Long-Term Outcomes of Gastrocnemius V-Y Plasty Gastrosoleus Fascial Turndown Flap for Chronic Tendo-achilles Injuries with Complex Gap (Kuwada Type IV Injuries).

INTRODUCTION: The Achilles tendon is one of the strongest and most ruptured tendons; with no appropriate treatment it either heals in elongation or gap nonunion. Management of such chronic tears is critical and several procedures have been described. Complex gaps of over 6-8 cm need a combination technique. PURPOSE OF STUDY: To assess the long-term functional outcome of surgical technique of combined gastrosoleus turndown flap augmented with V-Y plasty for chronic tendoachilles tear with a complex gap of over 8 cm. MATERIALS AND METHODS: We retrospectively analyzed all the patients who were operated for tendoachilles tears from 2013 to 2018 and selected 12 patients who had a gap of 8 cm. Demographic details, history, clinical and radiological findings, post-op follow-up were collected from hospital database. The acute, open, chronic tears with gap of < 8 cm, peripheral vascular diseases were excluded. All the procedures were done by senior surgeon using combined technique of gastrosoleus turndown flap with V-Y plasty. Functional outcome was assessed using modified Rupp score, calf diameter and VAS scoring system at latest follow-up of the patient. RESULTS: Assessing increase in calf diameter did objective analysis, average of 2.2 cm was regained which was statistically significant using paired T test. Each patient regained average 10° of dorsiflexion. Two patients had terminal 10° restriction of plantar flexion. All patients were able to do heel raise and single leg stance for at least 30 s. Subjective assessments done using modified Rupp score, five patients had excellent and seven patients had good outcome. Mean VAS for pain was 1.5 (1-3) and VAS for satisfaction was 7.5 (6-9). All patients returned to their pre-injury functional status. CONCLUSION: Combined surgical technique of gastrosoleus turndown flap augmentation with V-Y plasty for repairing complex defects in chronic achilles tendon tears is a fair option with satisfactory functional outcome and fewer complications. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00475-6.

A Single-Center Experience of Internal Pancreatic Fistulas.

Background Internal pancreatic fistula (IPF) is a complex disease with different etiologies, varied clinical presentations, and multiple management options. Unlike postoperative pancreatic fistula, IPF lacks guidelines for classification and management. The rarity of the disease makes randomized control studies unlikely and difficult to formulate guidelines. This has resulted in different approaches to managing IPF. IPF associated with both acute and chronic pancreatitis is treated with a step-up approach. Chronic pancreatitis-associated IPF treated with the traditional step-up approach is associated with increased morbidity. Prolonged fasting, drainage of protein-rich pancreatic fluid, and extended hospital stay add to the morbidity. Early surgical intervention in patients with IPF associated with chronic pancreatitis can treat both the fistula and underlying disease processes simultaneously. This may contribute to reduced morbidity and hospital stay. Methodology A retrospective observational study was conducted between June 2018 and May 2019. IPF patients with fluid amylase >1,000 IU/L and fluid albumin >3 g/dL were included in the study. Results In total, 32 patients were included in the study. A total of 13 patients had acute pancreatitis and 19 were associated with chronic pancreatitis. Pseudocyst and walled-off pancreatic necrosis were present in 18 patients. The duration of treatment for the traditional group was 8-14 weeks, and for the early surgery group, it was 8-10 days. Patients were followed up for two years, and none of the patients in the early surgery group had a recurrence. Conclusions The overall mortality of IPF is low but it has high morbidity. The delay in treatment may contribute to high morbidity; hence, early surgical intervention may change the clinical course. The primary pathology of the pancreas can be addressed simultaneously as well. In our study, early surgical intervention was associated with lesser morbidity and decreased duration of hospital stay while recurrence rates and mortality were comparable to the traditional management protocol.

Total Elbow Arthroplasty as Treatment of Non-union with Bone Loss of Distal Humerus - A Case Report.

INTRODUCTION: Total elbow arthroplasty (TEA) is a viable treatment for pain-free mobility in stiff elbow of sedentary patients with rheumatoid arthritis and ankylosis. Secondarily, TEA is useful in cases of stiff failed fixation and bone loss of distal humerus fractures. CASE REPORT: A Fifty one years old sedentary male presented to our institute with a history of injury to the right elbow (sideswipe injury). On clinical and radiological examination, it was open Grade III B fracture of distal humerus with bone loss. He was treated with wound debridement and initial temporary fixation with k-wires and later soft-tissue reconstruction. One year later, the patient upper limb was flail, limited range of motion (passive 40° 70°) and no infection. Radiology revealed non-union of condylar fragments with bone loss of distal humerus. The patient underwent TEA through standard triceps reflecting approach. He was implanted cemented modular Coonrad-Murray semi-constrained prosthesis Type III. The post-operative period was uneventful. At 4-year follow-up, the patient is pain free with elbow range of motion 5°120°. CONCLUSION: In failed osteosynthesis and sedentary patients, TEA is a SALVAGE surgery for pain-free mobility with its own long-term limitations.

Local Delivery of Single Dose Intra Epiphyseal Bisphosphonates to Prevent the Progression of Legg-Calve-Perthes Disease - Case Series.

INTRODUCTION: Legg-Calve´-Perthes disease (LCPD) or avascular necrosis of the capital epiphysis is an idiopathic disease characterized by interruption of the blood supply to the capital femoral epiphysis resulting in necrosis of the epiphysis. There are a variety of treatment modalities such as containment with braces early in disease to surgical procedures for children presenting late in their age group. The newer modalities of treatment are intravenous bisphosphonates, bone morphogenic protein in clinical subjects. CASE REPORT: Two children (Aged 7 years with catterall Stage II unilateral affection, aged 11 years catterall Stage III bilateral affection) were advised single-dose of zoledronic acid(2 mg) into epiphysis as day care procedure after due discussion with parents about other treatment modalities. Both the children were followed up quarterly with clinical examination and radiology. At the latest follow-up of 4 years both had satisfactory outcome. Child one was able to do normal play with intact lateral pillar. Child two had minimal collapse of left hip however clinically pain free. CONCLUSION: Local delivery of single dose of intra epiphyseal zoledronic acid is a relatively harmless procedure and effective in preventing the progression of disease pathology, especially in children with age group of 6-10 years.

Complete genome sequence of Treponema pallidum, the syphilis spirochete.

The complete genome sequence of Treponema pallidum was determined and shown to be 1,138,006 base pairs containing 1041 predicted coding sequences (open reading frames). Systems for DNA replication, transcription, translation, and repair are intact, but catabolic and biosynthetic activities are minimized. The number of identifiable transporters is small, and no phosphoenolpyruvate:phosphotransferase carbohydrate transporters were found. Potential virulence factors include a family of 12 potential membrane proteins and several putative hemolysins. Comparison of the T. pallidum genome sequence with that of another pathogenic spirochete, Borrelia burgdorferi, the agent of Lyme disease, identified unique and common genes and substantiates the considerable diversity observed among pathogenic spirochetes.

Analytical design of modified Smith predictor in a two-degrees-of-freedom control scheme for second order unstable processes with time delay.

A modified form of Smith predictor is designed for controlling unstable second order plus time delay (USOPTD) processes, with/without a zero. USOPTD process transfer functions arise in modeling of many chemical and biological systems, such as isothermal continuous stirred tank reactors (CSTR) carrying out autocatalytic reactions, crystallizers and non-isothermal CSTRs. The modified Smith predictor scheme requires the design of three controllers. Synthesis method is used for the design of the three controllers, and analytical formulas are given for these controllers. The method has two tuning parameters, and guidelines are provided for selecting the tuning parameters. Robust disturbance rejection performances are achieved. Different examples are considered, and simulation studies are given, to show the effectiveness of the proposed method. A significant improvement is obtained, when compared with recently reported methods.

Set point weighted modified Smith predictor for integrating and double integrating processes with time delay.

A simple method of designing the controllers for a modified form of Smith predictor is proposed for integrating and double integrating processes with time delay. The modified Smith predictor has two controllers, namely, a set point tracking controller and a load disturbance rejection controller for obtaining good set point tracking and load disturbance rejection, respectively. The set point tracking controller is designed using the classical direct synthesis method based on the process model without considering the time delay. The disturbance rejection controller is considered as a proportional-derivative (PD) controller and is designed using optimal gain and phase margin approaches. Set point weighting is considered for reducing undesirable overshoots and settling times in the modified Smith predictor. Guidelines are provided for selection of the desired closed loop tuning parameter in the direct synthesis method and the set point weighting parameter. The method gives significant load disturbance rejection performances. Illustrative examples are considered to show the performances of the proposed method. A significant improvement in control performance is obtained when compared to recently reported methods.

Are We Justified Doing Salvage or Amputation Procedure Based on Mangled Extremity Severity Score in Mangled Upper Extremity Injury.

INTRODUCTION: Mangled upper limb injuries are at surge because of industrialization, modernization, and severe motor vehicle accidents. The utility of various scoring systems are meant for decision making in mangled lower limb injuries, and the same have been extrapolated for mangled upper limb injuries to make a decision of salvage or amputation for the lack of separate scoring system. MATERIALS AND METHODS: We applied mangled extremity severity score (MESS) and mangled extremity syndrome index (MESI) scoring systems to 10 cases of mangled upper limb injuries during the period of November 2010 to September 2012 presented at our tertiary trauma care center. Average MESS score was 7.7 and MESI score was 18.1. Above elbow, amputation was needed in three patients, and salvage procedure was done in rest of the seven patients. All the patients were subjected to salvage procedure initially unless life threatening because of mangled limb injury. MESS scores over 7, MESI score over 20 is accepted for amputation in lower limbs, but could not be justified in our study for MESS whereas MESI was more reliable. Functional outcome was assessed using visual analog scale score and short form-36 (SF-36) score for all patients, which was satisfactory, elderly and diabetic patients were relatively less satisfied. CONCLUSIONS: (a) Upper limb and lower limb mangled injuries cannot be considered same because of their anatomy. The upper limb has more rich vascularity and efficient collaterals, small muscle mass, so ischemia time is relatively more. Therefore, the different scoring systems are needed for both. (b) In our case series, MESI scoring was more reliable then MESS score, but this needs a large prospective study to validate it. (c) Salvage should be prime realistic aim influenced by several factors. Prosthesis for upper limb is very expensive and not well tolerated, so even a woody limb is well accepted in our patients.

Limitations of a PI controller for a first-order nonlinear process with dead time.

A nonlinear process, the conical tank level process whose parameters vary with respect to the process variable, is considered. The time constant and gain of the chosen process vary as a function of level. A deliberate dead time is introduced in the system by delaying the valve opening. The limitations of the conventional PI controller tuned using Ziegler-Nichols settings for the chosen process are brought out. The servo and regulatory responses through simulation and experimentation for various magnitudes of set-point changes and load changes at various operating points with the controller tuned only at a chosen nominal operating point are obtained and analyzed. Regulatory responses for output load changes are studied. A benchmark system is presented to understand clearly how variations of system parameters affect the performance of the controller. A gain scheduled controller is proposed to handle the control problem. Present work illustrates the simplicity and effectiveness of the gain scheduling.

A simple method of tuning parallel cascade controllers for unstable FOPTD systems.

A simple method is proposed to design parallel cascade controllers for open loop unstable processes. A proportional (P)controller is considered for the secondary loop and a proportional integral (PI) controller is considered for the primary loop (P/PI control configuration). Coefficients of the corresponding powers of s (Laplace variable), in the numerator is matched with the coefficients of the corresponding powers of s in the denominator of a closed loop transfer function for a servo problem. Three simulation case studies are considered in this paper. The first case involves a stable secondary loop process and an unstable primary process, the second case involves both unstable primary and secondary processes and the third one, a simulation application to a nonlinear bioreactor model equations. For comparison purposes, P/PI controller design is also carried out by improved simultaneous relay autotuning method, synthesis method and minimizing ISE criterion method. It is found that the proposed method gives a better performance. Robust stability analysis using the complimentary sensitivity function is carried out. The present method is found to be more robust.

A Sub-acute Septic Arthritis of the Knee; a Sequelae to Thorn Prick Injury of Patella: A Case Report.

INTRODUCTION: Sub-acute septic arthritis of knee following a thorn prick injury to patella is an uncommon condition and seen in active playful children. The child may be afraid to narrate the incident to their parents or examining doctor, so a high index of suspicion is must. The delayed presentation is inevitable. Early synovitis due to the organic biological foreign body may progress to septic arthritis, if untreated may result in knee stiffness or chronic osteomyelitis of patella. CASE REPORT: We report a case of thorn prick injury to the left patella in an 8-years-old boy who neglected the incident of thorn prick while playing with his peer group 10 days ago and presented with features of sub-acute septic arthritis. He was treated by arthrotomy, double inspection of the patella, removal of foreign body, synovectomy, lavage, antibiotics, and aggressive rehabilitation with an excellent outcome. CONCLUSION: Sub-acute synovitis in active playful children should raise the suspicion of thorn prick even though no proper history is explained. Organic foreign body from plant materials is radiolucent and easily missed. High suspicion and timely surgical intervention, double inspection during arthrotomy identifies the foreign body. Once removed, with proper antibiotic and physiotherapy protocol followed has an excellent outcome.

Treatment of Stiff Elbow in Young Patients with Interpositional Arthroplasty for Mobility: Case Series.

INTRODUCTION: The elbow is a complex joint involving many articulations and complex biomechanics come into play. Elbow motion is crucial to upper limb movement that loss of 50% of elbow function equals to loss of 80% of upper extremity global function. Restoring movement and stability is challenging to the surgeon while treating a stiff elbow. Unlike other arthroplasties of hip and knee, total elbow arthroplasty (TEA) may not be a primary treatment. Interpositional arthroplasty (IPA) can be considered a viable option in posttraumatic arthritis of elbow in young patients. CASE REPORT: We report two cases of interpositional arthroplasties done in young patients secondary to posttraumatic event. The first case is 22-year-old female with a history of stiff elbow following a posttraumatic event 3 years back and the second case is 24-year-old male laborer with stiff elbow following trauma more the 10 years back for which he took native treatment. In both the cases through posterior approach to the elbow, we did osteolysis and prepared fascia lata grafts are interpositioned over the recreated articular surfaces. Both the patients in the follow-up have a good range of motion, stability and are satisfied. CONCLUSION: IPA is a good treatment option in young patients with posttraumatic arthritis. Elbow instability, fascia rupture, thigh pain, and hernia are the problems of IPA. IPA to TEA transition is possible.

Case Report of Two Cases of Patella Subacute Osteomyelitis in Diabetic Women A Rare Entity.

INTRODUCTION: Patella osteomyelitis is a rare entity in adults. Most often it is seen in children of five to twelve years of age because of its unique ossification and vascularity. Immuno compromised states like HIV, tuberculosis, intravenous drug abuse and trauma have been predisposing factors for adult patellar osteomyelitis. We report two cases of patellar osteomyelitis in adult diabetic women with uncontrolled glycemic levels and having no previous history of any trauma or systemic infection. CASE REPORT: A 43-year-old diabetic woman presented with complaints of left knee pain and swelling with no history of trauma. On examination, pointed tenderness was present over anterior aspect of patella with patellar grind test positive. Radiography and MRI revealed solitary well circumscribed patellar cyst. Lateral chondral blisters were noted while doing arthroscopy and secretions oozed out on puncturing. Curettage was carried out for the same. Culture and sensitivity revealed no growth and the patient was prescribed antibiotics for 6 weeks. Second case was a 46-year-old diabetic lady with similar presentation. MRI additionally showed abscess in intermuscular plains around knee joint. An aspirated fluid was negative for growth of organisms. Knee arthrotomy and curettage of patellar sinus tracts was done with evacuation of intramuscular abscess. Antibiotics were given for 6 weeks. Both patients had complete relief of symptoms. CONCLUSION: Patella osteomyelitis in adults is very rare. In patients with uncontrolled diabetes, vague anterior knee pain, elevated ESR and CRP, one should keep patellar subacute osteomyelitis as a differential diagnosis which can be further confirmed by X-ray, MRI or bone scan. An appropriate early treatment with antibiotics and surgical intervention can give a satisfactory result.

Management of Large Bone Defects in Diaphyseal Fractures by Induced Membrane Formation by Masquelet's Technique.

INTRODUCTION: Management of the large gap in long bone fractures is a challenging problem after compound injuries. A novel technique called as Masquelet's technique of "induced membrane formation", is used to bridge a gap of more than 5 cm using bone cement as a spacer in first stage and autologous cancellous bone graft to fill the gap in second stage. CASE PRESENTATION: We present two different and difficult cases with bone defects after open injuries associated with long bone fractures in this paper. First case is a 50-year-old lady with grade IIIa open fracture right distal femur with intra-articular extension and bone loss. She underwent wound debriment, stabilization of the fracture with locking compression plate along with antibiotic cement spacer, which is removed latter and underwent bone grafting. Another is a 15-year-old boy with open grade IIIb fracture tibia and fibula (mid-distal third junction) of right leg, wound debridement and ankle spanning triangular external fixation was applied on same day and after two months, external fixation was removed due to florid infection and plaster of Paris was applied. Instead of the tedious and demanding treatment options like Ilizarov, a new technique described by Masquelet is used here. It uses bone cement as a spacer to fill the cavity to form pseudo-membrane around it and in the second stage autologous cancellous bone graft fills the gap of even more than 5 cm, to achieve union. CONCLUSION: The membrane also secretes vascular and osteo-inductive factors to stimulate bone regeneration and also prevents resorption of the bone graft and achieves early fracture healing avoiding tedious options like bone transport in external fixator. By this two staged technique, union occurred clinically and radiologically in these two cases.

Isolation and characterization of precursors in bacteriophage T4 baseplate assembly. II. Purification of the protein products of genes 10 and 11 and the in vitro formation of the P(10/11) complex.

Two bacteriophage T4 proteins which are precursors to the phage baseplate have been purified to homogeneity. These proteins, P10 and P11, are components of the P(10/11) complex, which is the first intermediate in the assembly of T4 baseplate 1/6th arms. Each protein was isolated from cells infected with a T4 amber mutant defective in the production of the other protein. Thus these purified proteins have never been assembled into the P(10/11) complex in vivo. Sodium dodecyl sulfate/polyacrylamide gel electrophoresis and the ability of these proteins to block the phage killing activity of specific antisera were used to monitor the purification steps. Sedimentation equilibrium experiments reveal a molecular weight of 188,000 g/mol for P10 and 60,000 g/mol for P11. These data together with the previously determined molecular weights of the gene 10 and gene 11 polypeptide chains (King & Mykolajewycz, 1973) and the in vivo assembled P(10/11) complex (Berget & King, 1978b) are consistent with P10 being a dimer of the product of gene 10, P11 being a dimer of the product of gene 11, and P(10/11) being a tetramer containing one of each of these dimers. Purified P10 and P11 are active in assembly because they complement 10- and 11- defective extracts, respectively, to form viable bacteriophage in vitro. Furthermore, these proteins assemble in vitro to form a protein structure identical to the P(10/11) complex formed in vivo as determined by non-denaturing gel electrophoresis. This P(10/11) complex formed in vitro complements 10-/11- defective extracts to form viable phage. The overall extent of this in vitro assembly reaction is not affected by NaCl to 1.5 M or 2% Triton X-100. The reaction is, however, prevented by the denaturing effects of urea and sodium dodecyl sulfate.

Fine structure genetic and physical map of the phage P22 tail protein gene.

Bacteriophage P22 which are incapable of making functional tail protein can be propagated by the addition of purified mature tail protein trimers to either liquid or solidified medium. This unique in vitro complementation condition has allowed us to isolate 74 absolute lethal tail protein mutants of P22 after hydroxylamine mutagenesis. These phage mutants have an absolute requirement for purified P22 tail protein to be present in a soft agar overlay in order to form plaques and do not grow on any nonsense suppressing strains of Salmonella typhimurium. In order to genetically map and physically locate these mutations we have constructed two complementary sets of fine structure deletion mapping strains using a collection of Tn1 insertions in gene 9, the structural gene for the tail protein. Fourteen bacteriophage P22 strains carrying unique Tn1 transposon insertions (Ap phage) in gene 9 have been crossed with Ap phage carrying Tn1 insertions in gene 20. Phage carrying deletions that arose from homologous recombination between the Tn1 elements were isolated as P22 lysogens. The deletion prophage were shown to be missing all genetic information bracketed by the parental Tn1 elements and thus form a set of deletions into gene 9 from the 5' end of the gene. From the frequency of production of these deletion phage the orientation of the Tn1 insertions in gene 9 could be deduced. The genetic end points of the deletions in gene 9 and thus the order of Tn1 insertions were determined by marker rescue experiments using the original Ap phage. The genetic end points of the deletions in gene 20 were determined in similar experiments using nonsense mutations in gene 20. To locate the physical end points of these deletions in gene 9, DNA containing the Tn1 element has been cloned from each of the original Ap phage into plasmids. The precise point of insertion of Tn1 into gene 9 was determined by restriction enzyme mapping and DNA sequencing of the relevant portions of each of these plasmids. In vitro deletion of different 3' gene 9 sequences in the plasmid clones was accomplished through the use of unique restriction endonuclease sites in Tn1. The resulting plasmids form a set of deletions extending into the 3' end of the gene which are complementary compared to the deletion lysogens.(ABSTRACT TRUNCATED AT 400 WORDS)

Design of controller using variable transformations for a nonlinear process with dead time.

In this work, a globally linearized controller (GLC) for a first-order nonlinear system with dead time is proposed. This is similar to the GLC proposed by Ogunnalke [Ind. Eng. Chem. Process. Des. Dev. 25, 241-248 (1986)] for nonlinear systems without dead time. Two methods are proposed. One is based on the Smith prediction from the model in the transformed domain and the other is based on Newton's extrapolation method. The simulation study is made on the conical tank level process and the results are compared with those obtained using a conventional PI controller and the Smith PI controller based on the transfer function model about the operating point 39%. Finally, experimental results on the laboratory conical tank level process are also given.

Simple method of designing centralized PI controllers for multivariable systems based on SSGM.

A method is given to design multivariable PI/PID controllers for stable and unstable multivariable systems. The method needs only the steady state gain matrix (SSGM). The method is based on the static decoupler design followed by SISO PI/PID controllers design and combining the resulted decoupler and the diagonal PI(D) controllers as the centralized controllers. The result of the present method is shown to be equivalent to the empirical method proposed by Davison EJ. Multivariable tuning regulators: the feed-forward and robust control of general servo-mechanism problem. IEEE Trans Autom Control 1976;21:35-41. Three simulation examples are given. The performance of the controllers is compared with that of the reported centralized controller based on the multivariable transfer function matrix.

Ceruloplasmin and the reactions forming diferric transferrin.

The rate of formation of diferric-transferrin has been studied using various combinations of Fe(II), Tf, Cp and h serum. When the reactants were added in a correct physiological sequence, ceruloplasmin and diluted human serum showed the fastest rate of saturation of transferrin.

Long-term results of DeVega tricuspid annuloplasty.

DeVega tricuspid annuloplasty was performed in 74 patients undergoing mitral or mitral and aortic valve replacement between January, 1972, and December, 1985. Sixty-two hospital survivors have been followed up for a mean of 85.3 +/- 6.6 months. Actuarial survival at 14 years was 71.5 +/- 8.2%. None of the late deaths was related to the tricuspid annuloplasty. Three patients required tricuspid valve replacement for recurrence of tricuspid regurgitation (0.68% per annum). Eleven asymptomatic patients studied hemodynamically at a mean period of 53 months after the operation showed maintenance of the hemodynamic improvement. We recommend DeVega annuloplasty as the method of choice for moderate to severe tricuspid regurgitation in the absence of an organically diseased or deformed valve.