Medium-term Functional Outcomes Research Articles

ASPECT scores of patients with focal intracerebral hemorrhage were correlated with their short- and medium-term functional outcomes

ABSTRACT Purpose The Alberta Stroke Program Early CT Score (ASPECTS) is widely used to guide thrombolytic therapy and predict the functional outcome of patients with acute ischemic stroke (AIS). Whether ASPECTS can predict the functional outcome of patients with intracerebral hemorrhage (ASPECTS-H) remains unclear. Methods Patients with primary intracerebral hemorrhage (ICH) were collected and retrospectively analyzed. ASPECTS-H was assessed at admission. Patients were followed up at 30 days and 90 days after the onset of ICH. Occurrence of death within 90 days after ICH was the primary endpoint. Modified Rankin Scale (mRS) ≥ 3 was considered a poor functional outcome. Results A total of 149 patients met eligibility criteria; 61 (40.9%) had poor functional outcome at 30 days, and 37 (24.8%) had poor functional outcome at 90 days. Using binary logistic regression modeling, we found that a low ASPECTS-H was associated with a poor functional outcome. The risk ratio of a low ASPECTS-H was 2.31 at 30 days (P = 0.000; 95% CI, 1.560–3.421) and 2.711 at 90 days (P = 0.000; 95% CI, 1.677–4.381). The optimal cutoff value of ASPECTS-H to discriminate good and poor 30-day and 90-day outcomes was 7.5 (Sensitivity30-day = 0.636, 1-Specificity30 – day = 0.311; Sensitivity90-day = 0.580, 1-Specificity90-day = 0.270). Conclusions A low ASPECTS-H was an indicator of poor short-term and long-term functional outcomes of ICH.

Cataract surgery in patients with history of uveitis - medium term functional outcomes

Aim: Evaluating the functional outcomes in patients with history of uveitis who previously underwent cataract surgery during 2009-2019, analysis of the best postoperative visual acuity and IOP after first day, one month, 3 months and last postoperative. Material and methods: Comparative/retrospective study which included cataract surgery patients with a history of uveitis evaluated between January 2009 and December 2019 in Iasi, Department of Ophthalmology, “Sf. Spiridon” County Clinical Emergency Hospital. The study included a number of 102 eyes divided into two groups: 59 eyes from 51 patients (25 women and 26 men) the cataract and uveitis group (study group) and 43 cataract eyes (control group). All patients had cataract surgery performed by phacoemulsification and IOL-PC implantation, while the pre- and postoperative evaluation was performed according to a standardized protocol. The database was built in the EXCEL program and was statistically processed with the SPSS 18.0 program. Postoperative follow-up was performed at 1 day, 1 month, 3 months and last postoperative follow up (six month). Results: The average age of patients of the 2 groups was 65 years. In all cases, preoperative topical steroid anti-inflammatory treatment was administered for 1 week and postoperatively, for 6 weeks. General anti-inflammatory steroids (CSR) were administered preoperatively and postoperatively in 9 patients with intermediate or posterior uveitis for 8 weeks. In two cases a capsular tension ring was used to stabilize the bag. One case required ECCE + placement of IOL in the sulcus. Only one case required IOL explantation due to severe inflammation. Among the postoperative complications, the inflammatory glaucoma and recurrent uveitis predominated. Conclusions: Cataract surgery with IOL implantation resulted in improved postoperative visual acuity in patients with cataract and uveitis, which was maintained at the last follow-up. In the immediate postoperative period, both groups had similar functional results.

Perilunate fracture-dislocations: Clinical and functional outcomes at a mean follow-up of 3.3 years

IntroductionPerilunate lesions in the carpus are severe injuries whose functional consequences can limit patients’ ability to regain their pre-injury activity levels. The aim of this study was to evaluate the outcomes of a series of patients who suffered a perilunate fracture-dislocation and to assess their ability to resume their social and professional activities. HypothesisAfter surgical management of this injury, the medium-term functional outcomes will allow patients to return to their pre-injury social and professional activities. Materials and methodsThis was a single center, retrospective study. Included patients were adults who had suffered a perilunate fracture-dislocation that was treated emergently. The clinical and functional assessment consisted of comparing the mobility and grip strength between the injured and contralateral wrists, determining the functional outcome scores and the resumption of social and professional activities. A radiological assessment was done to look for instability of the proximal row of the carpus, nonunion or necrosis of the carpal bones, loss of carpal height, and presence of carpal osteoarthritis. ResultsTen patients were included with a mean follow-up of 39.4 months. The mean flexion/extension arc decreased significantly to 88° (20°–150) which was 55% of the healthy contralateral side (p=0.0026) while the grip strength decreased but not significantly (40.6 Kg vs. healthy side 62.4 Kg, p=0.063). The mean MWS was 58.75 (40-100), the mean PRWE was 32.9 (4–67.5) and the mean QuickDASH was 30.2 (0–77). Six of the ten patients (60%) were able to return to work, although three required occupational reclassifications. Four patients had signs of proximal row instability. There were seven instances of radiocarpal osteoarthritis, two of which were combined with mid-carpal osteoarthritis. DiscussionThis study found shorter range of motion and worse patient-reported outcomes than other published studies, which may be due to the severity of the perilunate fracture-dislocation injuries and the inclusion of polytrauma patients. Nevertheless, the subjective scores were comparable. These injuries have serious consequences on social and professional activities of manual workers. Level of evidenceIV; retrospective study.

Traumatic Glenohumeral Dislocation in Pediatric Patients Is Associated With a High Risk of Recurrent Instability.

The natural history of traumatic glenohumeral dislocation is well-established in young adults, but it is less clear in pediatric patients. We aimed to determine the rate of recurrent instability and medium-term functional outcome following shoulder dislocation in patients aged 14 years or younger. All patients aged 14 years or younger who sustained a glenohumeral dislocation from 2008 to 2019 presenting to our regional health-board were identified. Patients who had subluxations associated with generalized laxity were excluded. Data was collected regarding further dislocations, stabilization surgery, sporting activity and patient-reported outcomes using the Western Ontario Shoulder Instability (WOSI) Index and Quick Disabilities of the Arm, Shoulder, and Hand score. Forty-one patients with a radiologically confirmed traumatic glenohumeral dislocation were suitable for study inclusion [mean age at injury 12.3 y (range: 7.2 to 14.0 y), male sex 29 (70.7%), median 7.9 y follow-up]. The incidence rate of pediatric glenohumeral dislocation was 2.5 cases per 100,000 population (aged 0 to 14 y) per year. Recurrent dislocation occurred in 43.9% (n=18/41) at a median time of 14.7 months postinjury (range: 1 to 54 mo). Skeletal maturity was associated with significantly higher proportion of recurrent instability (immature 6/24 vs. mature 12/17, P=0.01). One in 5 patients required surgical intervention for recurrent instability [mean 8 (range: 1 to 14) dislocations before surgery]. Twenty-eight patients had completed outcome questionnaires. The median modified WOSI score was 87.1% [270 (interquartile range: 65 to 795)] and the median Quick Disabilities of the Arm, Shoulder, and Hand score was 3.4 (interquartile range: 0 to 9.7). Recurrent shoulder instability was significantly associated with poorer WOSI score (unstable 71.4% vs. stable 94.3%, 95% confidence interval of the difference 6.2-36.9, P=0.04). Traumatic glenohumeral dislocation in patients aged 14 years or younger occurs rarely but is not a benign event. One in 2 patients experienced recurrent dislocation and 1 in 5 ultimately underwent surgical stabilization. Level IV.

D-pouch: a modified ileal J-pouch for patients with ulcerative colitis and familial adenomatous polyposis.

Ileal J-pouch anal anastomosis (J-IPAA) is the standard approach for patients requiring restorative proctocolectomy due to familial adenomatous polyposis (FAP) or ulcerative colitis (UC). To obviate the risk of a J-tip leak, we modified the J-pouch with a D-pouch anal anastomosis (D-IPAA) designed to eliminate the ileal stump. The aim of our study was to evaluate the feasibility, safety and medium-term functional outcomes of D-IPAA. A retrospective comparison was made between D-IPAA and J-IPAA constructions after a restorative proctocolectomy. Clinical data were collated between October 2014-March 2018 recording operation duration, pouch construction time, pouch volume, intraoperative estimated blood loss, complication rates, readmissions and cumulative length of hospitalization. Continence was assessed at the final visit with the Wexner Cleveland Clinic Score along with the Cleveland Global Quality of Life (CGQL) scale. A total of 97 patients with FAP (n = 28) and UC (n = 69) who had J-IPAA (n = 54) or D-IPAA (n = 43) after proctocolectomy were identified. Patients were well matched with no differences noted in the intraoperative variables between the J- and D-pouch groups. The D-pouch construction time was shorter than that for a standard J-pouch. There was no difference in major or minor complications between groups.Apouchleak developed in each group: a cutaneous fistula from J tip leak in the J-IPAA groupand a pouch-vaginal fistula from the IPAAthe D-IPAA group. Clinical outcomes (the number of bowel movements) were equivalent in the two groups with the Wexner score significantly improving within each group up to 2.5years and with improvement in the CGQL after surgery. The D-pouch construction is safe and feasible for patients with UC and FAP with good functional outcome over the medium term and the potential to reduce the risk of pouchleaks.

Functional results after operative treatment of talus fractures

Fractures of the talus do not occur frequently, accounting for about 0.1% of all fractures. Failure to achieve anatomic reduction, exponentially increases the risk of postoperative aseptic osteonecrosis and posttraumatic osteoarthritis. The purpose of this study was to evaluate and compare the short-term and medium-term functional outcomes in patients who underwent open reduction and internal fixation of talus fractures. Materials and methods: At the University Clinic for Traumatology in the period between 2017 to 2020, 14 patients with talus fractures were surgically treated. The inclusion and exclusion factors were determined, all patients signed the consent and the study passed the ethics committee. Results: All patients underwent open reduction and internal fixation with screws or reconstructive plate. Follow-up was done on the 14th postoperative day, 1st month, 3rd month and 6th month. At the 6th month follow-up, the functional outcome was tested using the Kitaoka score unified by the American Orthopedic Foot and Ankle Society. This injury is too rare for conclusions to be brought out of and to be compared to larger studies. However, all major studies from reference trauma centers lead to the same conclusions, that the treatment of these fractures is complex Anatomical reduction is mandatory for a better outcome. Conclusion: A protocol for the treatment of posttraumatic osteoarthritis should be introduced, given the high rate of its occurrence despite the satisfactory surgical technique.

Clinical application of the small I‐Loc interlocking nail in 30 feline fractures: A prospective study

To describe medium-term functional outcome after nail osteosynthesis in feline traumatology and report clinically relevant recommendations for I-Loc angle-stable interlocking nail use in cats. Prospective clinical study. Client-owned cats (n = 29). Consecutive cases with femoral, tibial, or humeral fractures were included. Outcome measures included fracture and surgical procedure description, limb alignment, nail size vs body weight (BW), percentage of nail medullary canal (MC) fill, time to limb function at clinical union (CU), and complications. Descriptive statistics were reported and compared with historical data. Bone distribution was 53.3% femora, 30% tibiae, and 16.7% humeri. There were six epimetaphyseal and 24 diaphyseal fractures. Overall, 67% of fractures were comminuted. Open reduction and minimally invasive techniques were used in 73% and 27% of cases, respectively. Seventeen I-Loc 3 (cat mean BW 4.4 ± 2.2 kg) and 13 I-Loc 4 (cat mean BW 5.2 ± 1.2 kg) nails were placed with mean MC fill of ≤50%. Average time to CU was 7.2 weeks. At CU, lameness had resolved or was mild in every cat, and all cats ultimately regained full limb function. No major complications were encountered. Because of improved CU times, excellent functional outcomes, and low complication rate, our results provide evidence that I-Loc nails are safe and effective for feline traumatology. The I-Loc may be advantageous for fixation of epimetaphyseal fractures. Because of feline bone specific dimensional constraints, I-Loc 3 is likely appropriate for all feline humeri and most tibiae, while I-Loc 4 is well sized for feline femora.

Transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA) for ulcerative colitis: medium term functional outcomes in a single centre

BackgroundTransanal dissection of the rectum has been recently introduced for ileal pouch-anal anastomosis (IPAA) in UC showing promising results. Thanks to the precise identification of the rectotomy site the risk of long rectal stump is avoided, and a single stapled anastomosis is performed easily. The aim of this study is to analyze our initial experience of transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA), considering postoperative complications and medium-term functional outcomes.MethodsOur Center has experienced the transanal approach for proctectomy and IPAA since August 2018. All patients underwent Enhanced Recovery After Surgery (ERAS) protocol. Postoperative complications occurring within 30 days after surgery were taken into consideration. Fecal continence, genito-urinary activity and global quality of life at 1 and 6 months after ileostomy reversal have been assessed.ResultsUntil March 2019, 8 patients underwent transanal proctocolectomy and ileal pouch-anal anastomosis (TaIPAA). In all cases the laparoscopic approach was performed during the transabdominal phase; abdominal drainage was never used. At the time of the pouch construction a defunctioning loop ileostomy was created in all patients. Stoma closure was performed in all cases at a median time of 6 months after surgery. Postoperative complications occurred in only one patient, who showed rectal bleeding, not required a re-invertation. There were no cases of anastomotic leakage. Medium-term functional outcomes were determined prospectively using previously validated quality of life questionnaires (Cleveland Global Quality of Life). Fecal incontinence for liquid or solid stool, genitourinary and sexual functions were also investigated, showing comparable results with the literature data.ConclusionsIn our experience, transanal proctocolectomy and ileal pouch-anal anastomosis provided good short and medium-term functional results in UC.

Evaluation of Safety and Medium-Term Functional Outcomes of a Medial Fixed-Bearing Unicompartmental Knee Arthroplasty with Ultra-Highly Cross-Linked Polyethylene.

The primary objective of this study was to evaluate the in vivo safety of a unicompartmental knee arthroplasty design with sequentially annealed cross-linked polyethylene by evaluating reoperation rate, in particular those related to excessive polyethylene wear or breakage. The secondary objective was to examine functional outcomes via standardized questionnaires. This was a 5-year institutional review board-approved prospective single-surgeon case series of the first 152 consecutive patients with symptomatic medial unicompartmental osteoarthritis implanted with a partial knee replacement between May 2010 and December 2014. Study participants were asked to complete the Knee injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthrtis Index (WOMAC) questionnaires at preoperation and 2 to 5 years postoperation. Major complications and all reoperations were recorded and we produced Kaplan-Meier survivorship curves with the end point of revision to TKA. Pre- and postoperative differences for KOOS and WOMAC were evaluated by paired t-tests. The median length of follow-up was 7.2 (0-9.72) years. Seven patients required revision surgery to TKA (4.9% of patients): four with progression of arthritis in other compartments, two for infection, and one for loosening of the femoral component and subsequent progression of pain. There were no failures of polyethylene. Survival of cohort was 99.3 and 97.9% at 2 and 5 years, respectively. Patients significantly improved (p-value < 0.001) between preoperative assessment and at 2 years, with no decline at 5 years postoperation. These preliminary midterm results with this fixed-bearing design and cross-linked polyethylene were encouraging with no catastrophic failures of polyethylene. Patient reported outcomes were significantly improved and revision rates were acceptable and lower than registry reported results.

A comprehensive analysis of medium-term outcomes of open first dorsal compartment release for de Quervain’s syndrome

The primary aim of this study is to describe medium-term functional outcomes following first dorsal compartment decompression using a longitudinal incision in patients with de Quervain’s syndrome. The secondary aims are to describe the improvement in health-related quality of life and patient satisfaction, and to determine the cost-effectiveness of this procedure. Pre- and postoperative QuickDASH, EQ-5D-5 L, and satisfaction scores were collected prospectively over five years. Paired data were available for 36 patients (90% at mean 32 months follow-up). The median QuickDASH score improved significantly from 50 to 9.1 (p < 0.01). Median EQ-5D-5L index scores improved from 0.65 preoperatively to 0.73 (p = 0.03). The satisfaction rate was 97% and there were no cases of superficial radial nerve injury or neuroma. The cost per quality-adjusted life year gained was £356 (€398; $449). First dorsal compartment release using a longitudinal incision results in a significant improvement in function, with high levels of patient satisfaction, and low complication rates. In addition, health economic analysis revealed that this is a cost-effective procedure for the treatment of de Quervain’s syndrome. Level of evidenceIII (cohort study).

Tibial Plateau Fracture: Anatomy, Diagnosis and Management.

Tibial plateau fractures are peri-articular knee fractures of the proximal tibia. The presentation is dependent on the mechanism of injury. The tibial plateau is the bony platform of the distal half of the knee joint, and is made up of a medial and lateral condyle separated by the intercondylar eminence. The presentation of tibial plateau fractures can vary greatly as a result of the bimodal mechanism of injury and patient characteristics. The patient should be assessed for life- and limb-threatening injuries in accordance with British Orthopaedic Association Standards of Trauma guidelines. Imaging is undertaken to understand configuration of the fracture, which is classified by the Schatzker classification. Definitive management of the fracture depends on the severity, ranging from conservative to surgical management. Surgery is required for more severe tibial plateau fractures to restore articular congruity, mechanical alignment, ligamentous stability and to permit early mobilisation. Medium-term functional outcome after tibial plateau fractures is generally excellent when anatomy and stability is restored. At least half of patients return to their original level of physical activity. Surgical management of tibial plateau fractures is not without complication. Risk factors include postoperative arthritis, bicondylar and comminuted fractures, meniscal removal, instability, malalignment and articular incongruity. Tibial plateau fractures account for 1% of all fractures, and typically occur either as a fragility fracture or secondary to a high-energy impact. These latter injuries are associated with extensive soft tissue injury, life- and limb-threatening complications and long-term sequelae. While outcomes are generally good, severe injuries are at higher risk of infection and post-traumatic arthritis requiring knee arthroplasty. This article considers the anatomy, diagnosis and evidence-based management strategies for tibial plateau fracture.

Functional and radiological medium term outcome following supramalleolar osteotomy for asymmetric ankle arthritis- A case series of 33 patients

IntroductionAnkle arthritis is one of the most disabling and painful conditions. Up to 37.5% of ankle arthritis presents as asymmetric arthritis with ankle malalignment. Supramalleolar osteotomy is a joint sparing operation, which aims to realign the ankle joint that will prevent progression of arthritis and relieve patient's symptoms. AimThe aim of this study is to analyse the medium term functional and radiographic outcomes of patients who underwent supramalleolar osteotomy for asymmetric ankle arthritis. Materials and methodsThis is a retrospective outcome study of medium term outcome for 33 patients who underwent Supramalleolar osteotomy for asymmetric ankle arthritis by a single surgeon. We assessed the functional outcome of the patients with AOFAS and VAS score. The radiological parameters measured were Tibial articular surface ankle (TAS), Hind foot alignment angle (HFA) and Talar tilt angle (TT). We used the paired Student's t-test to compare the preoperative and postoperative radiographic measurements, AOFAS and VAS scores. We set the significance level at P < 0.05. ResultsWe had 21 patients who underwent lateral closing wedge osteotomy for varus deformity and 12 patients who underwent medial closing wedge osteotomy for valgus deformity. The mean followup was 72 months [29–73]. The mean AOFAS score significantly improved by 44.82 ± 7.97 (p < 0.0001). The VAS score significantly improved by 5.06 ± 1.41 (p < 0.0001). All the radiological parameters showed statistically significant improvement. All osteotomy united by 8–10 weeks. We had one case of late deep wound infection, which settled down with by metalwork removal. The arthritis progressed in three cases, two patients had fusion and one patient had ankle replacement. We had 90.9% survival rate for our osteotomy at 6 years. ConclusionSupramalleolar osteotomy is an excellent option for patients with asymmetric ankle arthritis with good functional and radiological outcome and good medium term survival rate.

C5/C6 brachial plexus palsy reconstruction using nerve surgery: long-term functional outcomes

IntroductionIn traumatic proximal brachial plexus lesions (i.e., C5/C6), reconstruction of the musculocutaneous, axillary and suprascapular nerves yields satisfactory short- and medium-term functional outcomes. HypothesisEarly functional outcomes after nerve surgery will be maintained in the long-term. MethodsA retrospective analysis was done using the medical records of 29 patients with C5/C6 palsy treated by nerve surgery. Active range of motion and strength at the elbow (i.e., flexion) and shoulder (i.e., flexion, abduction, external rotation with the elbow at the side of the body and with the arm 90° abducted ) were evaluated clinically using a goniometre and the British Medical Research Council grading scale, respectively. ResultsAt a mean follow-up of 46±15 months (25;76), the mean active elbow flexion was 126°±18° (90;150) and the mean strength was 3.8±0.5 (2;4). At the shoulder, mean active flexion, abduction, external rotation with the elbow at the side of the body and with the arm 90° abducted were 109°±39° (0;180), 99°±38° (0;180°), 12°±34° (−80;70) and 3°±21° (−40;50), while mean strength was 3.6±0.8 (0;4), 3.6±0.8 (0;4), 3.4±0.9 (0;4) and 2.5±1.2 (0;4), respectively. DiscussionIn cases of C5/C6 palsy, early nerve surgery yields satisfactory functional outcomes that are maintained over time for elbow flexion and shoulder elevation. However, when the teres minor is not reinnervated, it is difficult to restore satisfactory shoulder external rotation. Level of evidenceIV, Retrospective case study.

One-session bilateral total knee replacement: Late complications and survivorship

IntroductionThe early morbidity and mortality of one-session bilateral total knee arthroplasty (1-session BTKA) has been reported in the medical literature. However, there is less information about the long-term clinical impact of this strategy. The aim of this study was to report on the late complications (>90 days), clinical outcomes (KOOS and new KSS) along with the survivorship of 1-session BTKA. We hypothesised that 1-session BTKA will cause few late complications and that the implant survival will meet the criteria of the National Institute for Health and Clinical Excellence (NICE). MethodsThis single-centre retrospective study analysed a cohort of ASA-1 and ASA-2 patients who underwent 1-session BTKR over an 8-year period (2009 to 2016). The cohort consisted of 116 patients (66% women, 34% men) with mean age at inclusion of 69 years (32–85 years); 22% of patients were ASA-1 and 78% were ASA-2. The implant-related, infection-related or mechanical complications that occurred more than 90 days after the operation, the clinical outcomes (KOOS and New KSS) and radiological outcomes, along with the survivorship were determined during the scheduled follow-up visits at 3 months, 6 months and 1 year postoperative and during the long-term follow-up or during an intercurrent event. ResultsNo patients were lost to follow-up. Fifteen complications occurred (6.5%): four infections, four patellar problems (three cases of clunk syndrome and one of patellofemoral pain), four cases of stiffness, two of unexplained pain and one femoral periprosthetic fracture. Eight patients were readmitted to the hospital (7%); seven were reoperated (3%) and two implants were revised (1%). The functional outcomes (KOOS and New KSS) were significantly improved and 87% of patients were satisfied or very satisfied with this procedure. At a mean follow-up of 5 years, the survivorship estimated using the Kaplan–Meier method was 98.4% (95% CI: 0.933–0.996). ConclusionPerforming 1-session BTKA is a reliable strategy as it produces a low rate of late complications, excellent medium-term functional outcomes and survivorship that meets NICE criteria, thus confirming our hypothesis. Level of evidenceIV, retrospective case series.

Short and medium term functional outcome of hemi-replacement in complex proximal humerus fracture

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Complex proximal humerus fractures are common injuries are common just because of high incidence of road traffic accidents and old age population. The aim of this study was to evaluate the functional outcome in hemi-replacement in complex 3and 4 part of proximal humerus fracture.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This prospective study was conducted in the Department of Orthopaedics, Sir. T. Hospital, Bhavnagar from August 2010 to April 2014. Out of 30 patients 27 turned up for follow up 3 was lost. Functional and clinical assessments using the age and gender specific Constant-Murley score.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Excellent to good outcome as per Constant-Murley score was seen in 16 patients, moderate outcome in 8 patients and poor outcome in 3 patients.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; To spare proximal humerus in younger patients there should be do osteosynthesis procedure with every effort. In the elderly, especially with more complex four-part fractures and fracture dislocations, hemiarthroplasty and reverse total shoulder arthroplasty are specified to decrease complication rates and improve functional outcomes.&lt;/p&gt;

Focal therapy, time to join the multi-disciplinary team discussion?

Organ preserving management is common place in renal cancer, breast cancer and many other solid organ tumours. Current strategies in managing intermediate risk prostate cancer include either whole gland treatment, in the form of radical radiotherapy or radical prostatectomy, or active surveillance. The former is associated with significant post-treatment functional morbidity, whilst the latter associated with the burden of surveillance activity and patient anxiety. Focal therapy would logically fit as a middle ground for suitable patients in whom treatment would be recommended, but where much better functional outcomes may be possible. Ideally this comes without restricting the successful prevention of harm from the cancer. Historically limitations in developing tissue preserving focal therapy strategies in prostate cancer, were due to inaccuracies in tumour characterisation prior to treatment and during follow up. Consequently for example many patients undergoing an active surveillance strategy were being upgraded and upstaged within a short period. Recently high level evidence supporting the use of MRI and targeted biopsies, in particular the PROMIS and PRECISION trials have strengthened clinician confidence in accurate disease characterisation, thus making focal therapy to become a more feasible management option. With improved diagnostic strategies and the publication of reassuring medium term oncological and functional outcomes after focal therapy for intermediate risk prostate cancer, has the time come to require consideration of focal therapy within our multi-disciplinary team (MDT) meetings and with patients? In this review we will consider patient selection and the evidence for the various focal ablation options as well as the surveillance of these patients after treatment. The forthcoming trials to determine comparative effectiveness will be discussed.

Supra-patellar nailing for isolated closed tibial shaft fractures: Medium term functional outcomes from an Academic Level 1 Trauma centre

Aims The aim of this study was to assess functional outcome, at medium-term follow up, in patients undergoing intra-medullary nailing of tibial shaft fractures, using the supra-patellar approach.Materials and methods The study included patients with intra-medullary nailing, for diaphysial tibia fractures, between March 2013 to August 2015. An initial audit compared short-term functional outcomes at 15 months, between the supra and infra-patellar approaches, using a cohort of 20 patients (10 in each group). Subsequently, a larger cohort of 22 patients with supra-patellar nailing, were reviewed for medium term assessment of their functional outcomes at average 60 months (50 – 78 months) and the results between all 3 groups were compared. All patients were assessed using the Kujala and Oxford Knee Scores.Results The mean age of the cohorts was 38 years (18-87years). The mean follow-up was 15 months for the initial audit and 60 months for the medium-term results. The initial audit showed that the supra-patellar group had statistically significantly better Oxford and Kujala scores when compared to infra-patellar group (p < 0.05). At 5 years following supra-patellar nailing, the medium-term cohort showed improved outcome scores compared to the infra-patellar group at 1 year (p < 0.01) but showed no difference with the supra-patellar group at 1 year (p value >0.1).Conclusion Our study suggests that patients undergoing supra-patellar tibial nailing have better outcomes at 15 months compared to traditional infra-patellar nailing and more importantly, they continue to do well even at 5 years, despite perceived risks associated with this technique.

Trends and outcomes of non-traumatic major lower extremity amputations in an Irish tertiary referral hospital.

Data on vascular patients following amputation in Ireland is lacking, limiting capability to plan services. This paper seeks to benchmark survival and rehabilitation outcomes among vascular patients in Ireland following lower extremity amputation (LEA), and compare subgroups of those undergoing transfemoral (TFA) or transtibial amputation (TTA). A review was conducted of all patients who underwent non-traumatic TFA or TTA from 2000 to 2009 in a tertiary vascular surgery centre. Demographics, surgical data, perioperative outcomes, medium-term functional outcomes, and survival were assessed. One hundred and seventy-two patients (2:1 male: female) underwent 192 non-traumatic LEAs. Median age for TFA was 75years and TTA 67 (p= 0.002). A percentage of 36.5% had undergone prior attempts at surgical revascularization, 25% had undergone prior distal amputation or debridement. Thirty-three (17%) required stump revision. Twenty-three (13.2%) died in hospital. Median survival for those who died in hospital was 17days (0-367), versus 17months (2-106) for those who survived to discharge. LEA for vascular pathology has significant morbidity and mortality, with long in-patient stays and short median survival; there is need to focus on improving quality of life in postoperative pathways.

Operative vs Nonoperative Treatment of Distal Radius Fractures in Adults

No consensus has been reached to date regarding the optimal treatment for distal radius fractures. The international rate of operative treatment has been increasing, despite higher costs and limited functional outcome evidence to support this shift. To compare functional, clinical, and radiologic outcomes after operative vs nonoperative treatment of distal radius fractures in adults. The PubMed/MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched from inception to June 15, 2019, for studies comparing operative vs nonoperative treatment of distal radius fractures. Randomized clinical trials (RCTs) and observational studies reporting on the following: acute distal radius fracture with operative treatment (internal or external fixation) vs nonoperative treatment (cast immobilization, splinting, or bracing); patients 18 years or older; and functional outcome. Studies in a language other than English or reporting treatment for refracture were excluded. Data extraction was performed independently by 2 reviewers. Effect estimates were pooled using random-effects models and presented as risk ratios (RRs) or mean differences (MDs) with 95% CIs. Data were analyzed in September 2019. The primary outcome measures included medium-term functional outcome measured with the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the overall complication rate after operative and nonoperative treatment. A total of 23 unique studies were included, consisting of 8 RCTs and 15 observational studies, that described 2254 unique patients. Among the studies that presented sex data, 1769 patients were women [80.6%]. Overall weighted mean age was 67 [range, 22-90] years). The RCTs included 656 patients (29.1%); observational studies, 1598 patients (70.9%). The overall pooled effect estimates the showed a significant improvement in medium-term (≤1 year) DASH score after operative treatment compared with nonoperative treatment (MD, -5.22 [95% CI, -8.87 to -1.57]; P = .005; I2 = 84%). No difference in complication rate was observed (RR, 1.03 [95% CI, 0.69-1.55]; P = .87; I2 = 62%). A significant improvement in grip strength was noted after operative treatment, measured in kilograms (MD, 2.73 [95% CI, 0.15-5.32]; P = .04; I2 = 79%) and as a percentage of the unaffected side (MD, 8.21 [95% CI, 2.26-14.15]; P = .007; I2 = 76%). No improvement in medium-term DASH score was found in the subgroup of studies that only included patients 60 years or older (MD, -0.98 [95% CI, -3.52 to 1.57]; P = .45; I2 = 34%]), compared with a larger improvement in medium-term DASH score after operative treatment in the other studies that included patients 18 years or older (MD, -7.50 [95% CI, -12.40 to -2.60]; P = .003; I2 = 77%); the difference between these subgroups was statically significant (test for subgroup differences, P = .02). This meta-analysis suggests that operative treatment of distal radius fractures improves the medium-term DASH score and grip strength compared with nonoperative treatment in adults, with no difference in overall complication rate. The findings suggest that operative treatment might be more effective and have a greater effect on the health and well-being of younger, nonelderly patients.

Functional outcome after severe childhood traumatic brain injury: Results of the TGE prospective longitudinal study.

Childhood severe traumatic brain injury (TBI) is a leading cause of long-lasting acquired disability, but little is known about functional outcome. We aimed to 1) study clinical recovery and functional outcome over 24 months after severe childhood TBI, 2) identify early sociodemographic and severity factors influencing outcome, and 3) examine the clinical utility of the Pediatric Injury Functional Outcome Scale (PIFOS) to assess functional outcome. Children (0-15 years) consecutively admitted in a trauma centre after accidental severe TBI over 3 years were included in a prospective longitudinal study (Traumatisme Grave de l'Enfant cohort). We measured clinical/neurological recovery, functional status (Pediatric Injury Functional Outcome Scale, [PIFOS]), overall disability (pediatric Glasgow Outcome Scale [GOS-Peds]) as well as intellectual ability (Wechsler scales) and educational outcome (mainstream school vs special education) of survivors at 1, 3, 12 and 24 months post-injury. For 45 children (aged 3 to 15 years at injury), functional impairments were severe within the first 3 months. Despite the initial rapid clinical recovery and significant improvement over the first year, substantial alterations persisted for most children at 12 months post-TBI, with no significant improvement up to 2 years. Up to 80% of children still had moderate or severe overall disability (GOS-Peds) at 24 months. The severity of functional impairments (PIFOS) at 12 and 24 months was mostly related to socio-emotional, cognitive and physical impairments, and was significantly correlated with clinical/neurological deficits and cognitive (intellectual, executive) and behavioural disorders. Initial TBI severity was the main prognostic factor associated with functional status over the first 2 years post-injury. Our results confirm the significant impact of severe childhood TBI on short- and medium-term functional outcomes and overall disability. All patients should benefit from systematic follow-up. The PIFOS appeared to be an accurate and reliable tool to assess functional impairment evolution and clinically meaningful outcomes over the first 2 years post-injury.