Evaluating computed bony range of motion (BROM) by registering in-vitro cadaver-based functional range of motion (FROM) to a hip motion simulation.

BACKGROUND: While modern hip replacement planning relies on hip motion simulation (HMS), it lacks the capability to include soft-tissues and ligaments restraints on computed bony range of motion (BROM), often leading to an overestimation of the in-vivo functional range of motion (FROM). Furthermore, there is a lack of literature on BROM assessment in relation to FROM. Therefore, the study aimed to assess computed BROM using in-vitro cadaver-derived FROM measurements, registered to a CT-based in-house HMS, and to further investigate the effect of functional and anatomical hip joint centres (FHJC and AHJC) on BROM. METHOD: Seven limiting and three non-limiting circumducted passive FROM of four cadaver hips were measured using optical coordinate measuring machine with reference spheres (RSs) affixed to the pelvis and the femur, following CT-scan of the specimen. The RSs' centres were used to register the measured FROM in HMS, enabling its virtual recreation to compute corresponding BROM by detecting nearest bony impingement. FHJC, estimated from non-limiting FROM, was compared with AHJC to examine their positional differences and effect on BROM. RESULTS: Differences in BROM and FROM were minimal in deep flexion (3.0° ± 4.1°) and maximum internal rotation (IR) at deep flexion (3.0° ± 2.9°), but substantially greater in extension (53.2° ± 9.5°). Bony impingement was observed during flexion, and IR at deep flexion for two hips. The average positional difference between FHJC and AHJC was 3.1 ± 1.2 mm, resulting in BROM differences of 1°-13° across four motions. CONCLUSIONS: The study provided greater insight into the applicability and reliability of computed BROM in pre-surgical planning.

Paradoxical reaction in peripheral lymph node tuberculosis: a review for its prevalence, clinical characteristics, and possible treatment.

The paradoxical reaction (PR) is a transient worsening following tuberculosis treatment and it is not uncommon in lymph node tuberculosis (LNTB). PR in LNTB maybe  wrongly considered as treatment failure or relapse. This review was undertaken to address various aspects of PR associated with lymph node tuberculosis prevalence, underlying mechanism, clinical pattern, predictors, and possible treatment in an immunocompetent individual. A literature review was performed using various databases (PubMed, Scopus, Science Direct, and Google Scholar) to identify relevant articles for review. The prevalence of paradoxical reactions associated with LNTB varies from as low as 13.3% to as high as 35.3%  PR may occur during antitubercular treatment or be reported even after completion of treatment called post-therapy PR. An onset of PR may occur within a month of therapy to even 12 months from the initiation of an anti-tubercular drug. Delayed hypersensitivity reaction and reduction in immune suppression is believed to be possible mechanism leading to a paradoxical reaction. PR in LNTB is characterized by either progression of pre-existing nodal enlargement or formation of abscess, sinus formation, or appearance of new nodal enlargement or rarely extra-nodal involvement. PR is a diagnosis of exclusion and may show granuloma, positive AFB smear, or positive GeneXpert but AFB culture is always negative. Younger age, lymph node size of equal to or more than 3 cm, female gender, unilateral lymphadenopathy, and those with positive AFB on initial examination are predictors for PR in peripheral LNTB. The majority of PR in LNTB have a mild course and are generally self-limited.

Approach to post COVID-19 persistent cough: A narrative review.

A large proportion of patients who completely recovered from acute coronavirus disease 2019 (COVID-19) infection later continued to experience symptoms even after recovery, irrespective of the severity of the disease. Various terms with varying duration were used for those who had persistent symptoms, of which cough was the most common. We systematically searched the published literature concerning post-COVID-19 cough, its prevalence, and the potential ways to reduce it in clinical practice. The aim of this review was to provide an overview of existing literature concerning post-COVID-19 cough. Literature shows that augmented cough reflex sensitivity is responsible for persistent cough after acute viral upper respiratory infection (URI). Overall, the heightened cough reflex associated with SARSCoV2 induces neurotropism, neuroinflammation, and neuroimmunomodulation via the vagal sensory nerves. Therapies for post-COVID-19 cough aim at the suppression of cough reflex. For a patient who does not respond to early symptomatic treatment, Inhaled corticosteroids can be given a trial to suppress airway inflammation. More trials of novel cough therapies in patients with post-COVID-19 cough using various outcome measures need to be studied in future research. Several agents are currently available for symptomatic relief. However, non-response or refractory cough continues to preclude adequate symptom relief.

Tönnis angle and acetabular depth ratio: predictors of dislocation following hemiarthroplasty for hip fracture.

BACKGROUND: Despite efforts to mitigate possible modifiable risk factors, dislocations following hemiarthroplasty for hip fracture still occur, with reported incidence rates ranging from 1.5 to 11%. The aim of this study was to investigate whether acetabular dysplasia is a significant contributing factor to dislocation, and since non-modifiable, whether it should affect patient selection for this treatment option. METHODS: This is a multicentre nested case-control study of patients treated at 2 separate centres over a 10-year period from January 2011 to December 2020. All cases of hemiarthroplasty dislocation following hip fracture were identified from local databases, and 4 random controls were selected for every case. Tönnis angle (TA) and Acetabular-depth-ratio (ADR) was measured on the injured side using AP pelvis radiographs. Patients with TA > 10° and/or ADR < 250 were considered to have abnormal acetabular morphology. RESULTS: 35 cases of dislocation were identified and 140 random controls were selected. Cases of dislocation had a larger mean TA (8.8° vs. 5.5°, p < 0.001) and lower mean ADR (254 vs. 289, p < 0.001) than controls. 20 out of 35 (57%) cases were considered to have abnormal acetabular morphology, compared to 19 out of 140 (14%) controls. The odds of dislocation is 8.5 times greater (odds ratio = 8.49, 95%CI = 3.73, 19.39) in patients with abnormal TA and/or ADR. CONCLUSIONS: This study demonstrates that TA > 10° and ADR < 250 are useful criteria to identify patients at greater risk of hip hemiarthroplasty dislocation due to acetabular dysplasia. Special consideration to preoperative planning should be taken in these patients. Future research should focus on methods to minimise risk in this subset of patients, including evaluating total hip arthroplasty with dual mobility component vs hemiarthroplasty.

Does functional planning, 3D templating and patient-specific instrumentation improve accuracy in total hip replacement?- a randomized controlled trial.

AIMS: Debate continues as to the optimal orientation of the acetabular component in total hip arthroplasty (THA) and how to reliably achieve this. The primary objective of this study was to compare functional CT-based planning and patient-specific instruments with conventional THA using 2D templating. METHODS: A pragmatic single-center, patient-assessor blinded, randomized control trial of patients undergoing THA was performed. 54 patients (aged 18-70) were recruited to either Corin Optimized Positioning System (OPS) or conventional THA. All patients received a cementless acetabular component. All patients underwent pre- and postoperative CT scans, and four functional X-rays. Patients in the OPS group had a 3D surgical plan and bespoke guides made. Patients in the conventional group had a surgical plan based on 2D templating X-rays. The primary outcome measure was the mean error in acetabular anteversion as determined by postoperative CT scan. RESULTS: There was no statistically significant difference in the mean error in angle of acetabular anteversion when comparing OPS and conventional THA. In the OPS group, the achieved acetabular anteversion was within 10° of the planned anteversion in 96% of cases, compared with only 76% in the conventional group. The clinical outcomes were comparable between the groups. CONCLUSION: Large errors in acetabular orientation appear to be reduced when CT-based planning and patient-specific instruments are used compared to the standard technique but no significant differences were seen in the mean error.

Radiographic validation of a self-report instrument for hallux valgus.

BACKGROUND: Hallux valgus (HV) is a common condition causing substantial morbidity. Radiographic assessment is the gold standard for grading severity but is not always feasible in clinical/research settings. HV line-drawings, consisting of five drawings for each foot depicting a sequential increase in HV angle of 15°, have been clinically validated for self-reporting severity. We aimed to undertake radiographic validation of this self-report instrument. METHODS: Adults aged ≥50 from four GP practices were sent a health survey. Responders self-reported HV severity for each foot using the line-drawing instrument. Those reporting foot pain in the last year had radiographs taken at a research clinic from which intermetatarsal, hallux abductus and hallux interphalangeal abductus angles were calculated. Ten feet were randomly selected for each HV line-drawing grade for both feet. Associations between self-reported HV line drawings and radiographic measurements were assessed using Spearman's ρ correlation coefficients, mean radiographic angle measurement (95% confidence interval) and one-way analysis of variance. RESULTS: Increasing HV line-drawing grade was positively correlated with radiographic measurements for intermetatarsal and hallux abductus angles (Spearman's ρ = 0.602, p < 0.001; 0.821, p < 0.001, respectively). Hallux interphalangeal abductus angle showed an inverse correlation with increasing line-drawing grade (-0.204, p = 0.053). Differences in radiographic measures between HV line drawing grades were significant for intermetatarsal (F = 13.98, p < 0.001) hallux abductus (F = 38.90, p < 0.001) but not hallux interphalangeal abductus angle (F = 2.21, p = 0.075). CONCLUSION: Grading HV severity by self-reported HV line-drawings provides a valid representation of deformity determined from radiographic measurements and is a useful screening/self-reporting tool.

Patient reported outcomes and satisfaction following single incision Flexor Hallucis Longus (FHL) augmentation for chronic Achilles tendon pathologies.

BACKGROUND: Various procedures exist to augment or reconstruct the Achilles tendon (AT) in patients suffering from chronic pathologies. The aim of this study is to assess patient reported outcomes and satisfaction following single incision FHL augmentation using a short tendon harvest with interference screw fixation. METHODS: This is a multicentre case series where postoperative patient reported outcome and satisfaction scores were collected on 30 patients. Outcome measures included EQ-5D, EQ-VAS, Achilles Tendon Rupture Scores (ATRS), and satisfaction scores. Scores were also collected on the unaffected limbs for comparison. RESULTS: Mean patient age was 61 years (range 40-79, SD 11). Mean EQ-5D index value was 0.750 (0.100-1.00, SD 0.238), and mean EQ-VAS score was 74 (36-99, SD 15), at a mean follow-up of 57 months (4-118, SD 32). For patients with ≥24 months' follow-up, a mean deficit of 16 ATRS points was found between the operated and unaffected limb. Overall satisfaction was over 86%. In cases of chronic AT rupture, younger age and increasing time from initial injury to surgery were predictors of greater residual deficit. No serious complications or failures occurred. CONCLUSIONS: FHL augmentation using short tendon harvest and interference screw fixation is a safe treatment option. It appears to take at least 24 months to functionally recover following this procedure, and despite a residual function deficit, there is a high level of patient satisfaction. Further studies are required to determine optimal patient selection and timing of surgery.

Isolated Pulmonary Cysticercosis Presenting as Mass Lesion.

We report a case of pulmonary cysticercosis manifesting as a mass lesion. Cysticercosis confined to lungs is a rare manifestation of human cysticercosis. The disease mainly affects the central nervous system, skeletal muscles, and eyes. Pulmonary involvement is rare and usually presents as bilateral pulmonary nodules. The diagnosis was made based on positive enzyme-linked immunosorbent assay (ELISA) for anticysticercal antibodies, and the patient was started on antiparasitic therapy along with steroids. Symptomatic and radiological improvement was seen. There is no previous case report of isolated pulmonary cysticercosis presenting as mass lesion.

Does size of tendon gap affect patient-reported outcome following Achilles tendon rupture treated with functional rehabilitation?

AIMS: Functional rehabilitation has become an increasingly popular treatment for Achilles tendon rupture (ATR), providing comparably low re-rupture rates to surgery, while avoiding risks of surgical complications. Limited evidence exists on whether gap size should affect patient selection for this treatment option. The aim of this study was to assess if size of gap between ruptured tendon ends affects patient-reported outcome following ATR treated with functional rehabilitation. METHODS: Analysis of prospectively collected data on all 131 patients diagnosed with ATR at Royal Berkshire Hospital, UK, from August 2016 to January 2019 and managed non-operatively was performed. Diagnosis was confirmed on all patients by dynamic ultrasound scanning and gap size measured with ankle in full plantarflexion. Functional rehabilitation using an established protocol was the preferred treatment. All non-operatively treated patients with completed Achilles Tendon Rupture Scores (ATRS) at a minimum of 12 months following injury were included. RESULTS: In all, 82 patients with completed ATRS were included in the analysis. Their mean age was 51 years (standard deviation (SD) 14). The mean ATRS was 76 (SD 19) at a mean follow-up of 20 months (SD 11) following injury. Gap inversely affected ATRS with a Pearson's correlation of -0.30 (p = 0.008). Mean ATRS was lower with gaps > 5 mm compared with ≤ 5 mm (73 (SD 21) vs 82 (SD 16); p = 0.031). Mean ATRS was lowest (70 (SD 23)) with gaps > 10 mm, with significant differences in perceived strength and pain. The overall re-rupture rate was two out of 131 (1.5%). CONCLUSION: Increasing gap size predicts lower patient-reported outcome, as measured by ATRS. Tendon gap > 5 mm may be a useful predictor in physically demanding individuals, and tendon gap > 10 mm for those with low physical demand. Further studies that control for gap size when comparing non-operative and operative treatment are required to assess if these patients may benefit from surgery, particularly when balanced against the surgical risks. Cite this article: Bone Joint J 2020;102-B(11):1535-1541.

The effect of COVID-19 on the trauma burden, theatre efficiency and training opportunities in a district general hospital: planning for a future outbreak.

AIMS: The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. METHODS: The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. RESULTS: There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. DISCUSSION: The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. CLINICAL RELEVANCE: Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priorityTheatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services.Cite this article: Bone Joint Open 2020;1-8:494-499.