RESUMEN

The aim of the present study was to investigate the outcomes of wrist arthrodesis with simultaneous soft tissue rebalancing of the digits in the spastic wrist. In 43 wrists (40 patients) the surgical goals, patient selection, procedures and outcomes were assessed. Preoperatively, mean passive extension was to 44° below neutral and only two patients had volitional control. Postoperatively, 33 and 10 cases reported excellent and good outcomes, respectively. A mean Goal Attainment Score of 62.4 indicated better than expected outcomes. In total, 37 hands required simultaneous finger rebalancing: 24 underwent tendon transfers and 13 surgical releases. A total of 12 thumbs required tendon transfers, three soft tissue releases and five metacarpophalangeal joint stabilization. Ten patients experienced complications, most commonly wound problems and implant failure, predominantly observed in patients with severe wrist and elbow contractures. In conclusion, wrist arthrodesis with simultaneous soft tissue rebalancing of the digits offers a viable approach in patients with severe spasticity. Cautious patient selection and consideration of potential complications are crucial for good outcomes.Level of evidence: IV.

Asunto(s)

RESUMEN

Background: We performed a retrospective review of patients undergoing surgery for elbow spasticity. We present our findings and expected outcomes according to degree of elbow fixed flexion contracture. Methods: Data collected included age, Modified Ashworth Score, pre and post-operative range of motion, indications for surgery and the Goal Attainment Score. Contracture severity was classified into five groups based on goniometric measurements. Surgical procedures were categorised into three groups. Results: A total of 114 elbows underwent surgical release. The mean age at surgery was 18.5 years and the mean follow-up was 20 months. Preoperatively, the median Modified Ashworth Score was 2 and the mean contracture was 68° (35° fixed and 33° dynamic). The median number of structures released was 3 (range: 1-6). Surgical procedures were classified as biceps sparing (27%), biceps lengthening (53%) and extended releases (18%). Mean improvement in extension was 59°, and the mean improvement in Goal Attainment Score was 36 (mean attainment score 62). The mean residual contracture was 9°. Patient satisfaction was high with over 90% of surgical indications met. Discussion: Contracture severity of the spastic elbow can be categorised by degree of fixed flexion deformity and therefore treatment can be allocated accordingly.

RESUMEN

There are no planets intermediate in size between Earth and Neptune in our Solar System, yet these objects are found around a substantial fraction of other stars1. Population statistics show that close-in planets in this size range bifurcate into two classes on the basis of their radii2,3. It is proposed that the group with larger radii (referred to as 'sub-Neptunes') is distinguished by having hydrogen-dominated atmospheres that are a few percent of the total mass of the planets4. GJ 1214b is an archetype sub-Neptune that has been observed extensively using transmission spectroscopy to test this hypothesis5-14. However, the measured spectra are featureless, and thus inconclusive, due to the presence of high-altitude aerosols in the planet's atmosphere. Here we report a spectroscopic thermal phase curve of GJ 1214b obtained with the James Webb Space Telescope (JWST) in the mid-infrared. The dayside and nightside spectra (average brightness temperatures of 553 ± 9 and 437 ± 19 K, respectively) each show more than 3σ evidence of absorption features, with H2O as the most likely cause in both. The measured global thermal emission implies that GJ 1214b's Bond albedo is 0.51 ± 0.06. Comparison between the spectroscopic phase curve data and three-dimensional models of GJ 1214b reveal a planet with a high metallicity atmosphere blanketed by a thick and highly reflective layer of clouds or haze.

RESUMEN

Close-in giant exoplanets with temperatures greater than 2,000 K ('ultra-hot Jupiters') have been the subject of extensive efforts to determine their atmospheric properties using thermal emission measurements from the Hubble Space Telescope (HST) and Spitzer Space Telescope1-3. However, previous studies have yielded inconsistent results because the small sizes of the spectral features and the limited information content of the data resulted in high sensitivity to the varying assumptions made in the treatment of instrument systematics and the atmospheric retrieval analysis3-12. Here we present a dayside thermal emission spectrum of the ultra-hot Jupiter WASP-18b obtained with the NIRISS13 instrument on the JWST. The data span 0.85 to 2.85 µm in wavelength at an average resolving power of 400 and exhibit minimal systematics. The spectrum shows three water emission features (at >6σ confidence) and evidence for optical opacity, possibly attributable to H-, TiO and VO (combined significance of 3.8σ). Models that fit the data require a thermal inversion, molecular dissociation as predicted by chemical equilibrium, a solar heavy-element abundance ('metallicity', [Formula: see text] times solar) and a carbon-to-oxygen (C/O) ratio less than unity. The data also yield a dayside brightness temperature map, which shows a peak in temperature near the substellar point that decreases steeply and symmetrically with longitude towards the terminators.

RESUMEN

This case report describes a traumatic elbow dislocation in a patient with congenital radioulnar synostosis. It discusses the difficulties and potential complications of managing this complicated injury. Congenital radioulnar synostosis (CRUS) is a rare elbow pathology that is characterised by the abnormal fusion of the proximal radius and ulna bones at the elbow. This case report describes a traumatic posterior elbow dislocation in a 30 year old patient with CRUS. Patients with CRUS are more susceptible to elbow dislocation due to laxity of stabilising ligaments and increased stiffness of the forearm leading to greater force transfer to the elbow. CRUS should be considered in patients with difficult to reduce elbow dislocations.

RESUMEN

INTRODUCTION: Internal fixation of displaced middle-third clavicle fractures is a widely used treatment but is frequently associated with post-operative complications. The aim of this study is to investigate whether or not using a skin incision along Langer's lines, as opposed to a traditional transverse incision, reduces complications. METHODS: We retrospectively reviewed data on 108 patients who underwent open reduction and internal fixation of mid-shaft clavicle fractures between 2014 and 2018. Either an oblique incision along Langer's lines or a transverse incision was used according to surgeon's preference. A pre-contoured diaphyseal locking plate was used in all cases. We collected data on fracture classification, minor complications (irritation from plate, chest wall numbness, superficial wound infection) and major complications (irritation from plate necessitating metalwork removal, periprosthetic fracture, deep infection, neurovascular injury and non-union). Statistical analysis was performed using multivariant regression analysis and Fisher's exact tests. RESULTS: Fifty-seven patients underwent fixation using the oblique incision and 51 via the transverse incision. Age, gender and fracture pattern in the two groups were comparable. There were 14 minor and 6 major complications in the oblique group. In the transverse group, there were 16 minor and 5 major complications. The major complication rate was 10.5% in the oblique group and 9.8% in the transverse group. The overall major complication rate was 10.2%. No statistically significant difference in the rate of complications between the two groups was identified. CONCLUSION: Based on our data, an incision following Langer's lines does not reduce the rate of complications following fixation of displaced middle-third clavicle fractures.

Asunto(s)

RESUMEN

The ability to obtain binding free energies from molecular simulation techniques provides a valuable support to the interpretation and design of experiments. Among all methods available, the most widely used equilibrium free energy methods range from highly accurate and computationally expensive perturbation theory-based methods, such as free energy perturbation (FEP), or thermodynamic integration (TI), through end-point methods, such as molecular mechanics with generalized Born and surface area solvation (MM/GBSA) or MM/PBSA, when the Poisson-Boltzmann method is used instead of GB, and linear interaction energy (LIE) methods, to scoring functions, which are relatively simple empirical functions widely used as part of molecular docking protocols. Because the use of FEP and TI approaches is restricted to cases where the perturbation leading from an initial to final state is negligible or minimal, their application to cases where large conformational changes are involved between bound and unbound states is rather complex, if not prohibitive in terms of convergence. Here we describe a protocol that involves the use of extensive conformational sampling through molecular dynamics (MD) in combination with end-point methods (MM/GB(PB)SA) with an additional quasi-harmonic entropy component, for the calculation of the relative binding free energies of highly flexible, or intrinsically disordered, peptides to a structured receptor.

Asunto(s)

RESUMEN

AIM: This study aimed to determine if the ratio of cortical thickness to shaft diameter of the humerus, as measured on a simple anterior-posterior shoulder radiograph, is associated with surgical fixation failure. PATIENTS AND METHODS: 64 consecutive fractures in 63 patients (mean age 66.1 years, range 35-90) operated with surgical fixation between March 2011 and July 2014 using PERI-LOC locking plate and screws (Smith and Nephew, UK) were identified. Predictors of bone quality were measured from preoperative radiographs, including ratio of the medial cortex to shaft diameter (medial cortical ratio, MCR). Loss of fixation (displacement, screw cut out, or change in neck-shaft angle >4 degrees) was determined on follow-up radiographs. RESULTS: Loss of fixation occurred in 14 patients (21.9%) during the follow up. Patients were older in the failure group 72.8 vs. 64.2 years (p=0.007). The MCR was significantly lower in patients with failed fixation 0.170 vs 0.202, p=0.019. Loss of fixation is three times more likely in patients with a MCR <0.16 (41% vs. 14%, p=0.015). Increased fracture parts led to increased failure rate (p=0.0005). CONCLUSION: Medial cortex ratio is significantly associated with loss of surgical fixation and may prove to be a useful adjunct for clinical decision making in patients with proximal humeral fractures.

Asunto(s)

RESUMEN

BACKGROUND: Shoulder pain after a cerebrovascular accident or traumatic brain injury is a common but often under-recognized problem. It is due to a number of causes including inferior subluxation, spasticity, adhesive capsulitis, and heterotopic ossification. Many of these are amenable to surgical intervention. METHODS: Literature review of current evidence. RESULTS: This article shows that there are multiple treatment options in this group of patients, and it is important to understand these as clinicians in delivering quality care to this complex group of patients. CONCLUSION: This review article describes how careful clinical assessment can differentiate between causes of shoulder pain and guide best management.

Asunto(s)

RESUMEN

Sixty-one shoulders in 57 adolescents underwent primary arthroscopic shoulder stabilization for labral tears sustained during contact sports (all Stanmore type 1). Mean follow-up was 22 months, mean age 16.8 (13-18) years. Postoperatively, the median subjective improvement was 90%, median VAS pain was 0 and mean Oxford Instability Score was 26.8. Sixty-one per cent returned to preinjury sporting level. A higher than expected proportion reported recurrent dislocation, with 15% followed up for 1 year and 31% for 4 years. Of these 11 requiring further surgery, 90% of redislocations occurred while playing rugby. Sex, type of sport, hyperlaxity and tear morphology were not significantly related to recurrence. Adolescents are at high risk for recurrence following arthroscopic stabilization. Patients should be counselled for the higher recurrence rate and consideration should be made for other aetiological factors such as returning to contact sports and joint hyperlaxity.

Asunto(s)

RESUMEN

PURPOSE: The aim of this study was to determine the prevalence and pattern of upper limb involvement in children with cerebral palsy (CP), how this relates to function and how well these problems are recognised and treated. METHODS: One hundred consecutive patients with CP attending non-hand-related clinics were assessed. Function was assessed according to the Gross Motor Functional Classification System (GMFCS), the Manual Ability Classification System (MACS) and the ABILHAND-Kids system, and correlated to age and pattern of upper limb involvement. Patients were examined for contractures in the shoulder, elbow, wrist and hand. Concerns about the appearance of the hand were also assessed in older children. RESULTS: Overall, 83 % of patients had upper limb involvement, 36 % had a demonstrable contracture and 69 % had reduced hand control. The most common contracture patterns were the thumb in palm with clasp hand, shoulder adduction with internal rotation and wrist flexion with pronation. The thumb in palm with clasp hand pattern was associated with the greatest functional disability, followed by wrist flexion with pronation. Single contractures such as elbow flexion caused significant disability, whereas swan-neck contractures were, by far, less debilitating. Children aged 12 years and older had more concerns about the appearance of their hand. The ABILHAND score was strongly correlated to both the GMFCS and the MACS score. CONCLUSION: Different patterns of upper limb involvement exist in CP and some have a significant impact on function and cause cosmetic concerns that should not be underestimated, particularly in older children.

RESUMEN

Obstetric brachial plexus injuries are common, with an incidence of 0.42 per 1000 live births in the UK, and with 25% of patients being left with permanent disability without intervention. The shoulder is the most commonly affected joint and, as a result of the subsequent imbalance of musculature, the abnormal deforming forces cause dysplasia of the glenohumeral joint. In the growing child, this presents with changing pattern of pathology, which requires a multidisciplinary approach and a broad range of treatment modalities to optimize function.

Asunto(s)

RESUMEN

BACKGROUND: A series of infection control measures were introduced at the University Hospitals of Leicester NHS Trust in 2006-2007 to reduce the incidence of Clostridium difficile infection. AIM: The aim of this study was to assess the impact of these measures on the incidence of C. difficile and to record the associated mortality in hip fracture patients. PATIENTS AND METHODS: A case matched comparison of mortality was conducted between C. difficile positive patients and C. difficile negative patients admitted with a hip fracture between 1st January 2003 and 30th September 2007. An interrupted time series analysis was performed to assess the effect of various infection control policies on the incidence of C. difficile infection. RESULTS: The interrupted time series analysis showed that the only effective measure was changing antimicrobial prophylaxis to Co-amoxiclav in May 2007. This reduced the incidence of C. difficile from 7.1 to 1.5% (p<0.001). Six-month mortality in C. difficile positive patients was 71% 1 year before introduction of a diarrhoea treatment policy and 65% 1 year after (p=0.5) indicating treatment was ineffective. A matched cohort comparison over a 57-month period from January 2003 to September 2007 showed that the 6-month mortality was 67% in 170 C. difficile positive patients, 27% in 3247 C. difficile negative patients and 29% in the 170 C. difficile negative matched patients. CONCLUSION: This 38% excess mortality indicated that C. difficile increased mortality and did not simply colonise the sickest patients. Changing prophylaxis to Co-amoxiclav was the most effective measure. This reduced the incidence of C. difficile by 80% and thus reduced mortality by prevention rather than cure.

Asunto(s)