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

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

Adult Age Differences in Self-Reported Pain and Anterior CSF Space in Chiari Malformation.

Chiari malformation type I (CMI) is a neural disorder with sensory, cognitive, and motor defects, as well as headaches. Radiologically, the cerebellar tonsils extend below the foramen magnum. To date, the relationships among adult age, brain morphometry, surgical status, and symptom severity in CMI are unknown. The objective of this study was to better understand the relationships among these variables using causal modeling techniques. Adult CMI patients (80% female) who either had (n = 150) or had not (n = 151) undergone posterior fossa decompression surgery were assessed using morphometric measures derived from magnetic resonance images (MRI). MRI-based morphometry showed that the area of the CSF pocket anterior to the cervico-medullary junction (anterior CSF space) correlated with age at the time of MRI (r = - .21). Also, self-reported pain increased with age (r = .11) and decreased with anterior CSF space (r = - .18). Age differences in self-reported pain were mediated by anterior CSF space in the cervical spine area-and this effect was particularly salient for non-decompressed CMI patients. As CMI patients age, the anterior CSF space decreases, and this is associated with increased pain-especially for non-decompressed CMI patients. It is recommended that further consideration of age-related decreases in anterior CSF space in CMI patients be given in future research.

Radiation in orthopaedics (RIO) study: a national survey of UK orthopaedic surgeons.

OBJECTIVES: Orthopaedic surgeons have a responsibility to minimise risks of ionising radiation to patients, themselves and staff. This study aims to establish the understanding of radiation practice, legislation and risk by orthopaedic surgeons. METHODS: A nationwide online survey of UK-based orthopaedic surgeons was conducted. Participants answered 18 multiple-choice questions assessing level of radiation safety training, basic principles/knowledge of ionising radiation, relevant legislation and operating practice. RESULTS: A total of 406 surgeons completed the survey. 92% reported using intraoperative ionising radiation at least once per week. 38% received no formal training on radiation safety. Knowledge of basic principles of radiation and legislation was limited. There was variable knowledge when labelling an image intensifier machine and choosing its safest orientation. Poor uptake of radiation protection equipment was noted. Only 19% agreed they had adequate training in ionising radiation safety and 27% reported receiving adequate training in equipment emitting ionising radiation in the operating theatre. CONCLUSION: Many orthopaedic surgeons in the UK do not believe they are adequately trained in radiation safety. There is a deficiency amongst practicing surgeons in basic knowledge, relevant legislation and practicalities of the use of ionising radiation in the operating room. This could potentially put patients and health-care professionals at additional risk. We recommend that a standardised national training programme on the basic principles and safety of ionising radiation is implemented for all practicing orthopaedic surgeons. ADVANCES IN KNOWLEDGE: This paper is the first UK national survey amongst orthopaedic surgeons and is one of the largest reported internationally.

The use of ionising radiation in orthopaedic surgery: principles, regulations and managing risk to surgeons and patients.

The use of ionising radiation for plain film radiography and computerised tomography is fundamental in both diagnostics and treatment for orthopaedics. However, radiation is not without risk as high exposure can increase the risk of cancer. Little time is spent educating doctors about the relative risks of radiation, both to patients and themselves. In addition, there are common misunderstandings about the best ways to mitigate such risk. We aim to provide an overview of the fundamental principles of the use of ionising radiation and its risks within the context of orthopaedic surgery. While providing a narrative review of the current literature, we discuss the basic physics, standards of good practice and relevant UK and European regulations. We discuss the risks to patients and surgeons and suggest ways that these can be mitigated in the operating theatre. A thorough understanding of the risks, and appropriate procedural rules, with respect to the use of ionising radiation is essential for those in orthopaedic practice.

Impact of Surgical Status, Loneliness, and Disability on Interleukin 6, C-Reactive Protein, Cortisol, and Estrogen in Females with Symptomatic Type I Chiari Malformation.

Chiari malformation type I (CMI) provides an opportunity for examining possible moderators of allostatic load. CMI patients who had (n = 43) and had not (n = 19) undergone decompression surgery completed questionnaires regarding pain, disability, and loneliness, and provided serum samples for IL-6, CRP, estrogen, and free estradiol assays, and saliva samples to assess diurnal cortisol curves. ANOVAs examining surgical status (decompressed versus non-decompressed), loneliness (high vs. low), and disability (high vs. low) as independent variables and biomarker variables as dependent factors found that loneliness was associated with higher levels of cortisol, F(1, 37) = 4.91, p = .04, η2P = .11, and lower levels of estrogen, F(1, 36) = 7.29, p = .01, η2P = .17, but only in decompressed patients. Results highlight the possible impact of loneliness on biological stress responses and the need to intervene to reduce loneliness in patients with symptomatic CMI.

A comparison of anterior knee pain, kneeling pain and functional outcomes in suprapatellar versus infrapatellar tibial nailing.

INTRODUCTION: Anterior knee pain and kneeling pain are some of the most common complications following intramedullary nailing of tibial shaft fractures. With the increased uptake of suprapatellar nailing at our institution, we undertook a service evaluation to assess anterior knee pain and kneeling pain in patients who underwent the suprapatellar tibial nailing technique compared with the infrapatellar approach. METHODOLOGY: Data from all consecutive intramedullary tibial nailing operations between January 2014 and July 2017 were analysed from a prospectively collected database. All acute diaphyseal fracture nailing procedures were included. All patients were reviewed between six-month and four-year post-operation. Each patient was asked to complete a standardised questionnaire with three main outcome measures: pain on kneeling, presence of anterior knee pain and the severity of pain. RESULTS: After exclusions, a total of 148 patients were identified. A total of 102 responses were received, 41 in the infrapatellar group (73.2%) and 61 in the suprapatellar group (66.3%). A longer time from surgery to telephone follow-up response was noted in the infrapatellar group: 32.4 months (interquartile range, 16.1) vs. 19.3 months (interquartile range, 17.4), p < 0.001. A trend towards lower reported anterior knee pain was noted in the suprapatellar group (67.9% VS 53.7%). Most patients reported mild or no pain on kneeling, with no significant difference between the two groups. There was also no significant difference in severity of knee pain between the two groups and no significant effect on the Kujala score. CONCLUSION: With the comparable pain outcomes between the two groups, our analysis supports the continued use of the suprapatellar tibial nailing technique for tibial shaft fractures at our institution.

Compromise of Second-Line Antiretroviral Therapy Due to High Rates of Human Immunodeficiency Virus Drug Resistance in Mozambican Treatment-Experienced Children With Virologic Failure.

BACKGROUND: Virologic failure (VF) is highly prevalent in sub-Saharan African children on antiretroviral therapy (ART) and is often associated with human immunodeficiency virus drug resistance (DR). Most children still lack access to routine viral load (VL) monitoring for early identification of treatment failure, with implications for the efficacy of second-line ART. METHODS: Children aged 1 to 14 years on ART for ≥12 months at 6 public facilities in Maputo, Mozambique were consecutively enrolled after informed consent. Chart review and caregiver interviews were conducted. VL testing was performed, and specimens with ≥1000 copies/mL were genotyped. RESULTS: Of the 715 children included, the mean age was 103 months, 85.8% had no immunosuppression, 73.1% were taking stavudine/lamivudine/nevirapine, and 20.1% had a history prevention of mother-to-child transmission exposure. The mean time on ART was 60.0 months. VF was present in 259 patients (36.3%); 248 (95.8%) specimens were genotyped, and DR mutations were found in 238 (96.0%). Severe immunosuppression and nutritional decline were associated with DR. M184V and Y181C were the most common mutations. In the 238 patients with DR, standard second-line ART would have 0, 1, 2, and 3 effective antiretrovirals in 1 (0.4%), 74 (31.1%), 150 (63.0%), and 13 (5.5%) patients, respectively. CONCLUSION: This cohort had high rates of VF and DR with frequent compromise of second-line ART. There is urgent need to scale-up VL monitoring and heat-stable protease inhibitor formulations or integrase inhibitorsfor a more a durable first-line regimen that can feasibly be implemented in developing settings.

An examination of pain, disability, and the psychological correlates of Chiari Malformation pre- and post-surgical correction.

BACKGROUND: 50% of patients with Chiari Malformation (CM) report a history of depression; however, rates of other psychological symptoms are unknown. Further, it is unclear whether surgical correction impacts pain, disability, and psychological symptoms. OBJECTIVE: /Hypothesis: We examined rates of symptoms in a nationwide sample of CM patients who had (n = 639) and had not (n = 551) undergone surgical correction. We hypothesized lower symptom severity in the latter group. METHODS: Participants completed assessments and submitted pre-surgical MRI scans online (n = 286). Informed by the Fear-Avoidance Model of pain, we controlled for psychological symptoms when assessing pain/disability, and pain/disability when assessing psychological symptoms. RESULTS: Overall, high rates of depression (44% moderate-severe) and anxiety (60% moderate-severe) were reported. Groups (surgery vs. no-surgery) did not differ in the proportion of patients meeting cutoff scores for current disability; however, the no-surgery group was more likely to meet cutoffs for anxiety (χ2 = 11.26, p < .05), stress (χ2 = 14.63, p < .01) and health anxiety (χ2 = 4.63, p < .05). The surgery group reported lower levels of continuous affective pain F(1, 1065) = 10.28, p < .001), anxiety F(1,1026) = 4.96, p < .05) and stress F(1, 978) = 5.67, p < .05) although effect sizes were small (η2s ranging from 0.010 to 0.006, Cohen's D ranging from 0.17 to 0.25). CONCLUSION: CM patients experience high rates of psychological symptomatology regardless of surgical status, suggesting that all CM patients may benefit from evidence-based interventions to address anxiety and depression.

Quantification of changes in brain morphology following posterior fossa decompression surgery in women treated for Chiari malformation type 1.

PURPOSE: While 84% of patients surgically treated for Chiari malformation type 1 (CM1) demonstrate improved quality of life after posterior fossa decompression surgery, there are many risks associated with this surgery. Surgical planning to identify candidates likely to improve postoperatively may benefit from an improved understanding of morphological changes after decompression surgery. To evaluate these changes, we quantified 59 morphological parameters on 42 CM1 adult female patients before and after CM1 decompression surgery. METHODS: Fifty-nine morphological parameters in the posterior cranial fossa, cranio-cervical, and intracranial regions in the midsagittal plane were evaluated using 42 T1-weighted magnetic resonance images of female CM1 patients before and after surgery, and 42 healthy female controls. Morphological differences before and after surgery were compared through the development of a technique to establish the opisthion location, a key reference point not present after surgery. RESULTS: In addition to the expected reduction of the cranio-caudal dimension of the cerebellum, objective analyses showed a significant increase in the area of the cerebrospinal fluid spaces, posterior (6×) and inferior (2.6×) to the cerebellum (+ 112 ± 102 and + 140 ± 127 mm2, respectively). This increased area was primarily impacted by an average reduction in the occipital bone length of 24.5 ± 7.3 mm following surgery. Based on multiple angles, results demonstrated a 2°-4° anterior rotation of the cerebellum after surgery. CONCLUSION: Our results show that decompression surgery results in significant changes in the cerebellum and cerebrospinal fluid spaces. Further investigation should determine how these morphological changes impact clinical outcomes.

A Retrospective 2D Morphometric Analysis of Adult Female Chiari Type I Patients with Commonly Reported and Related Conditions.

Purpose: Researchers have sought to better understand Chiari type I malformation (CMI) through morphometric measurements beyond tonsillar position (TP). Soft tissue and bone structures within the brain and craniocervical junction have been shown to be different for CMI patients compared to healthy controls. Yet, several morphological characteristics have not been consistently associated with CMI. CMI is also associated with different prevalent conditions (PCs) such as syringomyelia, pseudotumor, Ehlers-Danlos syndrome (EDS), scoliosis, and craniocervical instability. The goal of this study was two-fold: (1) to identify unique morphological characteristics of PCs, and (2) to better explain inconsistent results from case-control comparisons of CMI. Methods: Image, demographic, and PC information was obtained through the Chiari1000, a self-report web-accessed database. Twenty-eight morphometric measurements (MMs) were performed on the cranial MR images of 236 pre-surgery adult female CMI participants and 140 female healthy control participants. Custom software was used to measure 28 structures within the posterior cranial fossa (PCF) compartment, craniocervical junction, oral cavity, and intracranial area on midsagittal MR images for each participant. Results: Morphometric analysis of adult females indicated a smaller McRae line length in CMI participants with syringomyelia compared to those without syringomyelia. TP was reduced in CMI participants with EDS than those without EDS. Basion to posterior axial line was significantly longer in CMI participants with scoliosis compared to those without scoliosis. No additional MMs were found to differ between CMI participants with and without a specific PC. Four morphometric differences were found to be consistently different between CMI participants and healthy controls regardless of PC: larger TP and a smaller clivus length, fastigium, and corpus callosum height in CMI participants. Conclusion: Syringomyelia, EDS, and scoliosis were the only PCs that showed significant morphometric differences between CMI participants. Additionally, four midsagittal MR-based MMs were found to be significantly different between healthy controls and CMI participants regardless of the presence of one or more PCs. This study suggests that the prevalence of comorbid conditions are not strongly related to CMI morphology, and that inconsistent findings in the radiographic literature cannot be explained by varying prevalence of comorbid conditions in CMI study samples.

Does cam osteochondroplasty compromise proximal femur strength?

Little is known about the effect on load bearing ability of cam-type femurs following osteochondroplasty. The aim of this study was to compare the change in deformation undergone by cam-type femoral acetabular impingement femur models after resection of different volumes. Dry-bone replicas (N = 10) of two cam-type femurs (cam A and B) underwent resections of increasing volume (Surgery I, II and III) representing conservative, adequate and radical resections. Deformation under cyclic loading of 700 N for five cycles after each surgery was compared. The 360° alpha angle and the change in head to neck ratio at four equidistant points along the femoral neck were used as measures of surgical efficacy and volume resected. Intact cam A and B replicas had a maximum alpha angle of 88° and 90°, respectively, which were reduced to 55° and 54° post Surgery I. Cam A replicas showed a significant reduction (p < 0.01) in mean axial displacement after Surgery I (up to 10% reduction in neck volume) and an increase after Surgery III (~20%-40% reduction in neck volume) compared to unresected controls (p < 0.01). Surgery II (~10%-15% reduction in neck volume) produced no significant change in mean displacement (p > 0.05). Cam B models exhibited lower mean displacement after Surgery I, II and III (p < 0.01) compared to unresected controls. Conservative surgery appears to improve the axial load bearing ability of dry-bone models. Radical resections may significantly decrease the fracture-resistant properties of bone following osteochondroplasty which should be noted when planning such a procedure.

Task-specific and general cognitive effects in Chiari malformation type I.

OBJECTIVE: Our objective was to use episodic memory and executive function tests to determine whether or not Chiari Malformation Type I (CM) patients experience cognitive dysfunction. BACKGROUND: CM is a neurological syndrome in which the cerebellum descends into the cervical spine causing neural compression, severe headaches, neck pain, and number of other physical symptoms. While primarily a disorder of the cervico-medullary junction, both clinicians and researchers have suspected deficits in higher-level cognitive function. DESIGN AND METHODS: We tested 24 CM patients who had undergone decompression neurosurgery and 24 age- and education-matched controls on measures of immediate and delayed episodic memory, as well as three measures of executive function. RESULTS: The CM group showed performance decrements relative to the controls in response inhibition (Stroop interference), working memory computational speed (Ospan), and processing speed (automated digit symbol substitution task), but group differences in recall did not reach statistical significance. After statistical control for depression and anxiety scores, the group effects for working memory and processing speed were eliminated, but not for response inhibition. This response inhibition difference was not due to overall general slowing for the CM group, either, because when controls' data were transformed using the linear function fit to all of the reaction time tasks, the interaction with group remained statistically significant. Furthermore, there was a multivariate group effect for all of the response time measures and immediate and delayed recall after statistical control of depression and anxiety scores. CONCLUSION: These results suggest that CM patients with decompression surgery exhibit cognitive dysfunction compared to age- and education-matched controls. While some of these results may be related to anxiety and depression (likely proxies for chronic pain), response inhibition effects, in particular, as well as a general cognitive deficit persisted even after control for anxiety and decompression.

Childhood sexual trauma, cannabis use and psychosis: statistically controlling for pre-trauma psychosis and psychopathology.

PURPOSE: Recurring evidence seems to suggest that sexual trauma in childhood may moderate associations between cannabis consumption and psychosis. It has also been suggested, however, that poor childhood mental health may explain linkages between these phenomena. METHODS: The current study, using data from the National Comorbidity Survey-Replication (N = 2,355), sought to revaluate the stability of the childhood trauma-cannabis interaction while statistically controlling for pre-trauma psychotic experiences and psychopathology in childhood. RESULTS: Psychotic experiences that occurred before childhood sexual trauma significantly influenced adult psychosis symptomatology (psychosis pre-rape B = 0.10; psychosis pre-sexual assault B = 0.23). Social phobia (B = 0.07) also conferred risk for adult psychosis. Pre-trauma childhood psychopathology, however, did not account for the interaction between childhood sexual trauma and cannabis consumption in a multivariate model. Childhood experiences of rape (B = 0.15) and an interaction between cannabis use and childhood sexual assault (B = 0.05) independently contributed to adult psychosis. Cannabis use conferred no independent risk. CONCLUSIONS: With specific regard to research methodology, the current findings offer further justification for the inclusion of childhood sexual trauma in analyses investigating associations between cannabis use and psychosis.

Delayed presentation of post-traumatic diaphragm rupture repaired by laparoscopy.

Diaphragmatic rupture is a serious but frequently missed condition that is potentially curable. While surgical management has classically been performed through open thoracotomy, a laparoscopic approach has been suggested as a preferable alternative. A man in his mid-50s presented with non-specific abdominal symptoms, 8 months after falling down some stairs. Diaphragmatic rupture was suspected after old rib fractures were noticed on an admitting chest radiograph. Further signs and symptoms presented following deterioration due to the unstable pathology. Prompt surgical treatment using laparoscopy was attempted with success and resulted in rapid and lasting improvement in symptoms.

Patterns of polydrug use in Great Britain: findings from a national household population survey.

BACKGROUND: Polydrug use potentially increases the likelihood of harm. As little is known about polydrug use patterns in the general population, it is difficult to determine patterns associated with highest likelihood. METHODS: Latent class analysis was performed on nine illicit substance groups indicating past year use of cannabis, cocaine, amphetamines, ecstasy, LSD, mushrooms, amyl nitrate, tranquillisers and heroin or crack. Analyses were based on data from a large multi-stage probability sample of the population of Great Britain (n=8538) collected in 2000. Multinomial logistic regression was performed highlighting associations between classes, and demographic and mental health variables. RESULTS: A three class solution best described patterns of polydrug use; wide range, moderate range, and no polydrug use. For males and young people, there was a significantly increased chance of being in the wide and moderate range polydrug use groups compared to the no polydrug use class. Hazardous drinking was more likely in the wide and moderate polydrug classes with odds ratios of 9.99 and 2.38 (respectively) compared to the no polydrug use class. Current smokers were more likely to be wide and moderate range polydrug users compared to the no polydrug use class with odds ratios of 4.53 and 5.85 respectively. A range of mental health variables were also related to class membership. CONCLUSIONS: Polydrug use in Great Britain can be expressed as three distinct classes. Hazardous alcohol use and tobacco use were strongly associated with illicit polydrug use, polydrug use appeared to be significantly associated with mental health, particularly lifetime suicide attempts.

Comparison of killer Ig-like receptor genotyping and phenotyping for selection of allogeneic blood stem cell donors.

The repertoire of killer Ig-like receptors (KIRs) can be determined at the level of DNA, RNA, or surface protein expression for selection of blood stem cell donors. We compared genotyping and phenotyping of the four inhibitory KIRs that are important in transplantation for leukemia in 73 unrelated persons. In 5 (7%) of the 68 individuals in whom the KIR2DL1 gene was present and in 10 (15%) of the 67 in whom KIR3DL1 was present, the corresponding receptor was not expressed by NK cells, as determined by flow cytometry analysis. In contrast, one or both allelic forms of KIR2DL2/KIR2DL3 were expressed by a high proportion of NK cells in all 73 individuals. However if both KIR2DL2 and KIR2DL3 genes were present, KIR2DL3 was preferentially expressed, as transcripts of KIR2DL2 was not detectable by RT-PCR in 42% of these individuals. In total, repertoire assessment for the four KIRs by genotyping vs phenotyping was not in complete agreement in 18 (25%) of the 73 individuals. Furthermore, among the samples that tested positive for the expression of a certain KIR gene, the levels of transcripts and surface expression varied considerably as measured by both real-time quantitative PCR and flow cytometry analysis. Extension of this comparative analysis to include all 12 KIR family members showed that KIR2DL3 and KIR3DL2 were the only genes whose transcripts were consistently detectable. These results caution the use of genotyping alone for donor selection or leukemia-relapse prognostication because some KIRs may be expressed at a very low level.

Phenotype and function of human natural killer cells purified by using a clinical-scale immunomagnetic method.

Infection, disease relapse, graft failure, and graft-versus-host disease (GVHD) are significant adverse events associated with allogeneic bone marrow transplantation. Donor natural killer (NK) cells may be an ideal cell type for prevention or treatment of all these adverse events. Therefore, we investigated the phenotype and function of human NK cells purified by using a clinical-scale immunomagnetic method. We found that the NK cell purification procedures did not adversely affect the expression of killer cell immunoglobulin-like receptors, adhesion molecules, intracellular cytokines, perforin, and granzyme B. Purified NK cells had extensive proliferative capacity and potent antitumor activity when assessed using an immunodeficient mouse model. While all mice transplanted with unpurified mononuclear cells developed GVHD, none of the mice transplanted with purified NK cells did. NK cells were highly susceptible to lysis by antithymocyte globulin (ATG), whereas G-CSF had a minimal effect on their natural cytotoxicity. These results support future clinical investigation of the use of purified NK cells for adoptive immunotherapy in the absence of ATG.