Sequential bilateral total ankle replacements: No difference in patient-reported outcomes between the first and second ankle.

BACKGROUND: Total ankle replacement is an established treatment for end-stage arthritis. However, there is little data examining outcomes in sequential bilateral replacements. This study aimed to compare outcomes between first and second ankles in sequential replacement. METHODS: Patients were retrospectively contacted to complete a follow-up questionnaire including the Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D-3 L, and a question assessing satisfaction. Electronic records identified demographics, procedural details, and complications. RESULTS: Twenty patients underwent sequential bilateral ankle replacement over the study period. At a mean follow-up of four years, 18 patients completed the follow-up questionnaire. There was no statistically significant difference between first and second ankles in terms of MOXFQ score, EQ-5D-3 L or satisfaction. Eleven complications were noted. CONCLUSIONS: We report excellent outcomes after sequential bilateral ankle replacement with no difference in outcomes between first and second ankles. These results can be used to counsel patients in the future and manage expectations. LEVEL OF EVIDENCE: IV.

Distribution of angle lambda and pupil offset as measured by combined Placido Scheimpflug Topography.

BACKGROUND: Angle lambda is the angle between the pupillary axis and the line of sight. It is important for accurate centration during anterior segment surgery. The purpose of this study is to identify the distribution of angle lambda and pupil center offset as measured by a combined placido disc Scheimpflug topography system. METHODS: A prospective non-randomized study was performed on 2178 eyes in Eye World Hospital, Giza, Egypt. Sirius device (CSO, Costruzione Strumenti Oftalmici, Florence, Italy, version 3.2.1.60) was used to measure average keratometry (K), anterior chamber depth (ACD), central corneal thickness (CCT), horizontal visible iris diameter (HVID), pupil radius (PR), pupil center intercept x-component (PCI-x), and pupil center intercept y-component (PCI-y). Axial length (AL) was measured by immersion A-scan Eyecube Ultrasonography device (Ellex, Adelaide, South Australia, Australia). Angle lambda was calculated by a trigonometrical equation. Pearson correlation was used to analyze the correlation between angle lambda and age and refraction. RESULTS: Average angle lambda in all eyes was 3.32° ± 1.99. Mean angle lambda was significantly smallest in myopia and largest in hyperopia. Age correlation to angle lambda was insignificant. Average PCI-x and PCI-y in all eyes was - 0.047 mm and + 0.091 mm, respectively. CONCLUSIONS: Angle λ is significantly larger in hyperopia than myopia, and the effect of age is insignificant. Pupil center offset was horizontally greater in hyperopia than in myopia. We therefore encourage the preoperative assessment of angle λ to avoid decentered ablation, especially when treating hyperopia.

Trabeculectomy with OloGen versus Mitomycin C for the Treatment of Silicone Oil-Induced Glaucoma.

AIM: To compare the intraocular pressure-lowering effect and success rate of trabeculectomy with OloGen to that of trabeculectomy with mitomycin C (MMC) in cases of silicone oil-induced glaucoma. MATERIALS AND METHODS: Forty eyes of forty patients with elevated intraocular pressure (IOP) after vitrectomy and silicone oil injection (followed by silicone oil removal) were assigned to two groups. Group A included 20 cases who underwent trabeculectomy with OloGen, while group B cases contained 20 cases undergoing trabeculectomy with MMC. The follow-up period was 24 months. Patients enrolled had IOP > 21 mmHg despite being on antiglaucoma medications. RESULTS: The mean postoperative IOP reduction was lower in group A than in group B at all follow-up visits, but this difference was not statistically significant (p > 0.05). Moreover, group A and B patients were found to be similar as regards the need for postoperative antiglaucoma medications on all follow-up visits. The Kaplan-Meier survival analysis curves for the two groups revealed slightly higher success rates in group B than in group A. However, these differences were not statistically significant for both qualified success (IOP ≤ 21 mmHg with or without antiglaucoma medications) and complete success (IOP ≤ 21 mmHg without antiglaucoma medications). There was no significant difference in the postoperative complication rate between the two groups. CONCLUSION: OloGen implant lowers IOP to a similar extent as MMC when combined with trabeculectomy for the treatment of silicone oil-induced glaucoma, and with comparable success rates. The rate of postoperative complications is similar for OloGen implantation and MMC.

Effect of facemasks on the tear film during the COVID-19 pandemic.

PURPOSE: To evaluate the effect of wearing facemasks on dry eye symptoms and on the tear film while comparing surgical face masks to N95 particulate respirators. METHODS: A prospective observational study was conducted at Ain Shams University Hospitals in the period from September 2020 to January 2021. Two hundred volunteers were recruited, and the daily number of hours spent by each participant wearing a facemask was recorded. Recruits were divided into two groups: 100 volunteers were allocated to Group A to use the surgical mask, and 100 participants to Group B to use the N95 particulate respirator. The tear film parameters were assessed at baseline by answering the Ocular Surface Disease Index (OSDI) questionnaire and performing tear break-up time (TBUT), corneal fluorescein staining, and Schirmer-I test Subjects then wore a facemask for 60 min and then the tear film parameters were reassessed by repeating TBUT, corneal staining and Schirmer-I test. RESULTS: Facemask use for 60 min significantly worsened all tear film parameters in both groups (P-value <0.0001). The deterioration was significantly larger in Group A subjects (P < 0.0001). The daily number of hours spent wearing a facemask correlated strongly with the OSDI and corneal staining. There was a strong negative correlation between the daily number of hours spent wearing a facemask and Schirmer test, and a weak negative correlation with TBUT. CONCLUSIONS: Wearing facemasks during the COVID-19 pandemic is a risk factor for worsening tear film parameters. This deterioration is significantly greater with surgical masks than with N95 particulate respirators and increases with the duration of facemask use.

Two to Five-Year Outcomes of Total Ankle Arthroplasty with the Infinity Fixed-Bearing Implant: A Concise Follow-up of a Previous Report.

LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Combined Trabeculotomy-Trabeculectomy Versus Trabeculectomy for Treatment of Silicone Oil-induced Ocular Hypertension.

PRCIS: Combined trabeculotomy-trabeculectomy (CTT) has a significantly better hypotensive effect than trabeculectomy and a higher success rate in cases of silicone oil-induced ocular hypertension. PURPOSE: To compare the ocular hypotensive effect of CTT with mitomycin-C (MMC) to that of trabeculectomy with MMC in cases of silicone oil-induced ocular hypertension. PATIENTS AND METHODS: Thirty eyes of 30 patients with high intraocular pressure (IOP) after vitrectomy and silicone oil injection (followed by silicone oil removal) were randomly allocated to 2 groups in this randomized trial. Group A was composed of 15 cases who underwent combined CTT with MMC while group B cases contained 15 cases undergoing trabeculectomy with MMC. Patients were followed up for 12 months. We included patients above 18 years old, having performed vitrectomy and silicone oil injection followed by oil removal, and having IOP >21 mm Hg uncontrollable by antiglaucoma medications. RESULTS: The postoperative IOP drop was significantly greater in group A than in group B at all follow up visits (P<0.05). Compared with preoperative IOP, both surgeries produced a significantly lower postoperative IOP at all follow-up visits (P<0.05). For group A, complete success rates (IOP≤21 mm Hg without ocular hypotensive medications) and qualified success rates (IOP≤21 mm Hg with or without ocular hypotensive medications) were both higher than for group B. CONCLUSION: Both surgeries effectively reduce IOP in cases of silicone oil-induced ocular hypertension, but CTT has a significantly better hypotensive effect and a higher success rate on the long-term.

Comparison Between Central Choroidal Thickness in Pregnant Diabetic Females and Pregnant Non-Diabetic Females.

OBJECTIVE: To compare choroidal thickness in pregnant women with and without diabetes mellitus (DM). METHODS: Sixty pregnant females (60 eyes) were enrolled in this cross-sectional controlled study. They were divided into two groups: Group A (30 patients; 30 eyes) were pregestational diabetic pregnant females, while Group B (30 patients; 30 eyes) were non-diabetic pregnant females. Exclusion criteria were high-risk pregnancy, diabetic retinopathy in Group A subjects, systemic or ophthalmological pathology, drug intake other than vitamin supplements and diabetic medications, and large errors of refraction. All patients underwent full ophthalmological examination and enhanced depth imaging optical coherence tomography (EDI-OCT) to measure the choroidal thickness in the nine zones of the Early Treatment Diabetic Retinopathy Study (ETDRS) map. RESULTS: Our results show that Group A eyes (of pregnant diabetic females) had a highly significant greater choroidal thickness than Group B eyes (of pregnant non-diabetic females) in all nine zones of the ETDRS map (p-value <0.01). Moreover, we found a positive linear correlation between the duration of DM and the degree of choroidal thickening. CONCLUSION: Pregnant diabetic females have a thicker choroid than that of pregnant non-diabetic females.

Primary total ankle replacement surgery is a cost-effective intervention.

AIMS: The primary aim was to assess the cost-effectiveness of primary total ankle replacements (PTAR) in the UK. Secondary aim was to identify predictors associated with increased cost-effectiveness of PTAR. METHODS: Pre-operative and six-month post-operative data was obtained over a 90-month period across the two centres receiving adult referrals in the UK. The EuroQol general health questionnaire (EQ-5D-3L) measured health-related Quality of Life (HRQoL) and the Manchester-Oxford Foot Questionnaire (MOXFQ) measured joint function. Predictors, tested for significance with QALYs gained, were pre-operative scores and demographic data including age, gender, BMI and socioeconomic status. A cost per QALY of less than £20,000 was defined as cost effective. RESULTS: The 51-patient cohort [mean age 67.70 (SD 8.91), 58.8% male] had 47.7% classed as obese or higher. Cost per QALY gained was £1669, rising to £4466 when annual (3.5%) reduction in health gains and revision rates and discounting were included. Lower pre-operative EQ-5D-3L index correlated significantly with increased QALYs gained (p < 0.01), all other predictors were not significantly (p > 0.05) associated with QALYs gained. CONCLUSIONS: PTAR is a cost-effective intervention for treating end-stage ankle arthritis. Pre-operative EQ-5D-3L was associated with QALYs gained. A pre-operative EQ-5D-3L score of 0.57 or more was not cost effective to operate on.

Repeatability and Interchangeability of Topometric, Anterior Chamber and Corneal Wavefront Data Between Two Scheimpflug Camera Devices.

PURPOSE: This study aims to assess the intra-operator repeatability and correlation of the Pentacam HR (device 1) and Sirius (device 2) in measuring anterior segment parameters and to evaluate the agreement of their readings and therefore their interchangeability in a clinical setting. METHODS: This is a prospective non-randomized study was conducted on the right eyes of 102 subjects coming to Eye World Hospital, Giza, Egypt. With each machine, four scans were taken by a single examiner. Each device was used to measure keratometric indices, corneal thickness, anterior chamber depth, anterior chamber angle, corneal diameter and corneal optical aberrations. RESULTS: Both devices show high repeatability for corneal thickness, corneal diameter, anterior chamber depth and keratometric indices (except for maximum keratometry, where device 1 shows high repeatability and device 2 shows low repeatability). On the other hand, both devices show poor repeatability for anterior chamber angle, Q-values, root mean square, spherical, coma and trefoil aberrations. The readings of the two devices are strongly correlated as regards only keratometric indices, corneal thickness and anterior chamber depth. In addition, the readings of the devices are in good agreement as regards only keratometric indices (except maximum keratometry), corneal thickness, anterior chamber depth, anterior chamber angle, root mean square, spherical and trefoil aberrations. CONCLUSION: Both devices showed variable intra-observer repeatability, with the device 1 showing slightly higher repeatability. Despite the similarity between some of the readings of the two devices, caution is advised before considering them interchangeable. We therefore do not recommend using them in alternation in refractive surgery.

Reimplantation of the resected tumour-bearing segment after recycling using liquid nitrogen for osteosarcoma.

Reconstruction after en block resection of malignant tumours is still the subject of debate. We questioned the effectiveness of reconstruction by reimplanting the tumour-bearing segment after recycling in liquid nitrogen. Ten patients with osteosarcoma around the knee were included, with a mean age of 21 years. The operative technique included wide en bloc excision, debridement, and management of the resected segment with liquid nitrogen followed by reimplantation and internal fixation. At a mean follow-up of 4.5 years there was no local or systemic recurrence and the mean functional score was 82.4%. The frozen graft united proximally and distally in all but one patient in a period ranging from six to ten months. The effectiveness of this reconstruction technique in properly selected patients with osteosarcoma is comparable to other techniques of biological reconstruction with the added benefit of being simple, cheap and durable.

A safer technique for the double elevation osteotomy in severe infantile tibia vara.

Infantile tibia vara is a deformity of abrupt angulation into varus due to an affection of the postromedial aspect of the proximal tibial physis. The deformity often includes internal tibial torsion and limb length discrepancy. Gradual correction of the deformity is currently the treatment of choice for these challenging cases as it requires less invasive surgery, allows progressive and adjustable correction, permits bone lengthening if needed and achieves a more accurate correction compared to acute correction. Elevation of the depressed medial tibial condyle allows restoration of the joint architecture. Different techniques described to elevate the depressed medial tibial plateau are all technically demanding and carry potential risks of unsalvageable intra-operative complications. The aim of this study is to report the results of a safer technique for the double elevation osteotomy combined with gradual correction using the Ilizarov frame, allowing it to be more reproducible, less technically demanding and avoid those potential complications. This study included 12 limbs in 8 patients (mean age 9 years), all were classified as stage V or VI according to the Langenskiold classification. All osteotomies healed completely in all patients. The mean time in the frame was 23 weeks. The mean preoperative femoral shaft-tibial shaft angle was 36° of varus. This improved to 5° of varus. The mean preoperative femoral condyle-tibial shaft angle was 58°. This improved to 84°. The mean preoperative angle of depressed medial tibial plateau was 63°. This improved to 8°. All patients were maintaining full extension of the knee at the final follow-up, and all patients noticed a significant improvement in their gait pattern. We believe that this technique is safer and less invasive compared to traditional and even newly described techniques for elevating the depressed medial tibial plateau and correcting the deformity in severe infantile tibia vara, which will allow it to be more reproducible.

Cryosurgery and impaction subchondral bone graft for the treatment of giant cell tumor around the knee.

Giant cell tumors are neoplasms of mesenchymal stromal cells with varied manifestations. There is no uniform accepted treatment protocol for these tumors. Curettage, although an accepted method of treatment, carries a high local recurrence rate. Adjuvant therapies including high-speed burr debridement, cryotherapy, and phenol treatment have been advocated to reduce local recurrence. We have used these adjuvants to determine if improved cure rate with improved outcomes could be attained with regard to local tumor control and functional outcome. Twenty-eight cases of proven giant cell tumors of the distal femur and proximal tibia were included in this prospective case series. The lesions were at the upper tibia in 14 cases and the lower femur in 14 patients. The patients were evaluated clinically, radiologically, and by histological examination. Companacci grading and Enneking staging were determined. The treatment was done in the following steps: Curettage and further debridement with a high-speed burr, cryotherapy, impaction of the cavity with subchondral iliac crest bone graft, and, finally, cementation with or without internal fixation. Functional evaluation was done by Enneking's system. The follow-up time was between 24-40 months with a mean of 34 months. The functional results of the procedure were rated as good to excellent with a mean of 93.9%. This technique has the advantages of joint preservation, excellent functional outcome, and low recurrence rate when compared with other treatment modalities. For these reasons, it is recommended as an adjuvant to curettage for most giant cell tumors of bone.

Retrograde femoral nailing in elderly patients with supracondylar fracture femur; is it the answer for a clinical problem?

BACKGROUND: Supracondylar fractures of femur constitute 7% of all femoral fractures. In elderly patients, they are invariably low-energy fractures predisposed to by osteoporosis. Treatment of these fractures in the elderly is a challenging task for most orthopaedic surgeons. There is no consensus on what would be the ideal treatment for such cases. This study looks at the results of retrograde femoral nailing as a treatment option for this vulnerable group of patients. PATIENTS AND METHODS: This retrospective study looks at 23 elderly patients with supracondylar fractures of the femur treated by retrograde femoral nailing. Patients had an average age of 75 years (range between 65 years and 97 years). All patients were assessed with regard to operative time, blood loss, hospital stay, and postoperative complications. All patients were assessed clinically and radiologically every 6 weeks for average period of 14 months (range 12 to 18 months). RESULTS: two patients died a few weeks postoperatively. Average operative time 70 minutes, average blood loss 350ml. Radiologically all cases united, 39.2% had angular malalignment. There were no cases of implant or fixation failure. CONCLUSION: Retrograde femoral nailing is a surgically limited and reliable procedure for elderly patients with supracondylar fractures of the femur without intra-articular extension. Although it has a high incidence of angular malalignment, the overall functional demands of this age group are perhaps not affected much by that particular complication.

A new double elevating osteotomy in management of severe neglected infantile tibia vara using the Ilizarov technique.

Neglected infantile Tibia Vara is a very challenging clinical problem with many technical problems including distorted joint line secondary to the medial tibial plateau depression, obesity leading to difficulty in exposure, performing osteotomies and difficulty in osteotomy fixation. The aim of this study is to evaluate the clinical and radiological results of treatment of severe neglected infantile Tibia Vara using a new osteotomy to elevate the depressed medial tibial plateau in conjunction with the Ilizarov technique. Seven tibias in five patients were included in this study. These were all Stage V and VI according to Langenskiold and Riska classification. The average age at surgery was 11.6 years (ranging from 8 to 15), and the average follow-up was 6.2 years (ranging from 3 to 10). A new double osteotomy technique was used to elevate the depressed medial tibial plateau and correct the varus deformity. Correction was done gradually using the Ilizarov Frame. The results were assessed clinically and radiologically. The femoral shaft -- tibial shaft angle improved from an average of 36 degrees of varus preoperatively to 4 degrees of varus. The femoral condyle-tibial shaft angle improved from an average of 58 degrees to 83 degrees. The angle of depressed medial tibial plateau improved from an average of 53 degrees to 10 degrees. We believe that our new double elevating osteotomy in conjunction with Ilizarov technique is an excellent modality for patients with stage V and VI according to the Langenskiold and Riska classification. The advantages of this technique include correction of the deformity with simultaneous correction of the joint architecture, immediate weight bearing, and avoidance of excessive dissection needed for internal fixation.