Real-world effectiveness of golimumab in the treatment of patients with active rheumatoid arthritis, psoriatic arthritis, or axial spondyloarthritis who failed initial TNF-α inhibitor therapy: a pooled analysis of European prospective observational studie.

OBJECTIVES: Rheumatoid arthritis (RA), psoriatic arthritis (PsA), and axial spondyloarthritis (axSpA) patients often experience secondary non-response to a first-line tumour necrosis factor alpha inhibitor (TNFαi). This pooled analysis of six observational studies in Europe (GO-BEYOND program) provides an estimate of second-line golimumab (GLM) effectiveness for these rheumatic diseases. METHODS: The GO-BEYOND studies included common disease-specific endpoints allowing for a pooled analysis. Patients had discontinued one prior TNFαi (due to loss of efficacy, tolerability, or inconvenience) and were followed for 12 months after GLM initiation. Primary endpoints included the proportion of patients achieving low disease activity (LDA, DAS28-CRP<3.2) in RA, minimal disease activity (MDA, fulfilment of 5 of 7 outcome measures) in PsA, or low disease activity (ASDAS<2.1) in axSpA at 6 months. Disease activity at 3 and 12 months and quality of life (QoL; EQ-5D-3L) were also assessed. Adverse events were monitored. Protocol-specified analyses were based on observed data. RESULTS: In 712 patients, (n=325, RA; 186, PsA; 201, axSpA), mean age was 54 years, 64% were female, and median disease duration was 5 years. Primary endpoints were achieved in 58.3% (RA), 45.5% (PsA), and 45.4% (axSpA) of patients; disease activity improvements were observed at 3 and 12 months and EQ-5D-3L results showed improved QoL over time. The treatment persistence rate at 12 months was 67.8% of patients. No new safety signals were observed. CONCLUSIONS: This pooled analysis of the GO-BEYOND studies showed that treatment with GLM was effective and represented a valid second-line option for RA, PsA, and axSpA patients.

Efficient hip joint distraction using the AO large femoral distractor in treating acetabular fractures associated with marginal impaction and intraarticular incarcerated fragments.

PURPOSE: The results after acetabular fracture are primarily related to the quality of articular reduction. Using the AO large femoral distractor, incarcerated fragments can be easily removed, and marginally impacted fragments can be elevated under direct visualization without further re-dislocating the joint. The current study aimed to evaluate our early results of using the AO large femoral distractor as an assisting tool during ORIF of acetabular fractures associated with marginal impaction or intraarticular incarcerated fragments. METHODS: Eighteen patients were included in this retrospective case series study diagnosed with an acetabular fracture associated with either marginal impaction injury or an intraarticular incarcerated fragment. On a usual operative table, all patients were operated upon in a prone position through the Kocher Langenbeck approach. The AO large femoral distractor was used to facilitate hip joint distraction. Postoperative fracture reduction and joint clearance were assessed in the immediate postoperative CT scans. RESULTS: The average age of the patients was 30 ± 8.2 years; 13 (72.2%) were males. All cases had a posterior wall fracture, and it was associated with transverse fractures, posterior column fractures, and T-type fractures in five (27.8%), two (11.1%), and one (5.6%) patients, respectively. Intraarticular incarcerated fragments were present in 13 (72.2%) cases and marginal impaction in five (27.8%). Fracture reduction measured on the postoperative CT scans showed an anatomical reduction in 14 (77.8%) patients, imperfect in four (22.2%), and complete clearance of the hip joint of any incarcerated fragments. CONCLUSION: The use of the AO large femoral distractor is a reliable and reproducible technique that can be applied to assist in the removal of incarcerated intraarticular fragments and to ease the reduction of marginally impacted injuries associated with acetabular fractures.

Primary arthrodesis for diabetic ankle fractures using a modified retrograde femoral intramedullary locking nail combined with lateral plating, surgical technique, and early results of a pilot study.

PURPOSE: We aimed to report the early results of performing acute ankle arthrodesis using a modified retrograde femoral intramedullary locking IMN concomitant with plating at the same setting for managing diabetic patients' acute ankle fractures. METHODS: We prospectively included patients who presented acutely with ankle fractures, where hemoglobin A1C (HbA1C) on admission was > 7%, and the Adelaide Fracture in the Diabetic Ankle (AFDA) algorithm score was 5 or above. All patients were treated by acute ankle arthrodesis using a modified retrograde femoral IMN combined with lateral plating. Functional assessment was reported according to a modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale (AOFAS), and complications were documented. RESULTS: Six patients had an average age of 55.7 years (37-65). The average HbA1C on admission was 7.9 (7.3-9), and the average AFDA score was 7.3 (6-8). The average operative time was 79.2 min (70-90). All patients, except for one, achieved union at the arthrodesis site after an average of 10.3 weeks (8-14). After an average last follow-up of 9 months (6-12), the average modified AOFAS was 73.2 (82 to 62); four patients had an excellent score and one good. Complications developed in two, one deep infection after 2 weeks treated by metal removal and Ilizarov, and the other patient developed a stress fracture at the tibial end of the nail, which was treated by open reduction and internal fixation using a plate and screws. CONCLUSION: Using a modified femoral IMN combined with lateral plating is a promising technique to achieve ankle arthrodesis in diabetic patients with acute ankle fractures with acceptable outcomes; however, further studies with larger numbers are needed. LEVEL OF EVIDENCE: IV.

Framework for developing cost-effectiveness analysis threshold: the case of Egypt.

BACKGROUND: Cost-effectiveness analyses rarely offer useful insights to policy decisions unless their results are compared against a benchmark threshold. The cost-effectiveness threshold (CET) represents the maximum acceptable monetary value for achieving a unit of health gain. This study aimed to identify CET values on a global scale, provide an overview of using multiple CETs, and propose a country-specific CET framework specifically tailored for Egypt. The proposed framework aims to consider the globally identified CETs, analyze global trends, and consider the local structure of Egypt's healthcare system. METHODS: We conducted a literature review to identify CET values, with a particular focus on understanding the basis of differentiation when multiple thresholds are present. CETs of different countries were reviewed from secondary sources. Additionally, we assembled an expert panel to develop a national CET framework in Egypt and propose an initial design. This was followed by a multistakeholder workshop, bringing together representatives of different governmental bodies to vote on the threshold value and finalize the recommended framework. RESULTS: The average CET, expressed as a percentage of the gross domestic product (GDP) per capita across all countries, was 135%, with a range of 21 to 300%. Interestingly, while the absolute value of CET increased with a country's income level, the average CET/GDP per capita showed an inverse relationship. Some countries applied multiple thresholds based on disease severity or rarity. In the case of Egypt, the consensus workshop recommended a threshold ranging from one to three times the GDP per capita, taking into account the incremental relative quality-adjusted life years (QALY) gain. For orphan medicines, a CET multiplier between 1.5 and 3.0, based on the disease rarity, was recommended. A two-times multiplier was proposed for the private reimbursement threshold compared to the public threshold. CONCLUSION: The CET values in most countries appear to be closely related to the GDP per capita. Higher-income countries tend to use a lower threshold as a percentage of their GDP per capita, contrasted with lower-income countries. In Egypt, experts opted for a multiple CET framework to assess the value of health technologies in terms of reimbursement and pricing.

Femoral head avascular necrosis in COVID-19 survivors: a systematic review.

The current systematic review aimed to document published cases of femoral head avascular necrosis (FHAVN) post-COVID-19, to report the COVID-19 disease characteristics and management patients received, and to evaluate how the FHAVN were diagnosed and treated among various reports. A systematic literature review was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines through a comprehensive English literature search on January 2023 through four databases (Embase, PubMed, Cochrane Library, and Scopus), including studies reporting on FHAVN post-COVID-19. Fourteen articles were included, ten (71.4%) were case reports, and four (28.6%) case series reported on 104 patients having a mean age of 42.2 ± 11.7 (14:74) years, in which 182 hip joints were affected. In 13 reports, corticosteroids were used during the COVID-19 management plan for a mean of 24.8 ± 11 (7:42) days, with a mean prednisolone equivalent dose of 1238.5 ± 492.8 (100:3520) mg. A mean of 142.1 ± 107.6 (7:459) days passed between COVID-19 diagnosis and FHAVN detection, and most of the hips were stage II (70.1%), and concomitant septic arthritis was present in eight (4.4%) hips. Most hips (147, 80.8%) were treated non-surgically, of which 143 (78.6%) hips received medical treatment, while 35 (19.2%) hips were surgically managed, 16 (8.8%) core decompression, 13 (7.1%) primary THA, five (2.7%) staged THA and three (1.6%) had first stage THA (debridement and application of antibiotic-loaded cement spacer). The outcomes were acceptable as regards hip function and pain relief. Femoral head avascular necrosis post-COVID-19 infection is a real concern, primarily attributed to corticosteroid usage, besides other factors. Early suspicion and detection are mandatory, as conservative management lines are effective during early stages with acceptable outcomes. However, surgical intervention was required for progressive collapse or patients presented in the late stage.

Modified Capsulorrhaphy Technique in Open Reduction of Developmental Dysplasia of the Hip.

BACKGROUND: Neglected patients with developmental dysplasia of the hip (DDH) are not uncommon. Various treatment modalities have been used. Capsulorrhaphy is one of the most critical steps during the process of open reduction of DDH. Inadequate capsulorrhaphy technique can increase the failure rate of open reduction procedures. This study presented the clinical and radiographic results of using a new capsulorrhaphy technique. METHODS: Between November 2005 and March 2018, 540 DDH in 462 patients were retrospectively reviewed. The mean age at surgery was 31 months. All patients underwent a modified capsulorrhaphy technique developed by the main author (with or without additional pelvic or femoral procedures). Postoperative patient assessment during the follow-up period was performed both clinically and radiologically. RESULTS: Follow-up period ranged between 36 months and 12 years. Based on the modified McKay score, good and excellent outcomes were obtained in 90.3%. Functional results were better in younger age (less than 39 mo). Both acetabular index and lateral center edge angle showed significant improvement at 3 years follow-ups. Proximal femoral growth disturbance (PFGD) was encountered in 92 hips. Classes 2 and 3 did not affect the functional results, whereas patients with PFGD classes 4 and 5 had fair to poor functional outcomes. There were 12 hips with redislocation. Revision was done using the same capsulorrhaphy technique. CONCLUSION: Using the index technique of capsulorrhaphy in DDH surgery is safe, reliable, and yields good functional and radiologic outcomes with a relatively low complication rate. LEVEL OF EVIDENCE: Level IV-therapeutic retrospective case series.

To Bury or Not to Bury the K-wires After Fixation of Both Bone Forearm Fractures in Patients Younger Than 11 Years Old: A Randomized Controlled Trial.

PURPOSE: The primary objective was to compare the re-fracture incidence of both radius and ulna fracture in 2 groups treated using intramedullary Kirschner wires (K-wires) where the wires were exposed in group I and buried in group II. The secondary objective was to compare the final functional outcomes and complications incidence. METHODS: Between March 2019 and February 2021, 60 pediatric patients with unstable radius and ulna fractures amenable to surgical intervention using intramedullary K-wires were randomized into group I (K-wires were exposed above the skin by 2 cm) or group II (K-wires were buried under the skin). In group I, K-wires were removed in the outpatient clinic, while in group II, they were removed under general anesthesia as a day-case procedure. Functional outcome per Price criteria was reported at 1-year follow-up. RESULTS: Included patients had a mean age of 7.6 years (range: 5 to 10 y). The mean operative time was significantly higher in group II (32.33±7.51 vs. 36.77±8.70 min, P =0.03), with no difference regarding intraoperative x-ray exposure (43.12±15.52 vs. 41.6±11.96 s, P =0.67). Fracture union was achieved after a mean of 44±2.6 days in group I and 43±1.87 days in group II, with no difference between both groups ( P =0.34). One patient had re-fracture in group I and no patients in group II; however, the difference was insignificant ( P =0.12). Infection occurred in 2 patients in each group. All patients reported excellent scores per Price criteria and achieved full wrist and elbow range of motion compared with the contralateral noninjured side. CONCLUSIONS: Exposed implants are a safe option when dealing with forearm fractures in patients younger than 11 years old, with the added advantage of fewer hospital admissions. Furthermore, it had a similar complication rate and functional outcomes compared with buried implants. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03906929. LEVEL OF EVIDENCE: Level II.

The Functional Luminal Imaging Probe (FLIP): A Good Tool for Adjustment of anal Canal Dimensions During Operative Management of Fecal Incontinence.

PURPOSE: Fecal incontinence is a troublesome problem in the field of colorectal surgery. The main aim of this study was to adjust the anal canal resistance during operative management of anal incontinence using Endo-FLIP. METHODS: This was a prospective cohort study held at Cairo university hospital. Hundred forty-eight incontinent patients treated by different surgical procedures were included. During the procedure the Endo-FLIP was applied to adjust the anal canal dimensions (ACL and ACD) so the ACR could be adjusted based on the flow equation. These were also assessed pre-operatively with Endo-FLIP system and the flow equation calculator. The clinical severity of the disease and outcome after surgical procedures were assessed and correlated to the physiologic parameters. RESULTS: ACL, ACD and ACR had had significant correlations to the degree of incontinence (P < .001). ACL, ACD and ACR showed statistically significant change with primary repair and gluteus maximus transposition operations. After treatment of fecal incontinence, in good responders' group, the mean resting anal canal resistance increased significantly to 4649.05 ± 1161.49 (postoperative) while in poor responders' group it was 1919.9 ± 1077.73. CONCLUSIONS: The Endo-flip can be used to measure the anal canal geometric parameters (ACL and ACD) and then anal canal resistance could be calculated by the flow equation - pre-and post-operatively- which help the adjustment of the surgical repair of sphincter injury in fecal incontinence patients which may improve the surgical outcome.

The evolution of surgical hip dislocation utilization and indications over the past two decades: a scoping review.

PURPOSE: To assess the evolution of surgical hip dislocation (SHD) utilization over the past 20 years, concentrating mainly on the patients' population (adults vs. paediatric), the hip conditions treated using this approach, and reporting on complications of this procedure. METHODS: This scoping review was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. A PubMed database search was performed using specific search terms for articles related to SHD published between January 2001 and November 2022. RESULTS: Initial search revealed 321 articles, of which 160 published in 66 journals from 28 countries were eligible for final analysis. The number of publications increased by 10.2 folds comparing the period from 2001 to 2005 with 2018 to 2022. USA and Switzerland contributed to more than 50% of the publications. Case series studies represented the majority of publications (65.6%). Articles including adult patients represented 73.1% of the publications while 10% were on paediatric patients; however, there was 14 folds increase in publications on paediatric patients comparing the first with the last five years. Managing non-traumatic conditions was reported in 77.5% of the articles, while traumatic conditions in 21.9%. Femoroacetabular impingement (FAI) was the most treated non-traumatic condition reported in 53 (33.1%) articles. In contrast, femoral head fractures (FHF) were the most treated traumatic condition, which was reported in 13 articles. CONCLUSION: The publications on SHD and its usage for managing traumatic and non-traumatic hip conditions showed an increasing trend over the past two decades from worldwide countries. Its use in adult patients is well established, and its utilization in treating paediatric hip conditions is becoming more popular.

Joint preservation surgery for correcting adolescents' spasmodic flatfoot deformity: early results from a specialized North African foot and ankle unit.

PURPOSE: We aimed to report early results of performing joint-preserving surgeries for managing spasmodic flatfoot deformity (SFFD) in adolescents. METHODS: A prospective case series study including 24 patients (27 feet) diagnosed with idiopathic SFFD not responding to conservative management. After reassessment under anesthesia, surgical procedures included soft tissue releases (Achilles tendon (AT), peroneus brevis (PB), peroneus tertius (PT) (if present), and extensor digitorum longus (EDL)), bony osteotomies (lateral column lengthening (LCL), medial displacement calcaneal osteotomy (MDCO), and double calcaneal osteotomy (DCO)), and medial soft tissue reconstruction or augmentation if needed. Functional evaluation was performed per the American Orthopedic Foot and Ankle Society (AOFAS) score, while radiological parameters included talo-navicular coverage angle (TNCA), talo-first metatarsal angle (AP Meary's angle), calcaneal inclination angle (CIA), talo-calcaneal angle (TCA), talo-first metatarsal angle (Lat. Meary's angle), and tibio-calcaneal angle (TibCA). The preoperative parameters were compared to the last follow-up using the Wilcoxon signed test. RESULTS: The mean age was 15.37 ± 3.4 years, 18 (75%) were boys, and the mean BMI was 28.52 ± 3.5 (kg/m2). Release of AT and fractional lengthening of PL, PT, and EDL were performed in all patients. LCL was needed in eight feet (29.6%), MDCO in 5 (18.5%), and DCO in 14 (51.9%). FDL transfer was required in 12 (44.4%) feet, and repair of the spring ligament in seven (25.9%). The mean operative time was 99.09 ± 15.67 min. All osteotomies were united after a mean of 2.3 ± 0.5 months. After a mean follow-up of 24.12 ± 8.88 months (12 and 36 months), the AOFAS improved from a preoperative mean of 43.89 ± 11.49 to a mean of 87.26 ± 9.92 (P < 0.001). All radiological parameters showed significant improvement, AP Meary's angle from a mean of 20.4 ± 5.3 to a mean of 9.2 ± 2.1, Lat. Meary's angle from - 15.67° ± 6.31 to - 5.63° ± 5.03, TNCA from - 26.48° ± 5.94 to 13.63° ± 4.36, CIA from 12.04° ± 2.63 to 16.11° ± 3.71, TibCA from - 14.04° ± 3.15 to - 9.37° ± 3.34, and TCA Lat. from 42.65° ± 10.68 to 25.60° ± 5.69 (P ≤ 0.001). One developed wound dehiscence (over an MDCO), managed with daily dressings and local antibiotics. Another one developed lateral foot pain after having LCL managed by metal removal. CONCLUSION: Careful clinical and radiological evaluation for the correct diagnosis of SFFD is paramount. Joint-preserving bony osteotomies combined with selective soft tissue procedures resulted in acceptable functional and radiological outcomes in this young age group.

Evaluation of debonding force of screw-retained lithium disilicate implant-supported crowns cemented to abutments of different designs and surface treatments.

STATEMENT OF PROBLEM: Straight preparable abutments provide an alternative to titanium bases (Ti-bases) for single-unit screw-retained implant-supported restorations. However, the debonding force between crowns with a screw access channel cemented to preparable abutments and Ti-bases of different designs and surface treatments is unclear. PURPOSE: The purpose of this in vitro study was to compare the debonding force of screw-retained lithium disilicate implant-supported crowns cemented to straight preparable abutments and Ti-bases of different designs and surface treatments. MATERIAL AND METHODS: Forty laboratory implant analogs (Straumann Bone Level) were embedded into epoxy resin blocks that were randomly divided into 4 groups (n=10 each) according to the abutment type used: CEREC group, Variobase group, airborne-particle abraded Variobase group, and airborne-particle abraded straight preparable abutment group. All specimens were restored with lithium disilicate crowns and cemented with resin cement to the corresponding abutments. They were thermocycled (from 5 to 55 °C for 2000 cycles) followed by cyclic loading (120 000 cycles). The tensile forces required to debond the crowns from the corresponding abutments were measured (N) by using a universal testing machine. The Shapiro-Wilk test of normality was used. Comparison between the study groups was done with 1-way ANOVA (α=.05). RESULTS: Tensile debonding force values were significantly different according to the type of abutment used (P<.05). The highest retentive force value was recorded in the straight preparable abutment group (928.1 ±222.2 N) followed by the airborne-particle abraded Variobase group (852.6 ±164.6 N), and the CEREC group (498.8 ±136.6 N); the lowest value was reported in the Variobase group (158.6 ±85.2 N). CONCLUSIONS: The retention of screw-retained lithium disilicate implant-supported crowns cemented to airborne-particle abraded straight preparable abutments is significantly higher than to non-surface treated Ti-bases and similar to airborne-particle abraded ones. Abrading abutments with 50-mm Al2O3 significantly increased the debonding force of the lithium disilicate crowns.

Total hip arthroplasty for post-firearm hip arthritis complicated by coloarticular fistula: A case report.

Hip firearm injuries are rare injuries that could lead to serious complications, such as posttraumatic hip arthritis and coloarticular fistula. We report a case of a 25-year-old male who sustained a pelvic injury caused by a single bullet which led to a bilateral acetabular fracture, concomitant with a colon injury treated on an emergency basis by a diverting colostomy; acetabular fractures were treated conservatively by traction. After the patient recovered from the abdominal injury, he was presented with bilateral hip pain and limited motion; plain radiographs showed bilateral hip arthritis with proximal migration of the femoral head and bilateral acetabular defect classified as Paprosky type ⅢA. Reconstruction of the hips was performed using the same technique: impaction bone grafting for acetabular defect reconstruction and a reversed hybrid total hip arthroplasty (THA) 6 months apart. The patient presented with loosening of the left THA acetabular cup 3 years later, which was revised; then he presented with a discharging sinus from the left THA with suspicion of coloarticular fistula, which was confirmed using CT with contrast material. A temporary colostomy and fistula excision were performed, and a cement spacer was applied to the hip. After clearing the infection, a final revision THA for the left hip was performed. Treating post-firearm hip arthritis by THA is challenging, especially in the situation of neglected cases with the presence of an acetabular defect. Concomitant intestinal injury increases the risk of infection with the possibility of coloarticular fistula formation, which could present later. Working with a multidisciplinary team is paramount.

Are the outcomes of single-stage open reduction and Dega osteotomy the same when treating DDH in patients younger than 8 years old? A prospective cohort study.

BACKGROUND: The primary objective was to report our early results after a one-stage procedure [open reduction (OR), Dega pelvic osteotomy (DPO), and femoral osteotomy (FO) when needed] for surgical management of a cohort of patients with developmental dysplasia of the hip (DDH). The secondary objective was to compare the functional, radiological, and complications among patients younger and older than 30 months. MATERIALS AND METHODS: This prospective cohort study included 71 hips with DDH in 61 patients with a mean age of 34.3 ± 19.5 months. All patients underwent one-stage surgical procedures, including OR + DPO and FO, if needed. Functional and radiographic assessment at the last follow-up was conducted using the modified Severin grading system and the Severin classification system, respectively, in addition to assessing the acetabular index (AI), osteotomies healing, and presence of complications. We divided patients into two groups, younger than 30 months (group I) and older than 30 months (group II). RESULTS: We included 35 hips in group I and 36 in group II. All hips received OR + DPO, while 25 (69.4%) hips in group II had FO. The operative time was significantly longer in group II (103.19 ± 20.74 versus 72.43 ± 11.59 min, p < 0.001). After a mean follow up of 21.3 ± 2.3 months, the functional outcomes were satisfactory in 62 (87.3%) hips (94.3% in group I and 80.6% in group II, p = 0.35). There was a significant improvement in the AI in all patients compared with preoperative values (27.2° ± 2.9 versus 37° ± 4.2, p < 0.05). Furthermore, 63 (88.7%) hips had satisfactory radiographic outcomes (94.3% in group I and 83.3% in group II, p = 0.26), and all osteotomies showed radiographic healing. The overall complications incidence was significantly lower in group I compared with group II (5.7% versus 30.6%, p < 0.05), and avascular necrosis occurred in 4 (5.6%) hips, all in group II (p = 0.06). CONCLUSION: One-stage procedure entailing open reduction, Dega pelvic osteotomy, and femoral osteotomy when needed for managing DDH in patients younger than eight years old revealed acceptable clinical and radiological outcomes. However, there was a higher need for a concomitant femoral osteotomy in patients older than 2.5 years, and complications were more frequent.

Randomized comparison of 4.5/6 Fr versus 6/7.5 Fr ureteroscopes for laser lithotripsy of lower/middle ureteral calculi: towards optimization of efficacy and safety of semirigid ureteroscopy.

BACKGROUND AND PURPOSE: To compare 4.5/6 Fr versus 6/7.5 Fr semirigid ureteroscopes in terms of safety and efficacy in adult non-obese patients with middle or lower ureteric stones. MATERIALS AND METHODS: A total of 198 patients with middle/lower ureteric stone and a BMI ≤ 30 kg/m2 were recruited. Patients were randomized according to the size of ureteroscope into two groups: group 1 where a 4.5/6 Fr semi-rigid ureteroscope was used, and group 2 where a 6/7.5 Fr semi-rigid ureteroscope was used. Patient's demographic, stone characteristics, intraoperative and postoperative outcomes including stone-free rate (SFR) and complications were compared. RESULTS: Preoperative characteristics in terms of age, sex, BMI, and stone location, side, size, and HU were comparable between both groups (p values > 0.05). The overall SFR was significantly higher in group 1 (0.004). Balloon dilatation was not required in all patients of group-1 compared with 33% of group-2 (p = 0.0001). The JJ stent was required in 10% of group-1 compared with 30% of group-2 (p = 0.0004). Failure to reach the stone due to tight ureter occurred in 8% of group 2 (p = 0.003), respectively. Traxer's grade 1 ureteral injury occurred in 2% of group-1 versus 14% of group-2 (p = 0.001). Consequently, hematuria was significantly lower in group-1 (1% vs. 8%; p = 0.01), respectively. The hospital stay < 9 h was significantly higher in group 1 (p = 0.0001). CONCLUSIONS: The 4.5/6 Fr semi-rigid Ureteroscope was associated with significantly higher SFR and shorter hospital stay, with lower ureteral injury, fewer double-J stenting, and without the need for intraoperative balloon dilatation for the ureter.

Surgical Technique: Abductor Reconstruction With Gluteus Maximus and Tensor Fascia Lata in Revision Total Hip Arthroplasty.

BACKGROUND: Abductor deficiency in revision total hip arthroplasty (THA) is a common problem that can lead to pain, limping, and instability. Repair and reconstruction of the abductors is challenging, with a high rate of failure reported in the literature. The purpose of this study is to describe a simplified technique of abductor repair augmented with the transfer of gluteus maximus (Gmax) and the tensor fascia lata (TFL). METHODS: We describe a novel abductor reconstruction with transfer of the anterior 30% of Gmax and the posterior 70% of TFL to the vastus lateralis origin. These transfers can be used in isolation or to augment repair of torn abductors to the greater trochanter. The technique is simple and quick to perform via a lateral approach, requiring dissection of only two muscle slips and minimal additional soft tissue dissection. RESULTS: We describe the use and outcomes of this technique on three patients undergoing revision THA with severe and irreparable abductor deficiency. Although these patients reported improved function after the reconstruction, there was persistence of mild to moderate limping. CONCLUSION: Abductor reconstruction with partial transfers of Gmax and TFL is a promising approach to manage abductor deficiency in revision THA. Larger series are required to determine the efficacy of this technique for restoring abductor function and improving patient reported outcomes.

Purchasing health services under the Egypt's new Universal Health Insurance law: What are the implications for universal health coverage?

BACKGROUND: Egypt's Universal Health Insurance (UHI) Law of 2018 implies major transformation to the health financing system. This commentary provides an assessment of the purchasing arrangements as stipulated by the UHI Law and Bylaw, their implications and contribution to progress towards universal health coverage (UHC). The purpose of this assessment is to inform the multi-year implementation process of the Law and propose options for progress towards UHC. METHODS: Guided by an analytical framework on purchasing, the qualitative analysis was based on the review of the legal provisions and structured discussions with key stakeholders. RESULTS: The Law foresees important changes, such as a purchaser-provider split, stricter referral rules and regulated cost-sharing. However, several purchasing aspects were not sufficiently specified in the legal provisions, for example benefit design and provider payment methods. It remains unclear for decision-makers how to proceed, hindering the Law's effective implementation. There are also concerns about the mixed provider payment system creating incoherent provider incentives. CONCLUSION: In view of the remaining legal unclarities on purchasing, progress towards UHC is restrained. Benefits design and the provider payment system should be further specified with a clearer governance structure around the purchasing decision-making processes. Additional technical options for strategic purchasing are suggested.

Management of anterior associated types of acetabular fractures utilizing the modified Stoppa and the pararectus approaches: a prospective cohort study and early experience from a level one Egyptian trauma centre.

PURPOSE: This study aimed to report the early experience (radiographic, functional, and complications outcomes) from an Egyptian (North African) level one trauma centre after utilizing the modified Stoppa and the pararectus approaches to manage anterior-associated types of acetabular fractures. PATIENTS AND METHODS: Between January 2014 and April 2018, 63 patients (40 males and 23 females) with a mean age of 33 ± 11.5 were included, 45 patients were treated through the modified Stoppa (group A), and 18 through the pararectus approach (group B). RESULTS: At a mean follow-up of 32.11 ± 15.36 months (range 12 to 64), 56 patients (43 group A and 13 group B) were evaluated. The post-operative anatomical reduction was achieved in 44 (78.6%) patients. At the last follow-up, Matta radiological outcome grades were excellent and good in 50 (89.2%) patients, fair and poor in six (10.8%). The mean Harris Hip Score (HHS) was 92.6 ± 7.6; the mean modified Merle D'Aubigné (MMD) score was 16.5 ± 1.5. Excellent functional outcome was reported in 42 (75.0%) and 25 (44.6%) patients according to HHS and MMD scores, respectively. There are four (7.1%) intra-operative iatrogenic complications (two in each approach), three (5.3%) vascular injuries (two in group B and one in group A), and one (1.8%) bladder injury in group A. CONCLUSION: Employing less-invasive anterior approaches for managing anterior associated types of acetabular fractures proved efficiency and safety. Good to excellent radiological and functional outcomes were achieved, with no significant difference between both approaches.

Surgical management of paediatric pelvic fractures: a prospective case series and early experience from a level one Egyptian trauma centre.

PURPOSE: We aimed to report our early experience treating paediatric pelvic fractures (PPF) surgically, reporting on indications, outcomes, and complications. METHODS: Patients aged 0-15 with PPF treated surgically at a level I trauma centre were included prospectively between 2016 and 2018. Fractures were classified according to AO/OTA classification system. Functional evaluation was performed using a modification of the Majeed functional scoring system. Radiological evaluation of vertical and posterior displacement was performed according to Matta and Tornetta criteria and the method described by Keshishyan et al. for assessing pelvic rotational asymmetry. RESULTS: We included 45 patients (77.8% males and 22.2% females), with a mean age of 9.53 ± 3.63 and 19.87 ± 8.84 months of mean follow-up. The functional outcome was excellent in 42 (93.3%) patients, good in two (4.4%), and fair in one (2.2%). Radiologically, the vertical displacement improved from 5.91 ± 4.64 to 3.72 ± 2.87 mm (p-value 0.065), the posterior displacement improved from 7.87 ± 8.18 to 5.33 ± 13.4 mm (p-value 0.031), and the symphyseal diastasis improved from 9.88 ± 7.51 mm to 7.68 ± 3.18 mm (p-value 0.071). Residual pelvic asymmetry improved from 1.2 ± 0.61 to 0.8 ± 0.7 (p-value 0.001). Complications occurred in 21 (46.7%) patients, 11 (24.4%) pin tract infection, six (13.3%) limb length discrepancy, two (4.4%) prominent metals, one (2.2%) subcutaneous haematoma, one (2.2%) infected ISS. CONCLUSIONS: We achieved acceptable functional and radiological outcomes after surgically treating a group of patients with PPF, which was relatively safe with minimal complications. The proper approach and fracture fixation tool should be tailored according to the fracture classification and the presence of associated injuries.

Treatment of genu valgum by a novel percutaneous transverse metaphyseal osteotomy of the distal femur in children and adolescents.

PURPOSE: To evaluate the outcomes of a novel percutaneous medial supracondylar femoral osteotomy and above-knee cast technique in children and adolescents as a minimally invasive surgical intervention for treatment of genu valgum. METHODS: In this prospective study, 60 patients (70 knees) with a tibiofemoral angle more than 15° were treated with a novel medial percutaneous supracondylar femoral osteotomy and above-knee cast and followed up for an average of 29 months. The radiological outcome was measured with MAD, TFA, and mLDFA. The functional outcome was evaluated by a modified Böstman score. RESULTS: The preoperative mean MAD, TFA, and mLDFA were 2.9 cm, 16.3°, and 79.2° respectively. The Böstman score averaged preoperatively 23.1. There was a significant improvement of all radiological and clinical outcome measures (P < 0.001). Per Böstman score, 2 knees in one patient (3%) showed an unsatisfactory result, while 14 (20%) and 54 (77%) knees had a good or excellent result, respectively. Two patients (three limbs) needed early re-casting. Other complications were not encountered. CONCLUSION: In experienced hands, percutaneous transverse metaphyseal femoral osteotomy and above-knee casting appear to be a safe, supracondylar cost-effective, and reliable minimally invasive acute correction technique in genu valgum in children and adolescents. LEVEL OF EVIDENCE: Level IV-therapeutic.

Weyl Semimetal Path to Valley Filtering in Graphene.

We propose a device in which a sheet of graphene is coupled to a Weyl semimetal, allowing for the physical access to the study of tunneling from two- to three-dimensional massless Dirac fermions. Because of the reconstructed band structure, we find that this device acts as a robust valley filter for electrons in the graphene sheet. We show that, by appropriate alignment, the Weyl semimetal draws away current in one of the two graphene valleys, while allowing current in the other to pass unimpeded. In contrast to other proposed valley filters, the mechanism of our proposed device occurs in the bulk of the graphene sheet, obviating the need for carefully shaped edges or dimensions.