Functional Outcomes and Quality of Life Following Complex Tibial Fractures Treated with Circular External Fixation: A Comparison between Proximal, Midshaft, and Distal Tibial Fractures.

AIM AND OBJECTIVE: The purpose of this study was to compare clinical results following complex proximal, midshaft, and distal tibial fractures and investigate whether there are differences in outcomes between these locations. MATERIALS AND METHODS: Patients between 18 years and 65 years of age and minimum follow-up of 12 months with complex tibial fractures treated with a circular ring fixator were included. Functional outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) functional and bone scores, Foot Function Index (FFI), Four Step Square Test (FSST), and Timed Up and Go Test (TUG). Quality of life was assessed by the EQ-5D score. RESULTS: A total of 45 patients were included: proximal fractures, n = 11; midshaft fractures, n = 17; and distal fractures, n = 17. ASAMI functional (p = 0.8) and bone scores (p = 0.3) were not different. Excellent and good bone scores were achieved in >90% in all groups. FFI was 30.9 + 24.7 in the proximal group, 33.9 + 27.7 in the midshaft group, and 28.8 + 26.9 in the distal group (p = 0.8). TUG was 9.0 + 2.7 sec in the proximal group, 9.0+3.5 in the midshaft group, and 8.5+2.0 in the distal group (p = 0.67). FSST was 10.7 + 2.5 sec in the proximal, 10.3 + 3.8 in the midshaft, and 8.9 + 1.8 in the distal fracture groups (p = 0.5). EQ-5D index value was highest in the distal (0.72), lowest in the proximal (0.55), and 0.70 in the midshaft fracture groups (p = 0.001). EQ-5D VAS was significantly different between the proximal (65) and midshaft (82.3) (p = 0.001) and between the distal (75) and proximal (65) fracture groups (p = 0.001). CONCLUSIONS: The results of this study suggest that the functional outcomes between proximal, midshaft, and distal complex tibial fractures are comparable. Their ability to ambulate afterward is comparable to age-related normative data, but complex tasks are more difficult and better compared to the ambulating ability of a healthy population aged 65 to 80 years. Patients with proximal tibial fractures had significantly more disability by at least one functional level and/or one health dimension. HOW TO CITE THIS ARTICLE: Naude JJ, Manjra MA, Birkholtz F, et al. Functional Outcomes and Quality of Life Following Complex Tibial Fractures Treated with Circular External Fixation: A Comparison between Proximal, Midshaft, and Distal Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):32-40.

Use of a Ponseti-hex Assisted Triple Arthrodesis: A Case Study of Bilateral Neglected Adult Clubfoot.

INTRODUCTION: Management of neglected clubfoot presents a challenging problem. Treatments traditionally involve extensive posteromedial soft tissue releases, bony procedures, and the Ilizarov technique of differential distraction. CASE REPORT: We present a case of bilateral neglected clubfoot in a 34-year-old female. Management involved the novel combination of the gradual distraction of prepared triple arthrodesis surfaces and the Ponseti regimen which was achieved using the three-dimensional corrective power of hexapod-type circular fixators. Both feet were corrected to achieve plantigrade painless feet. CONCLUSION: Combining the Ponseti regimen with a hexapod fixator has presented an excellent management strategy for neglected clubfeet in an adult. We further propose the use of a generic name, the Ponseti-hex technique, to cover for the use of all makes of hexapod external fixators.

Functional outcomes of the failed plate fixation in distal tibial fractures salvaged by hexapod external fixator.

PURPOSE: The purpose of this study was to evaluate the clinical and functional outcomes of failed plate fixation in distal tibia fractures salvaged with hexapod circular fixators. MATERIALS AND METHODS: The database of a specialized limb reconstruction center was searched for all patients with failed plate fixation undergoing limb reconstruction with a circular external fixator between 2008 and 2017. Patients between the ages of 18-65 years, with a symptomatic distal tibia malunion or non-union following plate and screw fixation were included. The SF-12 and Foot Function Index (FFI) scoring systems were used to measure clinical and functional outcomes. RESULTS: Ten patients with a mean age of 38 ± 13 years met the inclusion criteria. Seven patients had an infected non-union, two hypertrophic non-unions, and one a malunion. The mean follow-up was 41.7 ± 28.3 months. The mean duration of external fixation was 232.9 ± 146.6 days. The SF-12 demonstrated a mean score of 49.4 ± 7.7 for the physical component and a mean score of 55.3 ± 8.1 for the mental component. Five patients (50%) scored above 45 points for the SF12 physical component, and nine patients (90%) scored above 45 points for the mental component, indicating good outcome can be achieved. The mean FFI score was 24.9 ± 19.9, and six patients had a score below 14 points (good outcome). Radiological union was observed in all 10 patients at a mean of 29 ± 14 months. CONCLUSIONS: The results of this study suggest that hexapod circular external fixation is an attractive surgical alternative for the treatment of failed plate fixation of distal tibial fractures, and can reliably achieve bony union and result in very satisfactory clinical outcomes. LEVEL OF EVIDENCE: Level IV case series.

Comparison of the differential regulation of T and B-lymphocyte subsets in the skin and lymph nodes amongst three cattle breeds as potential mediators of immune-resistance to Rhipicephalus microplus.

Although varying natural resistance to ticks between highly resistant Brahman (Bos taurus indicus), resistant Bonsmara (5/8 B. t. indicus x 3/8 B. t. taurus) and susceptible Holstein-Friesian (B. t. taurus) breeds is documented in skin and blood, little information is available describing draining lymph nodes. To elucidate the cellular dynamics during Rhipicephalus microplus induced immune responses, this study analysed immune factors from these cattle breeds using histology, immunohistochemistry and flow cytometry. Following the collection of skin and lymph node samples before artificial tick infestation, cattle were infested with R. microplus larvae. Subsequent sampling coincided with the tick larvae and adult developmental stages. A significant influx of CD20+ B-lymphocytes in the dermis all cattle breeds was observed while CD3+ T-lymphocytes were significantly increased for more tick resistant breeds. Eosinophil infiltration in germinal centres of lymph nodes was significant for all cattle breeds while tingible body macrophages were significantly increased for adult infested Brahman animals. A negligible fluctuation in CD20+ and CD79α+ B-lymphocyte numbers was present in the lymph node of more resistant cattle breeds, while susceptible animals showed a decrease in B-lymphocytes after infestation, followed by an increase between larvae to adult infested time points. Increased variability of γd T-lymphocyte populations in lymph nodes was correlated with tick susceptibility. In addition, a more stable T helper lymphocyte population was identified in the lymph nodes for the Brahman cattle breed. Results suggest the association of tick susceptibility with differential B-lymphocyte regulation in lymph node tissues, increased variability of WC1+ γδ T-lymphocyte populations in the lymph node as well as a decrease in T helper lymphocytes in the lymph node.

The tibial bayonet method of wound closure.

Management of open lower limb fractures with soft tissue defects can be a technically challenging orthopaedic problem. Limited availability of orthoplastic services means that alternatives to the fix and flap concept are required in order to prevent infected non-unions from developing. The proposed 'bayonet apposition' allows the surgeon to temporarily shorten the limb without angulating the limb or creating a bone defect and removing viable bone. The viable bone edges are overlapped in a bayonet-like manner in order to appose the wound and skin edges. The limb length is restored by gradually distracting the bone segments once the soft tissues have healed. This is facilitated with a hexapod fixator for stabilization of the fracture and distraction. Prerequisites for utilizing this method are circumferential soft tissue damage to the lower limb with viable distal tissue. The bayonet method allows primary closure of a wound and rapid restoration of the native length of the limb.

Expression profiling, gene silencing and transcriptional networking of metzincin metalloproteases in the cattle tick, Rhipicephalus (Boophilus) microplus.

Tick proteins functioning in vital physiological processes such as blood meal uptake, digestion and reproduction are potential targets for anti-tick vaccines, since vaccination could inhibit these essential functions and ultimately affect tick survival. In this study we identified metzincin metalloproteases from Rhipicephalus microplus as potential vaccine candidates since they are implicated as essential to blood-cavity formation, bloodmeal digestion and reproduction in ixodid ticks. Eight transcripts encoding proteins that contain the characteristic metzincin zinc-binding motif HEXXHXXG/NXXH/D and a unique methionine containing "methionine-turn" were identified from native and in-house assembled R. microplus expressed sequence tag (EST) databases. These were representative of five reprolysin-like and three astacin-like metzincin metalloproteases. Reverse transcription-PCR analysis indicated that the reprolysins were most abundantly expressed in the salivary glands, whereas the astacins were most abundant in the midgut and ovaries. In vivo gene silencing was performed to assess a possible phenotype of these metalloproteases during adult female R. microplus blood feeding and reproduction. RNA interference (RNAi) against two of the reprolysins and one of the astacins significantly affected the average egg weight and oviposition rate. Evidently, this reverse genetic approach enabled the evaluation of the overall vital impact of tick proteins. Finally, integrated real time-PCR studies also revealed an extensive cross organ network between the R. microplus metzincin transcripts, supporting the use of a combinatorial metzincin-based anti- R. microplus vaccine.

RNAi in Arthropods: Insight into the Machinery and Applications for Understanding the Pathogen-Vector Interface.

The availability of genome sequencing data in combination with knowledge of expressed genes via transcriptome and proteome data has greatly advanced our understanding of arthropod vectors of disease. Not only have we gained insight into vector biology, but also into their respective vector-pathogen interactions. By combining the strengths of postgenomic databases and reverse genetic approaches such as RNAi, the numbers of available drug and vaccine targets, as well as number of transgenes for subsequent transgenic or paratransgenic approaches, have expanded. These are now paving the way for in-field control strategies of vectors and their pathogens. Basic scientific questions, such as understanding the basic components of the vector RNAi machinery, is vital, as this allows for the transfer of basic RNAi machinery components into RNAi-deficient vectors, thereby expanding the genetic toolbox of these RNAi-deficient vectors and pathogens. In this review, we focus on the current knowledge of arthropod vector RNAi machinery and the impact of RNAi on understanding vector biology and vector-pathogen interactions for which vector genomic data is available on VectorBase.