Frequency and reporting of complications after Dupuytren's contracture interventions: A systematic review and meta-analysis.

INTRODUCTION: Numerous complications are reported following interventions for Dupuytren's contracture; however, their incidence, management, and outcomes remain poorly reported. The aims of this review were to report the proportions of complications, compare likelihood of complications between interventions, and evaluate reporting of complications, including assessment, grading, management, and subsequent reporting of their impact on patient outcomes. METHODS: Extracted data included patient demographics, intervention details, complications, their management, and final outcomes. Analysis of descriptive data enabled review of complications reporting. Meta-analysis(MA) of non-comparative datasets enabled estimation of proportions of patients experiencing complications. Network meta-analysis(NMA) of comparative studies estimated the relative occurrence of complications between interventions. Risk of bias analysis was performed. RESULTS: 26 studies, comprising 10,831 patients, were included. Interventions included collagenase injection, percutaneous needle fasciotomy(PNF), limited fasciectomy(LF), open fasciotomy(OF), and dermofasciectomy(DF). Overall quality and consistency of outcomes reporting was poor. MA enabled estimates of probabilities for three common complications(infection, nerve injury, complex regional pain syndrome(CRPS)) across all interventions; the reported rates for LF were 4.5% for infection, 3% for nerve injury, and 3.3% for CRPS. As the commonest intervention, LF was used as the reference intervention for comparison of the commonest complications via NMA, including haematoma [OF OR 0.450(0.277, 0.695); PNF OR 0.245(0.114, 0.457)], infection [PNF OR 0.2(0.0287, 0.690); DF OR 2.02(1.02, 3.74)], and neuropraxia [PNF OR 0.0926(0.00553, 0.737)]. We noted that the complication incidence was higher the more invasive the intervention. CONCLUSIONS: There was limited reporting of complication occurrence, management, and outcomes following interventions, contributing to a gap in information for informed patient consent. MA was possible for reporting of proportions for infection, nerve injury, and CRPS across interventions. NMA enabled direct comparison of the six commonest complications between interventions. These findings can guide intervention selection. Improving consistency and quality in complications reporting is essential to aid counselling of patients regarding the true rates and consequences of the risks of interventions. TYPE OF STUDY/LEVEL OF EVIDENCE: 2.

Radiological Criteria for Acceptable Alignment in Paediatric Mid-Shaft Forearm Fractures: A Systematic Review.

Introduction: Forearm fractures are common in children. The remodelling capacity of growing long bones in children makes these potentially forgiving injuries, recovering with good outcomes despite minimal intervention. Clinicians rely on radiological characteristics that vary with age to guide treatment decisions and minimise adverse sequelae. The purpose of this review was to consolidate the evidence base of radiological indications for intervention in paediatric mid-shaft forearm fractures. Materials and methods: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed for this review. Citable research output reporting radiological criteria for mid-shaft forearm fractures in paediatric patients (age ≤16 years) was screened and analysed to ascertain acceptable radiological criteria for non-operative management. Results: A total of 2,059 papers were initially identified; 14 were selected following screening. Sagittal angulation >15°, coronal angulation >10°, and/or >50% (or >1cm) translation were the most common radiological indications for intervention in children aged 0 to 10 years. For children over 10 years of age, the most common radiological indication for intervention was sagittal angulation >10°, coronal angulation >10°, and/or >50% (or >1cm) translation. Conclusion: This study revealed a scarcity of high-quality evidence to guide management and significant variation in outcome reporting throughout the published literature. Since Noonan and Price's 1998 recommendations, there has been no significant evolution in the evidence-base guided threshold for intervention in paediatric mid-shaft forearm fractures. There remains a pressing need for a robust multicentre observational study using the patient-reported outcome measurement information system (PROMIS) to address this complex and controversial area of uncertainty in paediatric trauma management.

Radiological Criteria for Acceptable Alignment in Paediatric Mid-Shaft Forearm Fractures: A Systematic Review

@#Introduction: Forearm fractures are common in children. The remodelling capacity of growing long bones in children makes these potentially forgiving injuries, recovering with good outcomes despite minimal intervention. Clinicians rely on radiological characteristics that vary with age to guide treatment decisions and minimise adverse sequelae. The purpose of this review was to consolidate the evidence base of radiological indications for intervention in paediatric midshaft forearm fractures. Materials and methods: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were followed for this review. Citable research output reporting radiological criteria for mid-shaft forearm fractures in paediatric patients (age ≤16 years) was screened and analysed to ascertain acceptable radiological criteria for nonoperative management. Results: A total of 2,059 papers were initially identified; 14 were selected following screening. Sagittal angulation >15°, coronal angulation >10°, and/or >50% (or >1cm) translation were the most common radiological indications for intervention in children aged 0 to 10 years. For children over 10 years of age, the most common radiological indication for intervention was sagittal angulation >10°, coronal angulation >10°, and/or >50% (or >1cm) translation. Conclusion: This study revealed a scarcity of high-quality evidence to guide management and significant variation in outcome reporting throughout the published literature. Since Noonan and Price's 1998 recommendations, there has been no significant evolution in the evidence-base guided threshold for intervention in paediatric mid-shaft forearm fractures. There remains a pressing need for a robust multicentre observational study using the patient-reported outcome measurement information system (PROMIS) to address this complex and controversial area of uncertainty in paediatric trauma management.

National trends in the initial diagnosis and management of carpal tunnel syndrome: results from the ELECTS (ELEctrophysiology in Carpal Tunnel Syndrome) study.

INTRODUCTION: The optimal role of nerve conduction studies (NCS) in management of carpal tunnel syndrome (CTS) is unclear, with no standardised guidance. This study aimed to identify variation in practice in the initial diagnosis of patients with suspected CTS, alongside evaluating how NCS findings influence clinical decision making. METHODS: A national multicentre collaborative survey was conducted in 2021. All centres providing surgery for CTS were invited to participate, primarily via social media. All middle-senior grade orthopaedic/plastic surgeons and advanced care practitioners that regularly manage new referrals for suspected CTS were eligible to respond. Local representatives at each participating site submitted their responses to a central team who collated and analysed the results. RESULTS: A total of 137 healthcare professionals responded from 18 UK NHS Trusts. Of these 137, 124 (91%) reported not employing any validated clinical questionnaires in their routine practice, preferring to rely on clinical diagnosis and/or NCS if available, whereas 84 (61%) utilised NCS to aid diagnosis, with significant differences among professionals with differing experience (p < 0.01). The most common methods for determining the severity of CTS were history, examination and NCS. In symptomatic CTS with confirmatory NCS, over 50% of clinicians would choose surgical decompression as their first-line intervention. In cases of either negative NCS or atypical presentation, 37% and 51%, respectively, would consider conservative management (eg, splintage) or steroid injection first line. CONCLUSIONS: With growing waiting lists for NCS and surgery, national consensus guidelines should be developed to support decision making, while maximising efficient utilisation of increasingly constrained resources.

Aggressive angiomyxoma of the ischioanal fossa in a post-menopausal woman.

Aggressive angiomyxoma is a rare mesenchymal tumour, primarily arising in the soft tissue of the pelvis and perineum in women of reproductive age. There is a paucity of evidence on optimal management because of the rarity of these tumours, but the consensus has been for surgical excision. We present the case of a 65-year-old woman who was admitted with left-sided buttock pain and initially diagnosed with a perianal abscess. She underwent examination under anaesthesia rectum with surgical excision of the lesion, subsequent histopathological and immunochemical analysis was suggestive of aggressive angiomyxoma. To complement our case report, we also present a literature review focusing on aggressive angiomyxoma in the ischioanal fossa (also known as the ischiorectal fossa) with only eight cases of primary aggressive angiomyxoma involving the ischioanal fossa documented to date. The primary aims of this case report and literature review are to familiarise clinicians with the clinical, histopathological and immunochemical features of these tumours, and to increase appreciation that despite the rarity of aggressive angiomyxoma, it might be considered in the differential diagnosis of ischioanal lesions.

Are UK and Ireland trauma and orthopaedic surgeons maintaining their research output?

INTRODUCTION: Healthcare faces growing challenges. With reports of diminishing research output from the UK and Ireland in the leading surgical journals, this study aimed to ascertain whether this trend had been echoed in the trauma and orthopaedic literature. MATERIALS AND METHODS: Citable research output from the 10 globally leading trauma and orthopaedic journals was analysed from five individual years, over a 20-year period, to ascertain trends in absolute output, geographical mix, and level of evidence. RESULTS: The overall number of published articles fell by 14.5%. North America saw the greatest decline (-8.0%), followed by Japan (-5.6%) and Europe (-3.3%). The UK and Ireland (+2.9%) and the rest of the world (+13.9%) saw rising output. A decline in lower (levels IV and V) and a rise in higher (levels I, II and III) quality evidence was observed. The UK and Ireland had a greater proportion of higher-quality studies than North America and Japan, but lower than Europe and the rest of the world. The impact factor of the leading journal rose from 4.47 to 7.01. DISCUSSION: The research landscape has evolved, with leading journals placing greater emphasis on higher-quality evidence. UK and Irish research output remains stable, contributing 14% of the most highly cited publications in 2018, and challenging North America's dominance with a greater proportion of level I and II evidence in the leading journals. CONCLUSION: With the growing emergence of Europe and the rest of the world, UK and Irish authors must build upon the region's output despite political challenges such as Brexit. Increasing international collaboration will continue to play an important role.

Comparison of hyperparathyroidism types and utility of dual radiopharmaceutical acquisition with Tc99m sestamibi and 123I for localization of rapid washout parathyroid adenomas.

Tc99m-sestamibi dual-time imaging is a standard tool for localization of adenomas/hyperplasia in hyperparathyroidism. We investigated the degree and causes of localization failure among different types of hyperparathyroidism. Pre-operative parathyroid hormone levels and size of the gland were major determinants of Tc99m-sestamibi positivity; 123I scan may be helpful in localization failures. INTRODUCTION: Tc99m-sestamibi dual-time imaging is a standard tool for localization of adenomas/hyperplasia in hyperparathyroidism. However, parathyroid adenomas/hyperplasia has been reported to washout as fast as normal thyroid tissue ("rapid washout") which may lead to diagnostic failure. We aimed to evaluate the determinants of rapid washout and to determine the role of subtraction imaging for detection of parathyroid adenomas/hyperplasia with rapid washout. METHODS: Retrospective analysis of patients with hyperparathyroidism who have undergone Tc99m-sestamibi dual-time imaging and parathyroid surgery. Rapid washout was correlated to the type of hyperparathyroidism in surgically confirmed cases. Biochemical and pathological data were reviewed. RESULTS: A total of 135 hyperparathyroidism patients met the inclusion criteria. Ninety-six (72%), 29 (21%), and 10 (7%) had primary, secondary, and tertiary hyperparathyroidisms, respectively. Rapid washout was identified in 28/87 glands (32%), 14/53 glands (26%), and 1/16 glands (6%) with primary, secondary, and tertiary hyperparathyroidisms, respectively. Glands that were positive on late-phase Tc99m-sestamibi scans were significantly large being 1.7 (IQR 1.4-2.3) vs. 1.45 (IQR 1-2) cm (p = 0.003). High parathyroid hormone levels (PTH) were associated with early-phase Tc99m-sestamibi positivity in both primary (p = 0.01) and secondary hyperparathyroidism (p = 0.03) but not with last phase (p = 0.11, p = 0.37, respectively). Correlative imaging with subtraction scintigraphy was positive in 14/16 (87.5%) parathyroid adenomas. CONCLUSION: Pre-operative PTH levels and size of the gland were major determinants of Tc99m-sestamibi positivity on early-phase Tc99m-sestamibi scans, whereas size is an independent predictor of late-phase Tc99m-sestamibi positivity. Subtraction scintigraphy might be a useful tool in suspected cases of rapid washout adenomas/hyperplasia.

Inadequate pelvic radiographs: implications of not getting it right the first time.

Introduction Pelvic radiography is a frequent investigation. European guidelines aim to ensure appropriate use and adequate quality. When initial images are inadequate, repeat radiographs are often required, which may have significant patient safety and economic implications. Objectives The study aimed to assess the adequacy of pelvic imaging across three orthopaedic centres, to identify causes for inadequate imaging and to establish the cost of inadequate imaging from financial and patient safety perspectives. Methods Pelvic radiographs were identified on Picture Archiving and Communication System software at three UK hospitals. Radiographs were assessed against European guidelines and indications for repeat imaging were analysed. Results A total of 1,531 sequential pelvic radiographs were reviewed. The mean age of patients was 60 years (range 5 months to 101 years). Of this total, 51.9% of images were suboptimal, with no significant difference across the three hospitals (P > 0.05). Hospital 3 repeated radiographs in 6.3% of cases, compare with 18.1% and 19.7% at hospitals 1 and 2, respectively (P > 0.05). Hospital 3 identified pathology missed on the initial radiograph in 1% of cases, compared with 5.4% and 5.5% at hospitals 1 and 2, respectively (P > 0.05). Out-of-hours imaging is associated with a higher rate of suboptimal quality (69.1%) compared with normal working hours (51.3%; P = 0.006). Adequacy rates vary with age (χ 2 = 43.62, P < 0.001). Risk of having a suboptimal radiograph increases above the age of 60-years (χ 2 = 4.45, P < 0.05). The annual cost of repeat radiographs was £56,200 per hospital. Discussion and conclusion High rates of pelvic radiograph inadequacy can lead to missed pathology and the requirement for repeat imaging, which has significant patient safety and financial implications. Risk factors for inadequate radiographs include older patients and those having out-of-hours imaging.

Much more than just another guidance document.

As a pediatric hematologist oncologist with clinical and research interests in thrombosis in high-risk pediatric populations, and also as a member of the ISTH Early Career Task Force, I had the opportunity to develop a guidance document on 'Thromboprophylaxis for central venous catheters in the pediatric population' for the 'Guidelines and Guidance Documents' committee. In this communication, I share my experiences to date; I discuss my excitement and initial success, the steep learning curve required to build research acumen, the lessons learnt, and the opportunities and challenges faced. My experience with preparing the guidance document was much more than writing 'just another guidance document'.

A self-assembling ß-peptide hydrogel for neural tissue engineering.

We report a new class of ß-peptide based hydrogel for neural tissue engineering. Our ß-peptide forms a network of nanofibres in aqueous solution, resulting in a stable hydrogel at physiological conditions. The hydrogel shows excellent compatibility with neural cells and provides a suitable environment for cells to adhere and proliferate.

Physiological, anatomical and transcriptional alterations in a rice mutant leading to enhanced water stress tolerance.

Water stress is one of the most severe constraints to crop productivity. Plants display a variety of physiological and biochemical responses both at the cellular and whole organism level upon sensing water stress. Leaf rolling, stomatal closure, deeper root penetration, higher relative water content (RWC) and better osmotic adjustment are some of the mechanisms that plants employ to overcome water stress. In the current study, we report a mutant, enhanced water stress tolerant1 (ewst1) with enhanced water stress tolerance, identified from the ethyl methanesulfonate-induced mutant population of rice variety Nagina22 by field screening followed by withdrawal of irrigation in pots and hydroponics (PEG 6000). Though ewst1 was morphologically similar to the wild type (WT) for 35 of the 38 morphological descriptors (except chalky endosperm/expression of white core, decorticated grain colour and grain weight), it showed enhanced germination in polyethylene glycol-infused medium. It exhibited increase in maximum root length without any significant changes in its root weight, root volume and total root number on crown when compared with the WT under stress in PVC tube experiment. It also showed better performance for various physiological parameters such as RWC, cell membrane stability and chlorophyll concentration upon water stress in a pot experiment. Root anatomy and stomatal microscopic studies revealed changes in the number of xylem and phloem cells, size of central meta-xylem and number of closed stomata in ewst1. Comparative genome-wide transcriptome analysis identified genes related to exocytosis, secondary metabolites, tryptophan biosynthesis, protein phosphorylation and other signalling pathways to be playing a role in enhanced response to water stress in ewst1. The possible involvement of a candidate gene with respect to the observed morpho-physiological and transcriptional changes and its role in stress tolerance are discussed. The mutant identified and characterized in this study will be useful for further dissection of water stress tolerance in rice.

Parathyroid adenoma in a young female presenting as recurrent acute pancreatitis with a brown tumour of the mandible-A case study.

INTRODUCTION: Primary hyperparathyroidism is usually seen in females above the age of 50 years, with a prevalence of 21/1000,(1) whereas the incidence in patients aged 12-28 years is less than 5%.(2) A solitary adenoma is responsible for 80% of cases of primary hyperparathyroidism.(3) Primary hyperparathyroidism is most commonly asymptomatic.(4) The incidence of acute pancreatitis associated with hyperparathyroidism is less than 10%.(5,6) The incidence of hyperparathyroidism associated with a Brown tumour is less than 5%.(7) PRESENTATION OF CASE: A 19 year old female patient presented with recurrent acute pancreatitis and swelling over the mandible. Complete investigative workup revealed a solitary parathyroid adenoma causing hyperparathyroidism. Surgical exploration with excision of the parathyroid adenoma was performed, following which the patient recovered uneventfully. DISCUSSION: The patient was initially managed as a case of acute pancreatitis, and although not suspected initially, a high index of suspicion for hyperparathyroidism developed after a biopsy of the mandibular swelling showed the presence of osteoclastic giant cells indicating the possibility of a Brown tumour. Further investigations then revealed the presence of a solitary parathyroid adenoma with coexistent hyperparathyroidism which was then managed surgically. CONCLUSION: The young age of the patient, and her presentation with acute pancreatitis and a Brown tumour of the mandible make this an extremely rare presentation of parathyroid adenoma.

Sequestrated meningocoele within a naevus sebaceous of Jadassohn on the scalp of a child.

Sequestrated meningocoele is an uncommon developmental anomaly in which meningothelial elements are found in the skin or subcutaneous tissue without underlying bony defect. By contrast, naevus sebaceous of Jadassohn (NSJ) is a circumscribed hamartomatous lesion occurring in about 0.3% of newborns. We report a child with a histologically confirmed sequestrated meningocoele within an NSJ on his scalp vertex. Such an occurrence has not been reported previously.

Cervical epidural anaesthesia with ropivacaine for modified radical mastectomy.

BACKGROUND: Cervical epidural anaesthesia (CEA) using local anesthetics (LA) is a well established technique for the surgeries in the neck, chest and upper arms. Recently ropivacaine is introduced with better safety profile. OBJECTIVES: The aim was to observe the safety of Cervical epidural anaesthesia as an anaesthetic technique and to compare the efficacy of epidural 0.25% bupivacaine with 0.375% ropivacaine for radical mastectomies. METHODS: A double blind study was conducted on 40 ASA grade I / II females who received CEA with 10 ml of 0.25% of bupivacaine +25µg of fentanyl in group B (n=20) and 10 ml of 0.375% of ropivacaine +25µg of fentanyl in group R (n=20) epidurally. Assessment of the block, vital monitoring and complications noted. RESULTS: No significant differences observed in the onset of sensory block (5.05 min and 5.4 min in group B and R respectively, P>0.05).The mean motor blockade score, time to achieve complete blockade and time to grade I motor recovery was significantly longer in group B (2.3, 22.5 and 79.5 minutes respectively) as compared to group R (1.5, 18.3 and 66.3 minutes respectively, P<0.05). Respiratory distress developed in two patients of group B that required general anaesthesia (GA) with intubation. CONCLUSION: Use of 0.37% ropivacaine is safer than 0.25% bupivacaine for CEA for radical mastectomy. It provides good surgical anaesthesia with lesser degree of motor blockade and the respiratory effects.

Are UK otorhinolaryngologists maintaining their research output?

BACKGROUND: In the general surgical and anaesthetic literature, there has been a decline in research output originating from the UK. This study analysed the 10 globally leading and 2 UK leading otorhinolaryngology journals to determine whether this trend was also reflected within otorhinolaryngology. METHODS: Citable research output was analysed from 4 individual years, over a 10-year period (2000-2010), to determine absolute output, geographical mix and article type. RESULTS: The proportion of research output from the UK and Ireland grew 22.8 per cent among the leading global otorhinolaryngology journals, but fell 28.6 per cent among the leading two UK otorhinolaryngology journals. The converse trend was true for the USA and Canada. Output from European and the rest of the world grew among both sets of journals, while Japanese output fell. 'Research' articles remained the most prevalent type. CONCLUSION: These results are encouraging as they refute the fall in UK research output observed by other authors. In the face of growing challenges, it is important to maintain published output so that the fate that has befallen other specialties is not mirrored within UK otorhinolaryngology.