Midterm Outcomes of Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability in Ehlers-Danlos Syndrome.

Background: Patellar instability is frequently encountered in patients with Ehlers-Danlos syndrome (EDS). The clinical outcomes of isolated medial patellofemoral ligament reconstruction (MPFLR) for patellar instability in patients with EDS are unknown. Purpose: To evaluate midterm clinical outcomes of isolated MPFLR for patellar instability in patients with EDS and factors affecting these outcomes. Study Design: Case series; Level of evidence, 4. Methods: In a retrospective study, 31 patients (n = 47 knees) with EDS and patellar instability who underwent isolated MPFLR for recurrent patellar instability between 2008 and 2017 and had a minimum 2-year follow-up were identified. Preoperative radiographic images were measured for anatomic risk factors. Clinical outcomes-including postoperative complications-were evaluated. Factors associated with MPFLR failure were identified. Postoperative patient-reported outcomes (PROs)-including the pediatric version of the International Knee Documentation Committee, the Kujala score, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale, the Banff Patellofemoral Instability Instrument 2.0, and the Knee injury and Osteoarthritis Outcome Score-were collected, and factors affecting PRO scores were analyzed. Results: The mean age of the cohort was 14.9 ± 2 years. At a mean follow-up of 7.2 years, 18 of 47 (38.3%) knees required reoperations, of which 9 of 47 (19.1%) knees required revision stabilization for recurrent patellar instability. Also, 7 of 31 knees (22.6%) with autografts failed compared with 2 of 16 (12.5%) with allografts (P = .69). For autografts, 6 of 17 (35.3%) failures occurred with gracilis, but 0 of 13 (0%) occurred with semitendinosus (P = .02). Compared with patients without failures, patients with failed primary MPFLR were significantly younger (P = .0005) and were able to touch the palm to the floor with their knees extended (P = .03). For radiographic parameters, the patellar height and tilt were significantly higher in the failure group. The postoperative PROs were suboptimal at a mean follow-up of 5.2 years. All but 1 patient were satisfied with the final outcome. Conclusion: At the midterm follow-up, 38.3% of patients with EDS required further surgery after isolated MPFLR for patellar instability; half of these revisions (19.1%) were to address recurrent instability. Recurrent instability after isolated MPFLR was more likely in younger patients and those who could touch the palm to the floor with their knees extended. Postoperative PROs were inferior; nonetheless, patient satisfaction was high.

Culture Negative Pasteurella multocida Confirmed Prosthetic Hip Infection using Next-generation Sequencing.

Introduction: Prosthetic joint infections (PJIs) are a dreaded complication of joint arthroplasty. Zoonotic organisms such as Pasteurella multocida (PM) rarely cause PJIs. Still, these organisms can be challenging to treat due to a low suspicion index and inadequate growth on culture. Next-generation sequencing (NGS) can be used to identify organisms in culture-negative PJIs. This is the first reported case of a PM positive total hip arthroplasty PJI using NGS. Case Report: We report the case of a 70-year-old male presenting with a periprosthetic hip infection. PM was identified in high relative abundance on NGS and grew in culture. Subsequent intraoperative samples were culture negative for Pasteurella, but NGS demonstrated continued presence of Pasteurella. Conclusion: PM is a rare case of PJI, but a high index of suspicion must be maintained in the appropriate clinical context. NGS is a vital tool for the identification of culture-negative organisms like PM.

Consensus-Based Guidelines for Management of First-Time Patellar Dislocation in Adolescents.

BACKGROUND: The management of first-time patellar dislocation remains variable, with limited evidence to support or compare different operative and nonoperative modalities. The primary aim was to establish consensus-based guidelines for different components of nonoperative treatment following a first-time patellar dislocation. The secondary aim was to develop guidelines related to management after failed nonoperative treatment. The tertiary aim was to establish consensus-based guidelines for the management of first-time patellar dislocation with a concomitant osteochondral fracture. METHODS: A 29-question, multiple-choice, case-based survey was developed by 20 members of the Patellofemoral Research Interest Group of the Pediatric Research in Sports Medicine Society. The survey consisted of questions related to demographic information, management of first-time patellar dislocation without an osteochondral fracture, and management of first-time patellar dislocation with a 2 cm osteochondral fracture. The survey underwent 2 rounds of iterations by Patellofemoral Research Interest Group members and the final survey was administered to Pediatric Research in Sports Medicine members, using REDCap. Consensus-based guidelines were generated when more than 66% of respondents chose the same answer. RESULTS: Seventy-nine of 157 (50%) eligible members responded. Sixty-one were orthopaedic surgeons and 18 were primary sports medicine physicians. Eleven consensus-based guidelines were generated based on survey responses. Those that met the criteria for consensus included initial knee radiographs (99% consensus), nonoperative treatment for first-time patellar dislocation without an osteochondral fracture (99%), physical therapy starting within the first month postinjury (99%), with return to sport after 2 to 4 months (68%) with a brace (75%) and further follow-up as needed (75%). Surgical treatment was recommended if there were patellar subluxation episodes after 6 months of nonoperative treatment (84%). Patellar stabilization should be considered for a first-time dislocation with an osteochondral fracture (81.5%). CONCLUSION: Consensus-based guidelines offer recommendations for the management of first-time patellar dislocation with or without an osteochondral fracture. Several changing trends and areas of disagreement were noted in clinical practice. CLINICAL RELEVANCE: In the absence of high-level evidence, consensus-based guidelines may aid in clinical decision-making when treating patients following a first-time patellar dislocation. These guidelines highlight the evolving trends in clinical practice for the management of first-time patellar dislocation. Areas not reaching consensus serve as topics for future research.

Medical 3D Printing Using Desktop Inverted Vat Photopolymerization: Background, Clinical Applications, and Challenges.

Medical 3D printing is a complex, highly interdisciplinary, and revolutionary technology that is positively transforming the care of patients. The technology is being increasingly adopted at the Point of Care (PoC) as a consequence of the strong value offered to medical practitioners. One of the key technologies within the medical 3D printing portfolio enabling this transition is desktop inverted Vat Photopolymerization (VP) owing to its accessibility, high quality, and versatility of materials. Several reports in the peer-reviewed literature have detailed the medical impact of 3D printing technologies as a whole. This review focuses on the multitude of clinical applications of desktop inverted VP 3D printing which have grown substantially in the last decade. The principles, advantages, and challenges of this technology are reviewed from a medical standpoint. This review serves as a primer for the continually growing exciting applications of desktop-inverted VP 3D printing in healthcare.

Common Pediatric Fractures for Community Orthopaedic Specialists: Fix Them or Ship Them?

It is important to focus on common pediatric fractures seen in community emergency rooms, including supracondylar humerus, elbow, forearm, distal radius, and femoral shaft fractures, along with periarticular fractures around the knee and ankle in children. The principles of surgical and nonsurgical management of these fractures are based on the fracture type and age of the patient. The orthopaedic surgeon should be aware of important tips and tricks to help manage these injuries and be familiar with common complications that may occur when these injuries are encountered during trauma call.

Comparison of nutritional status of HIV positive children with homecare and institutional care/ orphanage - An eye opener cross sectional study.

Background: Nutrition has an important bearing on the health of Human immunodeficiency virus (HIV) positive children. Ascertaining the nutritional demands correctly and provisioning the nutritional needs to HIV positive/ Acquired Immunodeficiency syndrome (AIDS) children will go a long way in maximizing the therapeutic benefits reaped through ever improving pharmaceutical initiatives, and thus, contribute to prolonging the longevity of these children who have a whole life ahead of them. Objectives: To study the nutritional status, including dietary assessment and anemia status of HIV-positive children, and compare the outcomes among children under homecare (staying with families) and orphanages/institutional care. Methodology: A cross sectional study was carried out among children between 2 and 15 years who were attending Pediatric Outpatient department (OPD) of a tertiary care hospital in western Maharashtra. Data were collected from 106 children by the interviewer himself using pretested validated questionnaire along with anthropometric measures and relevant blood tests. A 24-h recall method was used to collect the dietary intake. Institutional ethical clearance was taken, and data were collected through informed consent of the parent/guardian accompanying the children. Results: Out of the 106 subjects studied, 54 (50.9%) were living in orphanages and 52 (49.1) were living with the family. Out of the 52 subjects of children under caregivers, 48.1% of the caregivers were unskilled workers and more than half of the subjects had a monthly family income of less than Rs 3,000. About 46.1% of the subjects' caregivers were illiterate. In the orphanage, 28 (51.8%) were males and 26 (48.2%) were females; 52 (49.1%) children were living with family of whom 30 (57.7%) were males and 22 (42.3%) were females. The prevalence of anemia (86.5%) and undernutrition (61.1%) was more among those living with family compared to the orphans living in orphanages and the same was statistically significant (P < 0.05). Among the children living in orphanages, the mean intake for most of the nutrients was more across all age groups. Within homecare, the mean nutrient intake of the females for all nutrients was more than the males across all age groups except 3-9 years, where it was more in males. Overall, all the children received less of water-soluble vitamins compared to recommended daily allowances (RDA), and the children of age group 5-15 years received less vitamin A and iron also. Conclusion: Adequate nutrition, which is best achieved through the consumption of a balanced healthy diet, is vital for health and survival for all HIV-infected children. Specific measures to be directed to children under homecare and measures directed to improve social factors need to be undertaken.

Cost-effectiveness of a novel strategy of HIV/AIDS care in Armed Forces: A stochastic model with Monte Carlo simulation.

BACKGROUND: Despite the initial success of HIV/AIDS policy, an increasing number of patients are failing the first-line antiretroviral therapy (ART) each year and the failure rates are increasing. There is a need for identification of novel strategies to reduce failure rates. The aims of the study are (1) to design a novel strategy to reduce ART failure rates and (2) to create a stochastic model using Monte Carlo (MC) simulation comparing the novel strategy with existing strategy. METHODS: A novel strategy based on annual plasma viral load testing and resistance testing for HIV treatment at baseline and at the time of failure was designed. A cohort of 1000 patients each was created for the existing strategy and a novel strategy. Assumptions were included from Indian studies and own data. The two strategies were compared over 20 years of follow-up using stochastic modeling and MC simulation was done for death rates, failure rates, and cost-effectiveness analysis. SimVoi add-in software for MS Excel was used for simulations. Student's t-tests were performed for comparing continuous variables, and the cumulative rates for various outcomes were plotted using Kaplan-Meier analysis. RESULTS: The novel strategy resulted in lower mortality over a 20-year period (279.9 + 7.13 deaths vs 130.43 + 6.03 deaths) with incremental cost per life saved at Rs 32,925 per year. Incremental cost-effectiveness ratio cost per quality-adjusted life year was Rs 1.33 lakhs/annum at constant rate of discounting and just under Rs 90,000 per annum using differential discounting. CONCLUSION: Armed Forces are likely to benefit by adopting the novel strategy that is cost-effective with a significant mortality benefit.

An Analysis of Integrated Child Development Scheme Performance in Contributing to Alleviation of Malnutrition in Two Economically Resurgent States.

BACKGROUND: Good economic growth is considered synonymous with good nutrition. In recent past, some states (like Bihar and Gujarat) have seen unprecedented economic growth. Despite this and introducing plethora of programs (including integrated child development scheme [ICDS]) to reduce malnutrition, one state might be performing well in reducing malnutrition whereas other with equally high economic growth rate might lag behind. Is mere economic growth good enough to alleviate malnutrition? OBJECTIVES: The aim of the article is to document a critical comparative analysis of malnutrition with special emphasis on ICDS (with respect to finances, infrastructure, training, performance) in the two economically resurgent states of Gujarat and Bihar. MATERIAL AND METHODS: An exploratory study using secondary data sources (for ICDS performance) to critically analyze malnutrition status in Bihar and Gujarat. RESULTS: Gujarat, which was criticized for placing excessive emphasis on economic growth, has shown sharp improvement in combating malnutrition. Undernourished children declined from 73.04% in 2007 to 25.09% in 2013, with just 1.6% being severely malnourished. On the other hand, Bihar too exhibited an impressive economic growth but still languishes at bottom with malnutrition rate of 82%. CONCLUSION: A high economic growth does not have automatic immediate positive gains on malnutrition alleviation.

Fracture of Proximal Humerus with dislocation of Glenohumeral joint in a 3 year old child: A case report.

INTRODUCTION: Though proximal humeral physeal injuries are common in children, reports of proximal humeral physeal injuries with disruption of glenohumeral joint are exceedingly rare. We here report such a case. CASE REPORT: A three year old male patient presented to us with proximal humeral physeal separation along with glenohumeral dislocation. Under general anaesthesia, closed reduction could be achieved. Thereafter, three Kirschner wires were used to fix the physeal injury. Wires were removed at six weeks and physiotherapy was started. Good range of motion was achieved, and follow up radiographs demonstrated no evidence of growth arrest at one year. CONCLUSION: In spite of significant displacement in cases of proximal humeral physeal injury with glenohumeral dislocation in children, closed reduction can be achieved and should be attempted.

Synthesis, cytotoxic and antimicrobial screening of a proline-rich cyclopolypeptide.

Present study describes the first total synthesis of a cyclic heptapeptide, stylisin 1 (8) via coupling of tetrapeptide Boc-L-tyrosinyl-L-prolyl-L-leucyl-L-proline-OH and tripeptide L-phenylalanyl-L-isoleucyl-L-proline-OMe followed by cyclization of linear heptapeptide segment. Structure elucidation of synthesized cyclopeptide was done on basis of detailed spectral as well as elemental analysis. From the results of pharmacological screening, it was concluded that cyclopeptide 8 possessed moderate cytotoxicity against Dalton's lymphoma ascites (DLA) and Ehrlich's ascites carcinoma (EAC) cell lines with IC(50) (inhibitory concentration, 50%) values of 10.6 and 14.6 microM. Furthermore, cyclopeptide 8 exhibited moderate to good antimicrobial activity against Gram -ve (negative) bacteria Klebsiella pneumoniae and Pseudomonas aeruginosa, dermatophytes and Candida albicans with minimum inhibitory concentration (MIC) of 6 microg/ml.