Molecular characterization and antibiotic resistance of Vibrio parahaemolyticus from Indian oyster and their probable implication in food chain.

Vibrio parahaemolyticus is one of the leading causes of diarrhoea and gastroenteritis in human on consumption of raw or insufficiently cooked seafood. This study was aimed at isolating and characterizing the pathogenic and pandemic V. parahaemolyticus from oysters (n = 90) in coastal parts of West Bengal, India; their antibiotic resistance and potential for involvement in the food chain. During bacteriological culture, typical V. parahaemolyticus colony was recovered in 88.9% samples followed by presumptive identification in 71 (78.9%) samples by characteristic biochemical (K/A) test. All the presumptive isolates (n = 71) were confirmed by species specific Vp-toxR PCR assay. Of these, 10 (14.08%) were tdh+ and none for the trh. Further, 5 (50%) of these tdh+ isolates were found to carry the pandemic potential gene in PGS-PCR assay; however, none in GS-PCR. Majority (80%) of these pathogenic (tdh+) isolates belonged to pandemic serovars (OUT: KUT; OUT: K24; O1: KUT; O1:K25; O10: KUT) and only 20% to non-pandemic serovars (OUT: K15; O9:K17). All the isolates (100%) exhibited resistance to cefpodoxime followed by ampicillin and cefotaxime (90%), ceftizoxime (60%), tetracycline (50%), ceftriaxone (40%), ciprofloxacin and nalidixic acid (10% each). Overall, the study findings suggested that 11.1% (10/90) of commonly marketed oysters in this area were harbouring pathogenic V. parahaemolyticus. Moreover, 5.5% (5/90) of the oyster population were harbouring pandemic strains of this pathogen. Besides, the pathogenic isolates from oysters were exhibiting a considerable genetic relatedness (53 to 70%) to human clinical isolates in PFGE analysis that relates to a substantial public health risk. Further, their multidrug resistance added gravity to the antimicrobial resistance (AMR), a globally growing public health threat and this is a critical area of concern especially during the treatment of foodborne gastroenteritis.

Choice of surgical approach influences the combined anteversion needed for a stable and impingement-free total hip arthroplasty.

BACKGROUND: Accurate component positioning is the key for successful outcome after total hip arthroplasty (THA). Positioning acetabular and femoral components in a safe zone of 25°-50° on the basis of combined anteversion (CA) has shown to reduce instability and impingement. This safe zone was described for THAs performed through the posterior approach and has not been validated for other surgical approaches. METHODS: Seventy patients who underwent unilateral uncemented THA were included in the study; 35 patients-using posterior approach and the remaining 35-using trans-gluteal approach. All patients included had a stable and impingement-free THA at a mean follow-up of 39.2 ± 9.5 months. CT scan was performed to assess component positioning by calculating CA. The values were compared between the two groups to study possible differences. RESULTS: CA in the trans-gluteal group was significantly lower (32° ± 3.7° vs 38.4° ± 4.6°, P < .001) compared to posterior group. The difference in CA was due to the differences in acetabular anteversion, which was significantly low in the trans-gluteal group than the posterior group (22.1° ± 3.6° vs 27.8° ± 4.2°, P < .001). The mean femoral anteversion was similar in both groups. All trans-gluteal hips fell within the safe zone of 20°-40°, and all posterior hips fell within the safe zone of 25°-50°. CONCLUSION: A safe zone of 25°-50° is valid for THAs performed from the posterior approach but not universally applicable. For trans-gluteal approach, a safe zone of 20°-40° is better to provide a stable and impingement-free THA. CA varies with the surgical approach. THAs performed through the trans-gluteal approach can be stable and impingement-free with lesser CA compared to THAs performed through the posterior approach.

PredictSuperFam-PSS-3D1D: A server for predicting superfamily for the annotation of twilight zone protein sequences.

Annotation of twilight zone protein sequences has been hitherto attempted by predicting the fold of the given sequence. We report here the PredictSuperFam-PSS-3D1D method, which predicts the superfamily for a given twilight zone (TZ) protein sequence. Earlier, we have reported that adding predicted secondary structure information into the threading methods could improve fold prediction especially for the TZ protein sequences. In this study, we have analysed the application of the same method to predict superfamilies. Here, in this method, the twilight zone protein sequence is threaded with the 3D1D profiles of the known protein superfamilies library. In addition, weightage for the predicted secondary structure (PSS) is also employed. The performance of the method is benchmarked with twilight zone sequences. In the benchmarks, 62 and 65 percentages of superfamily predictions are obtained with GOR IV and NPS@ predicted secondary structures, respectively. Receiver Operating Characteristic (ROC) curves indicate that the method is sensitive in predicting the superfamilies. A case study has been conducted with the hypothetical protein sequences of Schistosoma haematobium (Blood Fluke) using this method and the results are analyzed. Our method predicts the superfamily for TZ sequences for which, methods based on sequence similarity alone are inadequate. A web server has been developed for our method and it is available online at http://bioinfo.bdu.ac.in/psfpss.

Pairwise contact energy statistical potentials can help to find probability of point mutations.

To adopt a particular fold, a protein requires several interactions between its amino acid residues. The energetic contribution of these residue-residue interactions can be approximated by extracting statistical potentials from known high resolution structures. Several methods based on statistical potentials extracted from unrelated proteins are found to make a better prediction of probability of point mutations. We postulate that the statistical potentials extracted from known structures of similar folds with varying sequence identity can be a powerful tool to examine probability of point mutation. By keeping this in mind, we have derived pairwise residue and atomic contact energy potentials for the different functional families that adopt the (α/ß)8 TIM-Barrel fold. We carried out computational point mutations at various conserved residue positions in yeast Triose phosphate isomerase enzyme for which experimental results are already reported. We have also performed molecular dynamics simulations on a subset of point mutants to make a comparative study. The difference in pairwise residue and atomic contact energy of wildtype and various point mutations reveals probability of mutations at a particular position. Interestingly, we found that our computational prediction agrees with the experimental studies of Silverman et al. (Proc Natl Acad Sci 2001;98:3092-3097) and perform better prediction than iMutant and Cologne University Protein Stability Analysis Tool. The present work thus suggests deriving pairwise contact energy potentials and molecular dynamics simulations of functionally important folds could help us to predict probability of point mutations which may ultimately reduce the time and cost of mutation experiments. Proteins 2016; 85:54-64. © 2016 Wiley Periodicals, Inc.

Comparison of success of tracheal intubation using Macintosh laryngoscope-assisted Bonfils fiberscope and Truview video laryngoscope in simulated difficult airway.

BACKGROUND AND AIMS: Restriction of head and neck movements prevents the alignment of the oral, pharyngeal, and laryngeal axes and increases the incidence of difficult tracheal intubation in patients with cervical spine fractures. Video laryngoscopes have gained an important role in the management of difficult intubation, especially in situations with limited head and neck movements. This study compares the success of intubation using Macintosh laryngoscope assisted Bonfils® fiberscope (ML-BF) with TruviewPCD video laryngoscope (TV) in patients with simulated restricted head and neck movements. MATERIAL AND METHODS: One hundred and fifty-two patients satisfying the inclusion criteria were randomly allocated to two groups of 76 each. Patients were made to lie supine on the table without a pillow and a soft collar was used to restrict head and neck movements. After a standardized premedication-induction sequence, tracheal intubation was done either with ML-BF or TV. Success of intubation, time taken for successful intubation, hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were noted. RESULTS: Intubation was successful in all the 76 patients in direct laryngoscopy-Bonfils fiberscope group and 75 out of 76 patients in TV group within the specified time (90 s). The median time taken for successful intubation with TV and ML-BF were 44 (range 26-80) s and 49 (range 28-83) s, respectively. Hemodynamic changes, airway trauma, and postoperative oropharyngeal morbidity were similar in both groups. CONCLUSION: Both TV and ML-BF are equally effective for successful tracheal intubation in patients with simulated restricted head and neck movements. In cases of difficult laryngeal visualization with routine Macintosh laryngoscope, Bonfils can be used as an adjunct to achieve successful intubation in the same laryngoscopy attempt.

NOMA-GAP/ARHGAP33 regulates synapse development and autistic-like behavior in the mouse.

Neuropsychiatric developmental disorders, such as autism spectrum disorders (ASDs) and schizophrenia, are typically characterized by alterations in social behavior and have been linked to aberrant dendritic spine and synapse development. Here we show, using genetically engineered mice, that the Cdc42 GTPase-activating multiadaptor protein, NOMA-GAP, regulates autism-like social behavior in the mouse, as well as dendritic spine and synapse development. Surprisingly, we were unable to restore spine morphology or autism-associated social behavior in NOMA-GAP-deficient animals by Cre-mediated deletion of Cdc42 alone. Spine morphology can be restored in vivo by re-expression of wild-type NOMA-GAP or a mutant of NOMA-GAP that lacks the RhoGAP domain, suggesting that other signaling functions are involved. Indeed, we show that NOMA-GAP directly interacts with several MAGUK (membrane-associated guanylate kinase) proteins, and that this modulates NOMA-GAP activity toward Cdc42. Moreover, we demonstrate that NOMA-GAP is a major regulator of PSD-95 in the neocortex. Loss of NOMA-GAP leads to strong upregulation of serine 295 phosphorylation of PSD-95 and moreover to its subcellular mislocalization. This is associated with marked loss of surface α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor and defective synaptic transmission, thereby providing a molecular basis for autism-like social behavior in the absence of NOMA-GAP.

Estimated effect of ventilation and filtration on chronic health risks in U.S. offices, schools, and retail stores.

We assessed the chronic health risks from inhalation exposure to volatile organic compounds (VOCs) and particulate matter (PM2.5) in U.S. offices, schools, grocery, and other retail stores and evaluated how chronic health risks were affected by changes in ventilation rates and air filtration efficiency. Representative concentrations of VOCs and PM2.5 were obtained from available data. Using a mass balance model, changes in exposure to VOCs and PM2.5 were predicted if ventilation rate were to increase or decrease by a factor of two, and if higher efficiency air filters were used. Indoor concentrations were compared to health guidelines to estimate percentage exceedances. The estimated chronic health risks associated with VOC and PM2.5 exposures in these buildings were low relative to the risks from exposures in homes. Chronic health risks were driven primarily by exposures to PM2.5 that were evaluated using disease incidence of mortality, chronic bronchitis, and non-fatal stroke. The leading cancer risk factor was exposure to formaldehyde. Using disability-adjusted life years (DALYs) to account for both cancer and non-cancer effects, results suggest that increasing ventilation alone is ineffective at reducing chronic health burdens. Other strategies, such as pollutant source control and the use of particle filtration, should also be considered.

Green synthesis, characterization and drug delivery applications of a novel silver/carboxymethylcellulose - poly(acrylamide) hydrogel nanocomposite.

Biodegradable polymeric hydrogels are a unique class of macromolecular networks that can hold a large fraction of an aqueous solvent within their structures. They are particularly suitable for biomedical applications including controlled drug delivery, because of their ability to stimulate biological tissues. Many hydrogel-based networks have been designed and fabricated to meet the needs of pharmaceutical and medical fields. The investigation deals with the environment friendly synthesis of biodegradable semi interpenetrating hydrogel networks based on cross-linked poly(acrylamide) through an optimized rapid redox solution polymerization with N, N'Methylenebisacrylamide (MBA) in presence of Carboxymethylcellulose (CMC).The silver nanoparticles within hydrogel networks as nano reactors have been prepared by green synthesis via insitu reduction of silver nitrate (AgNO3) using Azadirachta Indica (Neem) plant extract under atmospheric conditions. The synthesized nanocomposites were characterised by FTIR spectroscopy, UV-Visible Spectroscopy, Scanning Electron Microscopy (SEM), Transmission electron microscopy (TEM) and Dynamic light scattering (DLS) technique. The thermal properties of the nanocomposite was analyzed by Thermogravimetric Analysis (TGA). The pH response and drug release profile of the synthesised biodegradable Silver-Hydrogel nanocomposite was investigated. Further, it was observed that physicochemical interaction between the polymeric nanocomposites and drug influences the degree of matrix swelling and therefore, its porosity and diffusion release process.

Effect of Integrated Yoga Module on Selected Psychological Variables among Women with Anxiety Problem.

The implementation of yogic practices has proven benefits in both organic and psychological diseases. Forty-five women with anxiety selected by a random sampling method were divided into three groups. Experimental group I was subjected to asanas, relaxation and pranayama while Experimental group II was subjected to an integrated yoga module. The control group did not receive any intervention. Anxiety was measured by Taylor's Manifest Anxiety Scale before and after treatment. Frustration was measured through Reaction to Frustration Scale. All data were spread in an Excel sheet to be analysed with SPSS 16 software using analysis of covariance (ANCOVA). Selected yoga and asanas decreased anxiety and frustration scores but treatment with an integrated yoga module resulted in significant reduction of anxiety and frustration. To conclude, the practice of asanas and yoga decreased anxiety in women, and yoga as an integrated module significantly improved anxiety scores in young women with proven anxiety without any ill effects.

Equal mixture of 2% lidocaine with adrenaline and 0.5% bupivacaine 20 mL provided faster onset of complete conduction blockade during ultrasound-guided supraclavicular brachial plexus block than 20 mL of 0.5% bupivacaine alone: a randomized double-blinded clinical trial.

INTRODUCTION: Recent evidence has questioned the advantage of local anesthetic (LA) combinations. This study tested the hypothesis that mixing rapid-onset (lidocaine) and long-duration (bupivacaine) LA would provide faster onset of complete conduction blockade (CCB) compared with bupivacaine alone and longer duration of analgesia compared with lidocaine alone during low-volume (20 mL) ultrasound-guided (USG) supraclavicular brachial plexus block (SCBPB). METHODS: Sixty-three patients receiving USG-SCBPB were randomly allocated into: group L: 20 mL 2% lidocaine with epinephrine 1:200 000; group B: 20 mL 0.5% bupivacaine; group LB: 20 mL of equi-volume mixture of both drugs. Sensory and motor blockade was recorded on a three point sensory and motor assessment scale at 10 min intervals for up to 40 min and the total composite score (TCS) at each time point was determined. The duration of analgesia was also noted. RESULTS: The mean time to CCB of group LB (16±7 min) was comparable (p>0.05) with group L (14±6 min) and group B (21±8 min) in patients who were attained CCB. However, the proportion of patients attaining complete conduction block (TCS=16/16) was significantly lower (p=0.0001) in group B (48%) when compared with group L (95%) and group LB (95%) at the end of 40 min. The median (IQR) duration of postoperative analgesia was longest in group B; 12.2 (12-14.5) hours, followed by group LB 8.3 (7-11) hours and 4 (2.7-4.5) hours in group L. CONCLUSION: At 20 mL LA volume, equal mixture of lidocaine and bupivacaine provided significantly faster onset of CCB compared with bupivacaine alone and longer duration of postoperative analgesia compared with lidocaine alone but shorter than bupivacaine alone during low-volume USG-SCBPB. TRIAL REGISTRATION NUMBER: CTRI/2020/11/029359.

Quantitative assessment of ultrasound-guided sciatic nerve block - A comparison of a single-point versus two-point injection technique: A randomised controlled, double-blinded trial.

Background and Aims: Sciatic nerve block at the popliteal level for lower limb procedures provides unpredictable success rates even with ultrasonographic (USG) guidance. This study aimed to compare USG-guided single-point versus two-point injection techniques. Methods: Sixty patients posted for foot surgeries under USG-guided sciatic nerve block were randomised into Group Single Point, receiving a single injection of 20 mL of 1.5% lignocaine with adrenaline just proximal to the sciatic nerve bifurcation, and Group Double Point, receiving two injections of 10 mL of 1.5% lignocaine with adrenaline, one at the point similar to the first group and a second injection 6 cm above the first point. Sensory blockade onset, time to complete sensory blockade, time to complete motor blockade, length of the nerve exposed and analgesia duration were evaluated. Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) statistics version 20 software. Results: Double-point injection technique showed a significantly faster time to complete motor blockade [14.46 (9.93) min], increased length of nerve exposed to local anaesthetic [23.23 (7.209) cm] and extended duration of analgesia [420.40 (99.34) min] compared to the single-point injection technique [20.89 (12.62) min, 18.78 (5.95) cm and 344.28 (125.97) min, respectively]. The onset of sensory blockade and the time to complete sensory blockade were comparable between the two groups. Conclusion: USG-guided popliteal sciatic nerve block with a double-point injection technique does not significantly shorten the time to complete the sensory block. However, the time to complete motor nerve block and duration of analgesia are prolonged significantly, which may be clinically beneficial for postoperative analgesia.

Ultrasound measurement of the distance of the phrenic nerve from the brachial plexus at the classic interscalene point and upper trunk: A volunteer-based observational study.

Background and Aims: The method of blocking the brachial plexus at the level of the upper trunk has been gaining popularity as a phrenic nerve-sparing alternative for interscalene block. We aimed to measure the distance of the phrenic nerve from the upper trunk and compare it with the distance between the phrenic nerve and the brachial plexus at the classic interscalene point by using ultrasound. Method: In this study, after ethical approval and trial registration, 100 brachial plexus of 50 volunteers were scanned from the emergence of the ventral rami and its course was traced to the supraclavicular fossa. The distance of the phrenic nerve from the brachial plexus was measured at two levels: the interscalene groove along the cricoid cartilage (classic interscalene block point) and from the upper trunk. The presence of anatomical variations of the brachial plexus, the classic traffic light sign, vessels across the plexus, and the location of the cervical oesophagus were also noted. Results: At the classic interscalene point, the C5 ventral ramus was observed to be just emerging or to have fully emerged from the transverse process. The phrenic nerve was identified in 86/100 (86%) of scans. The median (IQR) distance of the phrenic nerve from the C5 ventral ramus was 1.6 (1.1-3.9) mm and that of the phrenic nerve from the upper trunk was 17 (12-20.5) mm. Anatomical variations of the brachial plexus, the classic traffic light sign, and vessels across the plexus were seen in 27/100, 53/100, and 41/100 scans respectively. The oesophagus was consistently located on the left side of the trachea. Conclusions: There was a 10-fold increase in the distance of the phrenic nerve from the upper trunk when compared to that from the brachial plexus at the classic interscalene point.

Vitamin E differentially affects short term exercise induced changes in oxidative stress, lipids, and inflammatory markers.

BACKGROUND AND AIM: Physical activity or exercise is a proven deterrent of cardiovascular diseases. The purpose of this study was to examine whether vitamin E supplementation interfere with the potential benefits of exercise. METHODS AND RESULTS: A total of 455 apparently healthy men and women were recruited, for a 2-month aerobic/cardiovascular exercise program. Subjects were randomly assigned for soft gel vitamin E or placebo (800 IU), and required to give blood at 0, 2, 4 and 8 weeks of exercise. Levels of lipid and markers of oxidative stress and inflammation were measured along with the VO2 and duration time spent on treadmill. Statistical analysis did not show significant changes in the levels of lipids and markers of oxidative stress and inflammation. Favorable trends among both of the randomization groups were observed in lipids, and some of the oxidative stress and inflammatory markers. This study also established several interesting correlations between VO2, and lipids on one hand and markers of oxidation and inflammation on the other hand. Reduction in LDL levels positively associated with increased levels of MCP-1 (P < 0.008) among placebo group, and also decreased hCRP levels strongly correlated with the increases in VO2 (P < 0.0004) among the placebo, and vitamin E subjects (P < 0.01). CONCLUSIONS: Exercise training induces oxidative stress might be instrumental in favorable lipid reduction and markers of oxidative stress and inflammation. However interestingly, vitamin E didn't demonstrate favorable effects on the level of oxidative stress and inflammation associated with exercise.

Anesthetic management of a newborn with a cervical meningomyelocele.

Anesthesia of a newborn poses different types of challenges to the anesthesiologist. Cervical meningomyelocele adds to the difficulty with positioning and airway problems. We report a case of successful management of such a case.

PSS-3D1D: an improved 3D1D profile method of protein fold recognition for the annotation of twilight zone sequences.

Annotation of any newly determined protein sequence depends on the pairwise sequence identity with known sequences. However, for the twilight zone sequences which have only 15-25% identity, the pair-wise comparison methods are inadequate and the annotation becomes a challenging task. Such sequences can be annotated by using methods that recognize their fold. Bowie et al. described a 3D1D profile method in which the amino acid sequences that fold into a known 3D structure are identified by their compatibility to that known 3D structure. We have improved the above method by using the predicted secondary structure information and employ it for fold recognition from the twilight zone sequences. In our Protein Secondary Structure 3D1D (PSS-3D1D) method, a score (w) for the predicted secondary structure of the query sequence is included in finding the compatibility of the query sequence to the known fold 3D structures. In the benchmarks, the PSS-3D1D method shows a maximum of 21% improvement in predicting correctly the α + ß class of folds from the sequences with twilight zone level of identity, when compared with the 3D1D profile method. Hence, the PSS-3D1D method could offer more clues than the 3D1D method for the annotation of twilight zone sequences. The web based PSS-3D1D method is freely available in the PredictFold server at http://bioinfo.bdu.ac.in/servers/ .

Volar hook plate stabilization of volar marginal fragments in intra-articular distal radius fractures.

BACKGROUND: In the setting of intra-articular distal radius fractures, the volar lunate facet (VLF) is the only articular segment that resists volar carpal subluxation. So, it is important to achieve a stable fixation of this key fragment. The VLF, when small (also called as volar marginal fragment, VMF) is located distal to the watershed line making fixation with the conventional volar locking plates difficult or impossible. METHODS: 18 patients with either an AO: 2R3B3 or a C3 fracture consisting of a VMF underwent surgical repair through a volar approach. The VMF was stabilised using a anatomical volar hook plate. Remaining fracture components were stabilised using 2.4/ 2.0 mm locked plates. Fracture healing, ability of the hook plate to maintain reduction of the VMF and complications were assessed during follow up. Functional outcome was evaluated using Mayo score and patient rated wrist evaluation questionnaires. RESULTS: All fractures united at follow up. Reduction of the VMF was maintained through healing with a stable radiocarpal and distal radioulnar joint. The mean flexion - extension wrist arc was 105° ± 10.2° The mean grip strength reached 74.6 ± 6% of the opposite side. The mean Mayo wrist score was 75 ± 5.3 and the mean patient rated wrist evaluation (PRWE) score was 15.2 ± 4.3 indicating recovery of wrist function. CONCLUSION: It is important to identify VMFs in intra-articular distal radius fractures. Anatomically designed volar hook plate achieves excellent low-profile stable fixation of this key fragment to allow early mobilisation without fearing loss of reduction and volar carpal subluxation.

Trochanteric Flip (Ganz) Anterior Hip Dislocation for Fixation of Pipkin Fracture-Dislocations.

Safe surgical dislocation with a trochanteric flip osteotomy has been shown to be a reliable technique that provides excellent exposure for treating femoral-head fractures with minimal complications. This technique also allows associated labral injuries and acetabular fractures to be treated through the same approach. DESCRIPTION: The procedure is performed with use of a conventional Kocher-Langenbeck exposure with the patient in the lateral position. The trochanteric flip is performed, allowing exposure of the anterior capsule, which is incised to dislocate the head anteriorly. Fracture fixation is performed with use of mini-fragment screws followed by relocation of the head, closure of the capsulotomy, and fixation of the osteotomy. ALTERNATIVES: Fixation of femoral-head fractures can also be performed with use of alternate surgical approaches. Anterior-based surgical approaches like the Hueter approach or the Smith-Petersen approach are preferred with the goal of preserving the posterior extraosseous blood supply to the femoral head. The posterior Kocher-Langenbeck approach can also be utilized because there is no clear evidence suggesting that a properly performed posterior approach affects the blood supply of the femoral head. RATIONALE: Surgical hip dislocation is 1 of the preferred techniques for operative treatment of femoral-head fractures and is a versatile approach that provides circumferential exposure of the femoral head and acetabulum through an anterior dislocation. A compromised blood supply to the femoral head is much less likely with use of this approach compared with posterior-based surgical approaches. Compared with anterior-based surgical approaches, which are often restrictive, surgical dislocation is extensile and provides adequate exposure to treat associated injuries to the acetabulum and the labrum of the hip. EXPECTED OUTCOMES: Outcomes following surgical dislocation for femoral-head fractures are reportedly good to excellent in >80% patients. Urgent reduction of the hip joint followed by anatomical reduction of the fracture and stable fixation of the fracture and osteotomy leads to predictably good results. Notable complications include heterotopic ossification, which has been reported in up to 60% patients, as well as osteonecrosis of the femoral head (often related to the initial injury rather than the approach) and degenerative arthritis of the hip joint. IMPORTANT TIPS: The Gibson interval may be utilized to preserve the gluteus maximus.Identify all of the posterior structures starting proximally from the posterior border of the gluteus medius, and continuing to the piriformis, triceps coxae, quadratus femoris, and the vastus lateralis.Aim for a thickness of 1 to 1.5 cm when performing the osteotomy; an osteotomy that is either too thick or too thin can negatively affect outcomes. The osteotomy should begin just anterior to the posterior fibers of the gluteus medius to ensure that the osteotomy is anterior to the piriformis tendon. It should exit distally to the vastus lateralis origin.Carefully elevate the posterior margin of the gluteus minimis from the capsule to avoid the tethering effect during anterior translation of the osteotomized fragment.Capsular tears during the initial dislocation are common and should be incorporated into the anterior capsulotomy.Repair of large posterosuperior labral tears may improve outcomes.Fixation of the fracture can be performed with mini-fragment screws or headless screws. Non-fixable small fragments can be excised.The osteotomy should be reduced and fixed in a stable manner to prevent trochanteric nonunion and preserve abductor function.

A load-sharing nail - cage construct may improve outcome after induced membrane technique for segmental tibial defects.

INTRODUCTION: Induced membrane technique (IMT) is a well-established technique for treating segmental bone defects. Different variations of the technique have been described. Our objective was to evaluate radiological and functional outcome with IMT using a nail - graft filled titanium cage construct for segmental traumatic bone defects of the tibia. PATIENTS AND METHODS: 26 adult patients with moderate (> 5 cm) or large (> 10 cm) segmental tibial defects after acute open fractures or implant related infected nonunions underwent the procedure. The technique involved 2 stages. After standard debridement +/- implant removal and application of an antibiotic loaded cement spacer in stage 1, the second stage included placement of an intramedullary nail across the defect and an impacted graft filled titanium mesh cage was used to reconstruct the bone defect. Radiographic evidence of bony union, time to painless un-assisted weight bearing, return to work and functional evaluation with lower extremity functional scale (LEFS) were assessed. RESULTS: 5/26 cases were excluded due to failure in controlling infection. 100% union rates were achieved in the remaining 21 patients. 2 patients (9.5%) required repeat bone grafting. The mean time to painless un-assisted painless weight bearing was 26 ± 9.2 days and the mean time to return to work was 45 ± 12.5 days. The mean LEFS at a mean follow up of 27 months was 67 ± 4.7. CONCLUSIONS: Excellent union rates with good functional restoration can be achieved after IMT using the nail - cage construct for segmental tibial defects. Persistent infection is the biggest impediment for successful execution of the technique. Addition of a cage may also improve short-term functional outcome in terms of ability to weight bear and early return to work.