Axis Deviation Research Articles

Physeal-sparing ACL reconstruction provides better knee laxity restoration but similar clinical outcomes to partial transphyseal and complete transphyseal approaches in the pediatric population: a systematic review and meta-analysis.

The aim of this meta-analysis was to evaluate complete transphyseal (CTP), partial transphyseal (PTP), and physeal-sparing (PS) techniques for anterior cruciate ligament (ACL) reconstruction. A systematic literature search of the PubMed, Web of Science, Cochrane Library, and Scopus literature databases was performed on 10.05.2021. All human studies evaluating the outcomes of CTP, PTP, and PS techniques were included. The influence of the selected approach was evaluated in terms of rates of retears, return to previous level of sport competition, IKDC subjective and objective scores, Lysholm score, rate of normal Lachman and pivot-shift tests, limb length discrepancy, and hip-knee angle (HKA) deviation. Risk of bias and quality of evidence were assessed following the Downs and Black checklist. Forty-nine out of 425 retrieved studies (3260 patients) met the inclusion criteria. The results of the meta-analysis comparing CTP, PTP, and PS approaches for ACL reconstruction in the under 20-year-old population showed a significant difference in terms of differential laxity (CTP 1.98mm, PTP 1.69mm, PS 0.22mm, p < 0.001). No significant differences were seen in terms of growth malalignment, rate of normal Lachman and pivot-shift tests, and rate of normal/quasi-normal IKDC objective score. The present meta-analysis found overall similar results with the three ACL reconstruction approaches. The PS technique showed better results in terms of knee laxity than the PTP and CTP approaches, but this did not lead to a significant difference in terms of subjective and objective scores. No clear superiority of one technique over the others was found with respect to re-ruptures, growth disturbances, and axial deviations. While the argument for avoiding growth malalignment does not seem to be a crucial point, the PS technique should be the preferred approach in a young population to ensure knee laxity restoration. Level III.

Partial resection of lateral discoid meniscus changes lower limb axial alignment – A retrospective cohort study

AimThis study aimed to explore the changes in lower limb axial alignment and knee joint function after arthroscopic partial resection of the discoid lateral meniscus. MethodsPreoperative and postoperative full-length weight-bearing radiographs of the lower limb were obtained from a total of 161 patients with lateral menisci tears from September 2018 to September 2020 who underwent partial meniscal resection. The patients were divided into discoid meniscus group (DMG) and ordinary meniscus group (OMG). The measured mechanical axis deviation (MAD), proximal tibia angle (PTA), and distal femoral angle (DFA) in the axial alignment of the lower limb were determined before and after surgery. Knee joint function on the affected side was determined using the International Knee Documentation Committee (IKDC) subjective scale and the Lysholm knee scoring scale before surgery and at one, six, 12, and 24 months after surgery. ResultsFor MAD and DFA, there were statistically significant differences between the preoperative and postoperative findings within each group (P < 0.01); the MAD and DFA were smaller after surgery. The difference in preoperative and postoperative PTA of the DMG was statistically significant (P < 0.01), meaning that the PTA becomes larger after surgery. The differences in preoperative and postoperative PTA of the OMG, preoperative PTA between the two groups, and postoperative PTA between the two groups were not statistically significant (P > 0.05). Intragroup comparisons of the IKDC subjective scale and the Lysholm knee scoring scale before and after surgery revealed significant differences (P < 0.05). ConclusionArthroscopic partial resection of the discoid lateral meniscus is a safe and effective surgical method that can significantly improve knee joint function. Although the axial arrangement of the lower limbs will be slightly changed in the early stage, it will still be within the normal range after surgery in patients with normal lower limb axial alignment. For patients with varus or valgus before surgery, this procedure should be applied with caution.

Interpretation of Telemetry Among Patients With a Left Ventricular Assist Device.

Scenario: This rhythm strip was obtained on a 45-year-old woman with a medical history of coronary artery disease, prior coronary artery bypass graft, heart failure with reduced ejection fraction, and an implanted left ventricular assist device (LVAD). She arrived at the emergency department with fatigue, weakness, nausea, and vomiting. Her LVAD was operating at a 4.3 L/min flow rate, 5600 rotations per minute (rpm) speed, and 4.2 W of power. Assessment of her vital signs in the emergency department showed low-grade fever, tachypnea (respirations, 20/min), and desaturation (oxygen saturation by pulse oximetry, 92%) on room air. She tested positive for COVID-19 and was admitted to the cardiac LVAD floor. The nurse was concerned about an asystole alarm from the bedside monitor.Sinus rhythm at a heart rate of 69/min, rS morphology in lead II most likely due to left axis deviation, and low QRS wave amplitude. Additionally, an electrical baseline artifact related to LVAD oscillations is apparent in both leads.In patients with an LVAD, the electrocardiogram (ECG) provides essential information such as rate and rhythm; however, excessive electrical artifact and low QRS amplitude impair more advanced ECG interpretation and impact the computerized algorithms, leading to many telemetry alarms.The most pronounced ECG change associated with LVAD implantation is electrical artifact. The electrical artifact on the ECG, seen as many short bold spikes, corresponds to the rotational speeds of the LVAD motor: the faster the motor is rotating, the higher the frequency of the electrical artifact. Commercially available LVADs run at different rotational speeds in 3 ranges: 2400-3200 rpm, 5000-6000 rpm, and 8800-10 000 rpm, corresponding to oscillating frequencies of 40-53.3 Hz, 83.3-100 Hz, and 146.7-166.7 Hz, respectively. The ECG filters are imperfect and are not necessarily designed for noise caused by an LVAD. Most ECG telemetry systems have a filter between 0.05 and 40 Hz, as seen on the telemetry strip.This ECG shows low-amplitude QRS complexes in both leads. QRS complexes with low amplitudes occur after LVAD implantation owing to surgical removal of the myocardium to place the motor, as well as ischemia and inflammation from the procedure. The removal of myocardium also alters myocyte depolarization, which may explain the negative QRS complex in lead II suggestive of a left electrical axis deviation but requiring a 12-lead ECG to confirm.In this case, a combination of electrical artifacts from the LVAD motor and low QRS amplitudes is responsible for the asystole alarm. Modern telemetry systems use computerized algorithms to determine heart rate and rhythm on the basis of the detection of the QRS complex and the R-R interval between successive QRS complexes. Common computerized algorithms for heart rate detection use strict QRS amplitude criteria (ie, unidirectional QRS >5 mm in >2 ECG leads). These algorithms work only on whichever leads are being monitored on the central telemetry monitoring system, in this case, leads II and V1. If the amplitude of the QRS complex is too low to be detected or is obscured by electrical artifact, the algorithms fail to detect the rate and rhythm, subsequently causing the asystole alarm. Although more advanced filters are necessary to filter out the electrical artifact caused by the LVAD motor, repositioning the ECG leads to areas with more myocardium not removed during LVAD implantation will also increase QRS complex amplitude.The most important nursing action with an asystole alarm is to assess the patient; this patient was alert and oriented with good perfusion according to Doppler pressure. Remember, a pulse may not be palpable in LVAD patients. As all potentially emergent findings had been ruled out, the underlying causes for the false asystole alarms could be addressed. To reduce the burden of unnecessary asystole alarms, nurses can change the leads being monitored to see if one lead has less artifact and greater QRS amplitude. Nurses can also move the limb electrodes more centrally toward the heart to increase QRS amplitude and should avoid placing the electrodes over bony prominences or edematous areas, which are associated with reduced QRS amplitude.Current American Heart Association practice standards for in-hospital ECG monitoring provide a class I recommendation for continuous bedside ECG monitoring for patients with an LVAD. However, LVADs are associated with a substantial number of false alarms, and research has shown that few patients have truly actionable alarms. Further research and refinement of clinical standards are necessary.

In vitro accuracy of digital and conventional impressions in the partially edentulous maxilla

ObjectivesThis in vitro study compared the dimensional accuracy of conventional impressions (CI) with that of digital impressions (DI) in a partially edentulous maxilla. DIs were made by two intraoral scanners, Omnicam (OC) and Primescan (PS).Materials and methodsCI and both intraoral scanners were used to take 30 impressions of two identical reference models. CIs were poured with type 4 gypsum and the saw-cut models were digitized. The reference models simulated a maxilla with six prepared teeth that accommodated a cross-arch fixed partial denture. Center points of five precision balls and center points at the margin level of each prepared tooth were used to detect changes in dimensions and tooth axis between the reference model and the scans.ResultsFor DI, the largest deviations (176 µm for OC and 122 µm for PS) occurred over the cross-arch. For CI, the largest deviation (118 µm) occurred over the anterior segment. For shorter distances up to a quadrant, DI was superior to CI. For longer scan distances, DI was comparable (2 sextant and anterior segment) or inferior (cross-arch) to CI. Vertical and tooth axis deviations were significantly smaller for CI than for DI (p < 0.001).ConclusionsThe impression method affected the impression accuracy of a partially edentulous maxilla with prepared teeth. DI is recommended for scans up to a quadrant. Larger scan volumes are not yet suitable for fabricating a fixed partial denture because of the high scatter of accuracy values.Clinical relevanceIn contrast to conventional impressions, digital impressions lead to comparable or better results concerning scans up to a quadrant. Consequently, for larger scan volumes, several smaller scans should be performed or, if restoration-related not possible, it is recommended to take conventional impressions.

Case Report: Coexistence of acute post-streptococcal glomerulonephritis and rheumatic heart disease in a 9 years old girl

Background: Group A-haemolytic streptococcus (GAS), one of the most frequent pathogens in pediatric group causing various diseases, from acute pharyngitis (AP) to severe complication such as acute rheumatic fever (ARF) and acute post-streptococcal glomerulonephritis (APSGN). GAS, round gram positive bacteria typically form pairs or chains, was reported causing 1.78 million cases with 500.000 death due to its severe complication in 2005. Case Illustration: A 9-year-old female patient came to emergency unit (ER) complained swollen face and legs since 5 days ago, accompanied by tea color urine and reduced frequency and volume of micturition. Patient also complained shortness of breath which getting worse since yesterday, easily fatigue and dizziness. Moreover her mother also admitted that her daughter had history of migratory joints pain 3 weeks before admission, with sore throat a month ago. Blood pressure was 110/70 mmHg, Ross score was 8. Physical examination showed puffy face, pretibial edema, heart auscultation we heard pansystolic murmur. Chest radiography showed cardiomegaly and congestive pulmonum while laboratory exam showed ASTO 200, urinalysis showed red color, cloudy clarity, protein 1+, erythrocyte 3+, leukocytes 1+, urinary microscopic examination: 30-40 erythrocytes, 8-12 leukocytes, electrocardiography showed sinus tachycardia, prolonged PR interval, right atrial enlargement, right ventricle hypertrophy with right axis deviation. Patient was diagnosed with APSGN, hypertension grade II and heart failure due to rheumatic heart disease. Summary: APSGN and ARF rarely occur together, the coincidence might be due to streptococci with nephritogenic and rheumatogenic same strains. Early detection and treatment of GAS are crucial to prevent complications.

Flat problem to determine the forces of destruction of pieces n disintegrators while being grabbed in thick layer

Purpose. Research on analytical dependences of destructive stresses, acting on a piece of non-isometric shape at quasi-static deformation of a relatively thick layer of rock mass in disintegrators, on parameters of the piece shape, the pieces spatial orientation, also on the relative piece size in layer, taking into consideration the discrete nature of contact force application. Methodology. The flat scheme of a non-isometric shaped piece contacts in a thick layer of rock mass is obtained by composition of the central rectangular piece and the round pieces of average size for the given layer. The distribution of stress components in the layer of loose rock mass is accepted on the basis of the classical theory of elasticity and the theory of loose medium. The geomechanics criterion showing relationship of equivalent destructive stress and ultimate compressive strength of rock is used as a criterion of piece destruction in complex stress state. All force schemes of the piece loading are reduced to three-point bending schemes and two-point shear schemes, both across the long and the short sides of the piece. The most dangerous loading scheme is determined from the analysis of the mentioned schemes for each particular case. Dimensionless parameterization is applied both to specify the geometric parameters of pieces and to analyze the resulting destructive stresses. Findings. Analytical dependences of equivalent destructive stresses for an oblong piece are obtained depending on the piece relative length, the relative piece size in the rock layer, the angle of piece orientation relative to the direction of the maximum main stress and the side thrust coefficient in the layer. It has been set that lamellar pieces, especially those smaller than the average size for the layer, are destroyed mainly from the implementation of bending schemes across the long side, the shape of their fragments is improved by reducing the pieces relative length. Increasing the uniformity of the force field in the working zone of disintegrator also leads to improvement in the shape of fragments. On the other hand, as the shape of the piece approaches the isometric one, as well as when the piece relative size in layer raises, the probability of implementing shear schemes increases and the probability of implementing bending schemes decreases, including with a deterioration in the fragments shape compared to the original piece. At the same time, larger values of destructive stresses for the lamellar smaller pieces are proved analytically compared to the isometric bigger ones, all other things being equal. Originality. The versatility of application of the three-point bending scheme of a non-isometric shaped piece in combination with the two-point scheme of its shear for analysis of its destruction in the thick layer of rock mass is substantiated. For the first time, the dependences of equivalent destructive stresses for the non-isometric piece on its relative length, its relative size in layer, the angle of deviation of the pieces main axis from the main stress direction and on the side thrust coefficient in the layer have been obtained. Practical value. The results obtained allow making reasonable choice of parameters of disintegrators operational parts for destruction of materials in the thick layer, as well as predicting the change in lamellar pieces fraction during disintegration process. They give the possibility to determine key parameters of operational parts for new designs of disintegrators. This creates the basis for the development of calculation techniques for operational parts of modern samples of crushing and grinding equipment.

Intraoperative alignment correlates well with long standing radiographs - The X-ray grid method in complex knee surgery

ObjectiveWhile long standing radiographs (LSR) represent the gold standard for preoperative alignment assessment and planning of lower limb deformity corrections, there is no consensus about the intraoperative alignment assesments (IAC) due to various limitations of the common methods. The present study introduces a radiolucent X-ray grid with integrated radiopaque lines explicitly designed for fluoroscopic IAC and evaluates its reliability in comparsion to the LSR. MethodsPatients with posttaumatic and congenital lower limb deformity surgery and preoperative LSR as well as fluoroscopic IAC utilizing the X-ray grid were retrospectively included to the study. The mechanical axis deviation (MAD) in percentage of the maximum tibial width from the medial to the lateral in comparison between the image pairs was set as primary outcome parameter. Multiple rater and measurements determined intra- and interobserver reliabilit of both imaging methods. In addition, the effects of age, gender, body mass index (BMI), etiology, joint line convergence angle (JLCA), and extent varus or valgus deformity were analysed. ResultsA total of 84 patients were finally included. The mean absolute difference of MAD between the two techniques was 7.2 ± 0.8%. MAD between the LSR and IAC correlated at a high level (R = 0.96, p <0.001). The agreement decreased with increasing extent of deformity (p <0.01) and with higher deviation of JLCA between LSR and IAC (p <0.01). Intra- and interobserver concordance correlation coefficient (CCC) for MAD measurements were 0.99 for both imaging techniques. ConclusionFluoroscopy combined with the X-ray grid method is a valid tool for intraoperative assessment of lower limb alignment in deformity correction surgery, and the correlation between LSR and IAC is better than in other similar techniques described in the literature. However, in case of severe coronal alignment deformity and highly divergent JLCA, the agreement between both imaging techniques decreases significantly.

CALCULATION OF A TRAJECTORY FOR THE MOVEMENT OF A LOAD OF SWINGING SPRING

Pendulum oscillations in the vertical plane of a suspended weightless spring, while maintaining the straightness of its axis, are considered. In the literature, this type of pendulum is called a swinging spring. The required trajectory of the load of the swinging spring is modeled using a computer using the values ​​of the mass of the load, the stiffness of the spring and its length without load. In addition, the initial values ​​of the parameters for initiating oscillations of the oscillating spring are used: the initial angle of deviation of the spring axis from the vertical, the initial rate of change of this angle, as well as the initial parameter of the spring elongation and the initial rate of change of the elongation. The calculations were performed using the Lagrange equation of the second kind. Variants of finding conditionally periodic trajectories of movement of a point load of a swinging spring with a movable attachment point are considered.&#x0D; The relevance of the topic is determined by the need to research and improve new technological schemes of mechanical devices, which include springs. In particular, the study of the conditions for separating from chaotic vibrations of mechanical structure elements and determining the rational values ​​of parameters to ensure periodic trajectories of their vibrations.&#x0D; Calculation options are given to obtain periodic trajectories of cargo movement, when the given parameters are:&#x0D; - the length of the spring without load and its stiffness with an unknown value of the mass of the load;&#x0D; - the length of the spring without load and the value of the mass of the load with an unknown spring stiffness;&#x0D; - the value of the mass of the load and the stiffness of the spring with an unknown length of the spring without load.&#x0D; The results can be used as a paradigm for studying nonlinear coupled systems, as well as for calculating options for mechanical devices, when it is necessary to dissociate themselves from chaotic movements of loads, and provide periodic trajectories of their movement.

Popeye's sign and transthyretin amyloidosis.

A 76-year-old man with a history of cervical open-door laminoplasty for ossification of the posterior longitudinal ligament presented to our hospital with a symptom of exertional dyspnoea. A 12-lead electrocardiogram revealed I-degree atrioventricular block (PQ interval 262 ms), left axis deviation, and complete right bundle branch block (Panel A). A transthoracic echocardiogram indicated left ventricular hypertrophy with a maximum wall thickness of 17 mm and a left ventricular ejection fraction of 61% (Panel B1). Strain echocardiogram using speckled tracking showed marked diminution of global longitudinal strain with apical sparing (Panel B2). Physical examination found subconjunctival hemorrhage in right eye, several purpuric lesions in upper extremities, and a large bulge on his left upper arm when he flexed his arm, so-called Popeye’s sign, indicating a hallmark of biceps tendon rupture (see Supplementary material online, Video S1; Panel C; arrow). A monoclonal component was not detected by serum and urine immune-electrophoresis and free light chain assays. 99mTc-labelled bone scintigraphy showed grade 3 myocardial uptake (Panel D). Eventually, endomyocardial biopsy and genetic sequencing analysis of the transthyretin gene confirmed the patient as a wild-type transthyretin amyloidosis (Panel E). Popeye’s sign is uncommon, but pivotal to diagnose transthyretin amyloidosis.

Accuracy of two orthodontic mini-implant templates in the infrazygomatic crest zone: a prospective cohort study

BackgroundIn the clinic, most computer-aided design and manufacturing orthodontic mini-implant guides are suitable for the position between the tooth roots, and few templates are designed and used for the infrazygomatic crest zone. In this study, we took into account the structure of the infrazygomatic crest and 3D printing technology, developed two kinds of templates, and evaluated their clinical effects.MethodsSeventeen patients who accepted 30 mini-implant insertions in the infrazygomatic crest were selected. According to different implantation methods, three groups were divided. In Groups A and B, the mini-implants were positioned with an A-type or B-type template designed by EXOCAD software. In Group C, the mini-implants were inserted by an experienced orthodontist without any guides. We simulate the bucco-palatal, mesio-distal, and vertical head positions in the Segma implant guide software and measure the deviation from the virtual design position of the mini-implant. The linear deviation of the mini-implant tip and cap and the angular deviation of the long axis of the mini-implant in the bucco-palatal direction, mesio-distal direction, and vertical direction were also measured. The results were statistically analysed by SPSS software.ResultsThe deviations of Group A and Group C’s miniscrew cap in the bucco-palatal direction, Group A and Group B, Group A and Group C’s miniscrew tip in the mesio-distal direction, and Group B and Group C’s miniscrew tip and cap in the vertical direction were statistically significant (P < 0.05). There was a significant difference in the deviations of Group A and Group C’s miniscrew tip and cap in the vertical direction (P < 0.01).ConclusionsIn the vertical direction, the accuracy of implantation with the template is higher than that of the traditional method without the template to avoid piercing the maxillary sinus mucosa in the infrazygomatic crest zone.

MATHEMATICAL MODELING OF THE VEHICLE STABILITY CONTROL OF THE VEHICLE

The paper reviews the scientific and technical literature on the development of electronic stability systems with brake force distribution, which led to the conclusion that for all-terrain wheeled vehicles such systems should be built using inertial navigation sensors - gyroscopes and accelerators. The proposed functional scheme of the stability system with brake force distribution is built using the principles of platformless inertial systems, in which the orientation of the car body relative to the axes of the inertial coordinate system is carried out by calculating in the onboard digital computer quaternion in contrast to Euler angles can be calculated with the required degree of accuracy using a fairly simple algorithm. Algorithms for estimating the current parameters of perturbed motion of the wheel body in the process of its urgent braking, namely, the angle of deviation of the elongated axis of the body from a given direction, angular velocity and lateral displacement of the center of gravity relative to a given trajectory. On the basis of the current estimation of the listed parameters the algorithm of stabilization of the case of the wheeled car in the mode of its urgent braking is formed.

Vector analysis of Contoura Vision for the correction of myopia and myopic astigmatism.

To evaluate the visual outcomes of Contoura Vision (CV) with automatic eye tracking system in eyes with myopia and myopic astigmatism. This prospective study included 160 eyes (80 patients) with moderate myopia and irregular astigmatism between January and August 2018. Subjects were randomly divided into CV group (80 eyes) that underwent CV femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and a control group (80 eyes) that underwent wavefront-optimized FS-LASIK. Visual outcomes and astigmatic vector analysis were evaluated and compared between preoperatively and 3mo postoperatively. Basic details were similar in both groups (P>0.05). At 3mo postoperatively, uncorrected distance visual acuity was 20/16, 20/20, and 20/25 in 24, 76, and 80 eyes of patients in CV group, respectively. The CV group was better in predictability of astigmatism correction at 3mo postoperatively. In CV group, 64 eyes had deviation of astigmatic axis within 15° and 28 eyes had deviation of astigmatic axis within 5°, both were better than those in the control group. The number of eyes with residual astigmatism within 0.5 D were less in CV group (48 eyes) than the control group (40 eyes). Compared with the preoperative, C7 significantly reduced to 0.056±0.030 in CV group at 3mo after the procedure (P<0.05), and were significantly lower than those in the control group (P<0.05). CV with automatic eye tracking system is safe and effective for the correction of myopia and myopic astigmatism.

Study of Dilated Cardiomyopathy in Correlation with Electrocardiography and Echocardiography in Patients less than 40 Years Age

Background: DCM is a disease of the heart muscle, primarily affecting the left ventricle and characterized by ventricular dilatation, impaired systolic function, and reduced myocardial contractility. The present study was conducted to study the electrocardiographic and echocardiographic findings in patients with dilated cardiomyopathy in patients less than 40 years in Varun Arjun Medical College, Banthra, Shahjahanpur over 2 years. Material and methods: The present study was performed in 100 patients (50 males and 50 females) of dilated cardiomyopathy over 2 years. Diagnosis of dilated cardiomyopathy was done by echocardiography. After selection of patients, detail history and complete clinical examination was carried out. ECG and Echocardiography was done among all these patients using standard techniques. Results: The axis was normal in majority (85%). Left axis deviation was seen in 9% and right axis deviation in 6%. The most common abnormality was ventricular ectopics seen in 43% of patients. Sinus tachycardia and left bundle branch blocks were seen in 40% of subjects. Non specific ST-T changes were seen in 27% whereas atrial fibrillation was present in 12%. LVH was seen in 20% and left atrial enlargement in 14% of subjects.

Cardiovascular Abnormalities and Gene Mutations in Children With Noonan Syndrome.

Background: Common cardiac abnormalities in Noonan syndrome (NS) include congenital heart diseases (CHD), pulmonary valve stenosis and hypertrophic cardiomyopathy (HCM). Molecular diagnoses are enabling earlier and more precise diagnosis of patients who have a subtle or atypical presentation. The aims of this study were to investigate genotype-phenotype associations with respect to Noonan syndrome (NS)-associated cardiac abnormalities and catheter or surgery-based interventions conditions. Methods: From January 2019 to December 2021, 22 children with a confirmed molecular diagnosis of NS combined with cardiovascular abnormalities were consecutively enrolled into the current study. A comprehensive review was carried out of echocardiography and electrocardiogram results, second-generation whole-exome sequencing results and catheter or surgery-based interventions conditions. Results: The main manifestations of electrocardiogram abnormalities were QTc prolongation, abnormal Q wave in the precordial lead and limb lead, right ventricular hypertrophy and left or right deviation of the electrical axis. The most commonly detected abnormality was pulmonary valve dysplasia with stenosis, seen in 15 (68.2%) patients, followed by atrial septal defect in 11 (50%) patients. Seven genes (RAF1, RIT1, SOS1, PTPN11, BRAF, SOS2, and LZTR1) were found to contain disease-associated variants. The most commonly observed genetic mutations were PTPN11 (27%) and RAF1 (27%). Each genotype was associated with specific phenotypic findings. RIT1, SOS1, PTPN11, and SOS2 had common echocardiography features characterized by pulmonary valve stenosis, while RAF1 was characterized by HCM. Interestingly, patients with BRAF mutations were not only characterized by HCM, but also by pulmonary valve stenosis. In the cohort there was only one patient carrying a LZTR1 mutation characterized by left ventricle globose dilation. Ten cases underwent catheter or surgery-based interventions. All the operations had immediate results and high success rates. However, some of the cases had adverse outcomes during extended follow-up. Based on the genotype-phenotype associations observed during follow-up, BRAF and RAF1 genotypes seem to be poor prognostic factors, and multiple interventions may be required for NS patients with severe pulmonary stenosis or myectomy for HCM. Conclusions: The identification of causal genes in NS patients has enabled the evaluation of genotype-cardiac phenotype relationships and prognosis of the disease. This may be beneficial for the development of therapeutic approaches.

Navigated, gap-balanced, adjusted mechanical alignment achieves alignment and balancing goals in a very high percentage but with partially non-anatomical resections.

Navigated, gap-balanced adjusted mechanical alignment (AMA) including a 0° varus tibial cut and modification of angles and resections of the femoral cuts to obtain optimal balance accepting minor axis deviations. Objectives of this study were (1) to analyse to what extent AMA achieves the goals for leg alignment and gap balance, and (2) in what percentage non-anatomical cuts are needed to achieve these goals. Out of 1000 total knee arthroplasties (TKA) all varus knees (hip-knee-ankle (HKA) angle < 178°; n = 680) were included. All surgeries were performed as computer assisted surgery (CAS) in AMA technique. CAS data at the end of surgery were analysed with respect to HKA and gap-sizes. All bone cuts were quantified. Depending on the amount of deformity, a subgroup analysis was performed. It was analysed whether the amount of deformity influences the non-anatomical cuts by correlation analysis. AMA reached the goals for postoperative HKA (3° corridor) in 636 cases (93.5%). While extension and flexion gap balance were achieved in more than 653 cases (96%), flexion and extension gap size were equalled in 615 knees (90.4%). The resections of the lateral tibia plateau and distal and posterior medial femoral condyle were anatomical (Tibia: 7.0 ± 1.7mm; medial condyle distal: 7.8 ± 1.4mm; medial posterior: 8.2 ± 1.8mm). The number of non-anatomical resections for those cuts were low; 67 (9.9%); 24 (3.5%); 32 (4.7%). For the medial tibia plateau and the lateral posterior condyle, the cuts were non-anatomical in a high percentage of cases; Tibia: 606 (89.1%), lateral posterior condyle: 398 (58.5%). Moderate but significant correlations were found between resection differences and amount of deformity (medio-lateral: tibia: 0.399; distal femur: 0.310; posterior femur: 0.167). No correlations were found between resection differences and gap values. AMA reaches the intended target for HKA and gap balance in over 612 (90%) of cases and maintains the medial femoral condyle anatomically. Non-anatomical tibial resection causes increased external rotation of the femoral component and by that non-anatomical cut of the posterior lateral condyle. Nonanatomical resections of AMA might be one reason for the persisting high rate of unsatisfied patients after TKA. Anatomical and individual alignment philosophies might help to reduce this rate of dissatisfaction.

Varus morphology and its surgical implication in osteoarthritic knee and total knee arthroplasty

BackgroundKnee varus alignment represents a notorious cause of knee osteoarthritis. It can be caused by tibial deformity, combined tibial–femoral deformity and/or ligament imbalance. Understanding malalignment is crucial in total knee arthroplasty to restore frontal plane neutral mechanical axis. The aim of this study was to determine which factor contributes the most to varus osteoarthritic knee and its related surgical implications in performing a total knee arthroplasty.MethodsWe retrospectively evaluated 140 patients operated for total knee arthroplasty due to a varus knee. Full-leg hip to ankle preoperative X-rays were taken. Radiological parameters recorded were: mechanical axis deviation, hip–knee–ankle, anatomical–mechanical angle, medial neck shaft angle, mechanical lateral distal femoral angle (mLDFA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), lateral proximal femoral angle, lateral distal tibial angle (LDTA), femoral bowing, and length of tibia and femur. We also determined ideals tibial and femoral cuts in mm according to mechanical alignment technique. A R2 was calculated based on the linear regression between the predicted values and the observed data.ResultsThe greatest contributor to arthritic varus (R = 0.444) was MPTA. Minor contributors were mLDFA (R = 0.076), JLCA (R = 0.1554), LDTA (R = 0.065), and femoral bowing (R = 0.049). We recorded an average of 7.6 mm in lateral tibial cut thickness to restore neutral alignment.ConclusionsThe radiological major contributor to osteoarthritic varus knee alignment is related to proximal tibia deformity. As a surgical consequence, during performing total knee arthroplasty, the majority of the correction should therefore be made on tibial cut.

SUCCESSFUL ABLATION IN PEDIATRIC PATIENT WITH SURGICAL REPAIR OF RASTELLI AV CANAL TYPE SECUNDARY TO REFRACTORY VENTRICULAR TACHYCARDIA

TYPE: Late Breaking Case Report TOPIC: Critical Care INTRODUCTION: The management of the patient with post surgical cardiac pathology is complex, frecuently requiring critical care and multidisciplinary interventions to have success. We present a complicated clinical case with complicated ventircular tachycardia treated with ablation of the ventricular arrhythmogenic focus. CASE PRESENTATION: 5-Year-old female with down syndrome and rastelli type “A” av channel weight 18 kg. It is admitted in picu for corrective repair, presenting as a complication of refractory ventricular tachycardia under medical management. With post-surgical echocardiogram without residual defects, lvef of 79%. Extubed in its first 48 post-surgical hours, shows collapse rhythm, beginning amiodarone, lidocaine and even electric cardioversion, ventilatory support and vasoactive without improvement. Cardiac and myocardial profile: troponin i: 300 ckmb: 24 myoglobin: 311, probnp: 2501. ecg: monomorphic ventricular fibrillation, abnormal axis deviation, incomplete right branch block, right ventricular hypetrophy. Undergo catheterism with ablation of arrhythmogenic focus in anterior lateral wall of the left ventricle. DISCUSSION: Transcathether ablation by radio frequency constitutes a curative therapeutic alternative for different cardiac tachyarrhythmias already proven in pediatric patients, it has demonstrated a high effectiveness of the problem resolution. CONCLUSIONS: Radiofrequency ablation is an excellent therapeutic tool in critical medicine for surgical complications such as ventricular tachycardia refractria with ventricular arrithmogenic focus. DISCLOSURE: Nothing to declare. KEYWORD: refractory ventricular tachycardia

Transcatheter Myotomy to Relieve Left Ventricular Outflow Tract Obstruction: The Septal Scoring Along the Midline Endocardium Procedure in Animals.

Left ventricular outflow tract obstruction complicates hypertrophic cardiomyopathy and transcatheter mitral valve replacement. Septal reduction therapies including surgical myectomy and alcohol septal ablation are limited by surgical morbidity or coronary anatomy and high pacemaker rates, respectively. We developed a novel transcatheter procedure, mimicking surgical myotomy, called Septal Scoring Along the Midline Endocardium (SESAME). SESAME was performed in 5 naive pigs and 5 pigs with percutaneous aortic banding-induced left ventricular hypertrophy. Fluoroscopy and intracardiac echocardiography guided the procedures. Coronary guiding catheters and guidewires were used to mechanically enter the basal interventricular septum. Imparting a tip bend to the guidewire enabled intramyocardial navigation with multiple df. The guidewire trajectory determined the geometry of SESAME myotomy. The myocardium was lacerated using transcatheter electrosurgery. Cardiac function and tissue characteristics were assessed by cardiac magnetic resonance at baseline, postprocedure, and at 7- or 30-day follow-up. SESAME myotomy along the intended trajectory was achieved in all animals. The myocardium splayed after laceration, increasing left ventricular outflow tract area (753 to 854 mm2, P=0.008). Two naive pigs developed ventricular septal defects due to excessively deep lacerations in thin baseline septa. No hypertrophy model pig, with increased septal thickness and left ventricular mass compared with naive pigs, developed ventricular septal defects. One animal developed left axis deviation on ECG but no higher conduction block was seen in any animal. Coronary artery branches were intact on angiography with no infarction on cardiac magnetic resonance late gadolinium imaging. Cardiac magnetic resonance chamber volumes, function, flow, and global strain were preserved. No myocardial edema was evident on cardiac magnetic resonance T1 mapping. This preclinical study demonstrated feasibility of SESAME, a novel transcatheter myotomy to relieve left ventricular outflow tract obstruction. This percutaneous procedure using available devices, with a safe surgical precedent, is readily translatable into patients.

Results after skin traction for femur shaft fractures in children below the age of four years

PurposeNonsurgical management has been identified as the treatment of choice for femoral shaft fractures in children below four years of age. For various reasons, the surgical approach has become increasingly popular in recent years. The aim of this study is to report results after vertical skin traction and analyze the benefits of this technique as well as to point out advantages compared with surgery in this age group.MethodsThe authors performed a retrospective data analysis, including all patients with femoral shaft fractures below the age of four who were treated with vertical skin traction at our institution between January 2006 and December 2016.ResultsSkin traction for a femoral shaft fracture was performed for 36 patients (mean age 1.6 years; 1 day–3.5 years). The mean duration of traction was 18.5 days (14–30). Complications included soft tissue affections (n = 5), which all healed spontaneously. Consolidation was observed in all fractures. Initial axial deviations and shortening did not change during traction until consolidation (p > 0.05), and no relevant torsion deformity occurred (p = 0.01). Patients gained full weight-bearing within 12.3 days (7–40) following end of traction. At the final follow-up, after a mean of 29.3 months (12–192), leg-length discrepancy (mean 7.1 mm; 5–20) was found on radiograms in nine cases, and axial deviations (mean 7.7°; 5–25) were documented in seven cases. None of the patients had limitations in daily activities or sports.ConclusionSkin traction is a technically easy, safe, and non-invasive treatment modality for femoral shaft fractures in children below the age of four years. Strong results are obtained benefited from a high potential of growth-related correction, and in principle no anesthesia is needed. A prolonged hospitalization and socio-economic factors maintain the ongoing debate in comparison with the surgical approach.Level of evidenceLevel III, retrospective.

Prognostic value of preoperative electrocardiography in predicting myocardial injury after vascular surgery.

The current European guidelines recommend that a preoperative electrocardiogram (ECG) should be performed routinely in patients scheduled for high-risk surgery. However, the evidence regarding ECG as a predictor of perioperative cardiac complications is weak. To evaluate the association of preoperative ECG with short- and long-term outcomes in patients undergoing high-risk vascular procedures. This was a substudy of the international Vascular events In noncardiac Surgery patIents cohort evaluatioN (VISION) Study and included consecutive patients undergoing vascular procedures in a single tertiary center. In each patient, a preoperative 12-lead ECG was evaluated by two experienced clinicians following the Polish Cardiac Society recommendations. We performed routine perioperative troponin monitoring at five time points (one preoperative and four postoperative measurements) to evaluate whether preoperative ECG abnormalities are associated with myocardial injury after noncardiac surgery (MINS) and 1-year major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, and stroke. The study group comprised 348 patients, 80.5% of whom were male and the median age (interquartile range [IQR]) was 65 (59-72) years. The incidence of MINS and 1-year MACE was 18.7% and 14.4%, respectively. Multivariable analysis showed that none of the predefined ECG abnormalities (ST depression, left axis deviation, atrial fibrillation, and bundle branch block) was associated with the incidence of MINS or 1-year MACE. This study confirmed that preoperative ECG abnormalities are frequent in patients undergoing high-risk vascular surgery. However, we did not find evidence supporting the relation between preoperative ECG abnormalities and postoperative adverse cardiac outcomes in high-risk patients.