its management. METHODS: A nested case-control study was performed at a tertiary referral hospital where 50 patients encountering IF during primary TKA operated by a single surgeon team between January 2016 to May 2021, were compared with 150 (3:1) age-, gender- and implant-matched patients not encountering IF. Demographic data, risk factors, outcomes and complications of both groups were compared at a minimum follow up of 1 year. RESULTS: The incidence of IF was 0.45%, with 44 fractures in the femur (88%), six (12%) in the tibia and none in the patella. Medial collateral ligament avulsion fracture (54.54%) in the femur and medial plateau fracture (66.66%) in the tibia were the most common fracture types. At final follow up, the fracture group had higher rates of 90-day re-admissions (8% vs. 2.66%, P = 0.095), deep infection (4% vs. 0.66%, P = 0.15) and revisions (6% vs. 1.33%, P = 0.06). The mean Knee Society Score was not significantly different between the two groups (152.22 ± 9.25 vs. 161.68 ± 11.22, P = 0.642) with union being achieved in all but one patient at a mean duration of 9.6 weeks. CONCLUSIONS: Patients with severe and fixed deformities have a higher risk for IF. The occurrence of fracture and the complexity of surgery equally contribute to the higher complication rates. Appropriately managed fractures have comparable functional outcomes.

Critical Appraisal of Paediatric Embryonal Cancers Treated with Image-guided Intensity-modulated Proton Therapy.

AIM: To carry out a comprehensive critical appraisal of image-guided intensity-modulated proton therapy practice for craniospinal irradiation (CSI). MATERIALS AND METHODS: An image-guided intensity-modulated proton therapy database of 45 consecutive paediatric patients with central nervous system embryonal malignancies treated between January 2019 and April 2022 were critically appraised for demography, diagnosis, treatment planning strategy and treatment delivery accuracy. RESULTS: Most patients (median age: 7.5 years; male:female ratio: 34:11) had medulloblastoma (56%), followed by recurrent ependymoma (19%), pinealoblastoma (5%), germ cell (5%) and others (15%). The dose to the planning target volume-craniospinal (PTV-CS; length 39.06-79.59 cm) varied from 21 to 35 GyRBE, whereas the combined median dose to craniospinal and boost was 54 GyRBE. In all patients, the 95% isodose line covered the cribriform plate completely and optic nerves mostly, with a median V95% of 100% and 82.96%, keeping Dmax to the lens <3.9 GyRBE. In skeletally immature patients (88.38%), the anterior vertebral body was completely covered in 18.18% and underdosed in 70.15% of the cases, resulting in a median Dmean of 10.11 GyRBE to the oesophagus. Lateral spine coverage was maintained on the edges of the vertebral body in 52.2%, whereas it extended beyond in 48.8%. The median V98% for clinical target volumes and V95% for PTVs of the brain, spine and craniospinal were >97%, with excellent conformity (0.89) and homogeneity (0.07) indices for PTV-CS. All neurological organs at risk received a median Dmax ranging from 36 to 44 GyRBE from the combined CSI and boost regimens. Analysis of patient-specific quality assurance results revealed that 545 (97.67%) planar dosage verification had gamma (3% at 3 mm) values >95%. The online patient set-up verification showed translational and rotational deviation within 2 mm and 0.5° in 88-94% and 97% of the cases. Systematic and random error were within 0.90 mm and 1.71 mm in translation and 0.1° and 0.2° in rotation. CONCLUSION: A change in practice pattern was observed. The findings from our comprehensive critical appraisal add to the growing library of CSI practice and may serve as a reference for inter-institutional comparison.

Schizencephaly in Hereditary Hemorrhagic Telangiectasia.

BACKGROUND AND PURPOSE: The presence of malformations of cortical development in patients with hereditary hemorrhagic telangiectasia has been reported on previous occasions. We evaluated a sample of adults with hereditary hemorrhagic telangiectasia for the presence of malformations of cortical development, spatial coincidence of malformations of cortical development and AVMs, and the coincidence of brain and pulmonary AVMs. MATERIALS AND METHODS: A total of 141 patients 18 years of age or older who were referred to the Augusta University hereditary hemorrhagic telangiectasia clinic and underwent brain MR imaging between January 19, 2018, and December 3, 2020, were identified. MR imaging examinations were reviewed retrospectively by 2 experienced neuroradiologists, and the presence of malformations of cortical development and AVMs was confirmed by consensus. Demographic and clinical information was collected for each case, including age, sex, hereditary hemorrhagic telangiectasia status by the Curacao Criteria, mutation type, presence of malformations of cortical development, presence of brain AVMs, presence of pulmonary AVMs, and a history of seizures or learning disabilities. RESULTS: Five of 141 (3.5%) patients with hereditary hemorrhagic telangiectasia had malformations of cortical development. Two of the 5 patients with polymicrogyria also had closed-lip schizencephaly. One of the patients had a porencephalic cavity partially lined with heterotopic GM. The incidence of spatially coincident polymicrogyria and brain AVMs was 40% (2/5 cases). Of the patients with hereditary hemorrhagic telangiectasia and malformations of cortical development, 4/5 (80%) had pulmonary AVMs and 2/5 (40%) had brain AVMs. CONCLUSIONS: To our knowledge, we are the first group to report the presence of schizencephaly in patients with hereditary hemorrhagic telangiectasia. The presence of schizencephaly and porencephaly lends support to the hypothesis of regional in utero cerebral hypoxic events as the etiology of malformations of cortical development in hereditary hemorrhagic telangiectasia.

Pre-operative planning and templating with 3-D printed models for complex primary and revision total hip arthroplasty.

Background: Complex primary and revision THR requires comprehensive understanding of abnormal bony anatomy. Evaluation and classification of acetabular bone defects is essential to manage them appropriately. It is difficult to appreciate complex defects using conventional 2-Dimensional radiological modalities. 3D printed models can provide both visual and tactile reproduction of the bony anatomy, with potential for better pre-operative planning and making these complex surgeries more precise and accurate. Materials and methods: Anatomical 3D models of pelvis and femur were made based on CT scans of 27 patients undergoing complex primary THR/Revision THR by FDM (Fusion Deposition Modeling) technology using Flash Forge-Dreamer 3D printer with ABS (plastic) material. Models were used for pre-operative planning and simulation of surgery. Aims of the study were to study the accuracy of 3D models in predicting the implant sizes, accuracy in evaluation of acetabular bone defects and validating the utility of 3 D models through surgeon feedback. Results: The acetabular cup size and placement was accurate in 25 (92.6%) patients. Preoperative acetabular bone defect was accurately estimated in all the patients. There were no neurovascular complications at early and 1-year follow-up in this case series. Model realism and reliability survey response from five surgeons was graded, with average overall usefulness of 3D models of 4.86/5, average model realism was 4.9/5, average usefulness for planning was 4.74/5 and usefulness for teaching was 5/5. Conclusion: 3D models are accurate and help in assessing acetabular bone deficiencies reliably in complex and revision THR. Anatomical models help in surgical planning and simulation, enabling surgeons in predicting the correct implant sizes and importantly placement of acetabular cup and for management of bone defects. The safe trajectory of acetabular screws can be simulated and determined, thereby avoiding penetration into pelvis and neuro-vascular injuries.

Comparison of patient reported outcomes after robotic versus manual total knee arthroplasty in the same patient undergoing staged bilateral knee arthroplasty.

Background: Robotic-assisted total knee arthroplasty (RATKA) has been proven to improve accuracy of component positioning and reducing alignment target outliers. However, the clinical benefit of robotics is often debated. Recent studies have shown reduced pain and faster recovery in the immediate post-operative period and may be associated with improved PROMs and satisfaction. The aim of this study was to assess PROMs and satisfaction in a unique patient population undergoing bilateral staged TKA to compare manual (MTKA) and RATKA in the same patient. Methods: 55 patients underwent bilateral staged TKA, performed by a single surgeon at a single institute. Patients who underwent TKA for the first knee with manual technique and RATKA for the second side, were eligible for inclusion in the study. Primary outcome assessed was the Oxford Knee Score and secondary outcomes included the Forgotten Joint Score (FJS), patient satisfaction, mean duration for independent ambulation after TKA, and patient perspectives on recovery evaluated with a questionnaire. Results: Both RATKA and MTKA were associated with comparable PROMs. Though RATKA was associated with improved joint perception (Mean FJS after MTKA surgery was 70.3 (SD = 10.66) and significantly lower than the mean FJS after RATKA (73, SD = 10.95, p-value < 0.01), but the difference was not clinically relevant. A higher proportion of patients were more likely to be very satisfied or satisfied after RATKA. A significant proportion of patients felt the knee operated with RATKA was less painful and felt more natural compared to MTKA at final follow-up (p < 0.01). Majority of patients would undergo RATKA again and recommend robotic-TKA to others. Conclusion: Robotic-assisted surgery was associated with improved patient satisfaction, faster independent ambulation compared to manual techniques. PROMs however, were comparable without clinically significant differences. Patients preferred robotic-assisted surgery, with a significantly higher proportion perceiving knee operated by RATKA felt more natural.