Search

Background: Anterior cruciate ligament (ACL) reconstruction (ACLR) has higher failure rates in young active patients returning to sports as compared with older, less active individuals. Augmentation of ACLR with an anterolateral procedure has been shown to reduce failure rates; however, indications for this procedure have yet to be clearly defined. Purpose/Hypothesis: The purpose of this study was to identify predictors of ACL graft failure in high-risk patients and determine key indications for when hamstring ACLR should be augmented by a lateral extra-articular tenodesis (LET). We hypothesized that different preoperative characteristics and surgical variables may be associated with graft failure characterized by asymmetric pivot shift and graft rupture. Study Design: Case-control study; Level of evidence, 3. Methods: Data were obtained from the Stability 1 Study, a multicenter randomized controlled trial of young active patients undergoing autologous hamstring ACLR with or without a LET. We performed 2 multivariable logistic regression analyses, with asymmetric pivot shift and graft rupture as the dependent variables. The following were included as predictors: LET, age, sex, graft diameter, tear chronicity, preoperative high-grade knee laxity, preoperative hyperextension on the contralateral side, medial meniscal repair/excision, lateral meniscal repair/excision, posterior tibial slope angle, and return-to-sports exposure time and level. Results: Of the 618 patients in the Stability 1 Study, 568 with a mean age of 18.8 years (292 female; 51.4%) were included in this analysis. Asymmetric pivot shift occurred in 152 (26.8%) and graft rupture in 43 (7.6%). The addition of a LET (odds ratio [OR], 0.56; 95% CI, 0.37-0.83) and increased graft diameter (OR, 0.62; 95% CI, 0.44-0.87) were significantly associated with lower odds of asymmetric pivot shift. The addition of a LET (OR, 0.40; 95% CI, 0.18-0.91) and older age (OR, 0.83; 95% CI, 0.72-0.96) significantly reduced the odds of graft rupture, while greater tibial slope (OR, 1.15; 95% CI, 1.01-1.32), preoperative high-grade knee laxity (OR, 3.27; 95% CI, 1.45-7.41), and greater exposure time to sport (ie, earlier return to sport) (OR, 1.18; 95% CI, 1.08-1.29) were significantly associated with greater odds of rupture. Conclusion: The addition of a LET and larger graft diameter were significantly associated with reduced odds of asymmetric pivot shift. Adding a LET was protective of graft rupture, while younger age, greater posterior tibial slope, high-grade knee laxity, and earlier return to sport were associated with increased odds of graft rupture. Orthopaedic surgeons should consider supplementing hamstring autograft ACLR with a LET in young active patients with morphological characteristics that make them at high risk of reinjury.

Background: Anterior cruciate ligament (ACL) reconstructions (ACLRs) with graft diameters Purpose: To investigate the differences in clinical outcomes between 4-strand (4S) and 5S hamstring autografts for ACLR in patients who underwent ACLR alone or concomitantly with a lateral extra-articular tenodesis (LET) procedure. Study Design: Cohort study; Level of evidence, 2. Methods: Data from the STABILITY study were analyzed to compare a subgroup of patients undergoing ACLR alone or with a concomitant LET procedure (ACLR + LET) with a minimum graft diameter of 8mm that had either a 4S or 5S hamstring autograft configuration. The primary outcome was clinical failure, a composite of rotatory laxity and/or graft failure. The secondary outcome measures consisted of 2 patient-reported outcome scores (PROs)—namely, the ACL Quality of Life Questionnaire (ACL-QoL) and the International Knee Documentation Committee (IKDC) score at 24 months postoperatively. Results: Of the 618 patients randomized in the STABILITY study, 399 (228 male; 57%) fit the inclusion criteria for this study. Of these, 191 and 208 patients underwent 4S and 5S configurations of hamstring ACLR, respectively, with a minimum graft diameter of 8mm. Both groups had similar characteristics other than differences in anthropometric factors—namely, sex, height, and weight, and Beighton scores. The primary outcomes revealed no difference between the 2 groups in rotatory stability (odds ratio [OR], 1.19; 95% CI, 0.77-1.84; P = .42) or graft failure (OR, 1.13; 95% CI, 0.51-2.50; P = .76). There was no significant difference between the groups in Lachman ( P = .46) and pivot-shift ( P = .53) test results at 24 months postoperatively. The secondary outcomes revealed no differences in the ACL-QoL ( P = .67) and IKDC ( P = .83) scores between the 2 subgroups. Conclusion: At the 24-month follow-up, there were no significant differences in clinical failure rates and PROs in an analysis of patients with 4S and 5S hamstring autografts of ≥8mm diameter for ACLR or ACLR + LET. The 5S hamstring graft configuration is a viable option to produce larger-diameter ACL grafts.

BACKGROUND Vitiligo is a hypopigmentary disease of the skin which is associated with impaired quality of life and depression. In our present study, we evaluated the serum levels of homocysteine, vitamin B12, and folic acid in patients with vitiligo and controls in a tertiary care centre and also their association with the extent and activity of vitiligo. METHODS An analytical cross-sectional study was conducted on 40 patients with vitiligo and 40 controls visiting a tertiary care centre for a period of one year. Detailed history regarding demographic data, history of disease, family history, duration of the disease etc. was recorded. Vitiligo Disease Activity Score (VIDA SCORE) and vitiligo area scoring index (VASI) of each body region was calculated. After explaining the procedure, fasting (5 ml) blood sample was drawn and the levels of homocysteine, vitamin B12, and folic acid were measured. Data was analysed using SPSS software and P value less than 0.05 was considered statistically significant. RESULTS There was statistical significance between vitiligo patients and controls of serum vitamin B12, homocysteine and folic acid (P < 0.05) and there was significant association for males in cases and controls (P < 0.05). CONCLUSIONS Vitiligo is associated with elevated levels of serum homocysteine and decreased levels of vitamin B12 and folic acid. KEY WORDS Vitiligo, Homocysteine, Vitamin B12, Folic Acid, Depigmentation

Neutrophil or polymorphonuclear leukocytes are critical to host defense. They act by migrating (chemotaxis) to site of inflammation or infection, phagocytoze the microorganisms to form phagosome. Reactive Oxygen species and hydrolytic enzymes are released (respiratory burst activity) into this phagosome to kill ingested microorganisms (microbicidal activity). Thyroid hormones are essential for proper differentiation, growth and metabolism of an organism. Increasing evidence indicates that thyroid hormones also play an active role in immunity. Subclinical hypothyroidism is associated with normal thyroid hormone levels with increased thyroid stimulating hormone level. While studies indicate elevated TSH to have some effects on immune functions, there is very little evidence regarding its effect on functional features of neutrophils. In this cross-sectional comparative study, we evaluated the phagocytic, chemotactic, candidacidal, and respiratory burst activity of neutrophils in subclinical hypothyroid and euthyroid subjects. Phagocytosis and metabolic function of the neutrophils was assessed using Nitro-blue tetrazolium test. Chemotaxis, directional movement of the PMNs was measured using the N-Formyl methionyl-leucyl-phenylalanine as chemoattractant. Phagocytic activity was evaluated by exposing leukocytes to candida suspension and counting the number of candida ingested and killed. Microbicidal activity of neutrophils was assessed by the ability of leukocytes to kill Candida albicans in both subclinical hypothyroid and euthyroid subjects. Our study demonstrated that chemotactic and mean phagocytic activity was significantly less in those with subclinical hypothyroidism as compared to euthyroid control group (p value = 0.005 and 0.045 respectively). Respiratory burst activities of both unstimulated & stimulated neutrophils were relatively reduced in subclinical hypothyroidism (p value of 0.08 and 0.07). Candidicidal activity was similar in both groups. We conclude that subclinical hypothyroid individuals having excess of thyroid stimulating hormones are associated altered functional characteristics of neutrophils.

Background: Persistent anterolateral rotatory laxity after anterior cruciate ligament (ACL) reconstruction (ACLR) has been correlated with poor clinical outcomes and graft failure. Hypothesis: We hypothesized that a single-bundle, hamstring ACLR in combination with a lateral extra-articular tenodesis (LET) would reduce the risk of ACLR failure in young, active individuals. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This is a multicenter, prospective, randomized clinical trial comparing a single-bundle, hamstring tendon ACLR with or without LET performed using a strip of iliotibial band. Patients 25 years or younger with an ACL-deficient knee were included and also had to meet at least 2 of the following 3 criteria: (1) grade 2 pivot shift or greater, (2) a desire to return to high-risk/pivoting sports, (3) and generalized ligamentous laxity (GLL). The primary outcome was ACLR clinical failure, a composite measure of rotatory laxity or a graft rupture. Secondary outcome measures included the P4 pain scale, Marx Activity Rating Scale, Knee injury Osteoarthritis and Outcome Score (KOOS), International Knee Documentation Committee score, and ACL Quality of Life Questionnaire. Patients were reviewed at 3, 6, 12, and 24 months postoperatively. Results: A total of 618 patients (297 males; 48%) with a mean age of 18.9 years (range, 14-25 years) were randomized. A total of 436 (87.9%) patients presented preoperatively with high-grade rotatory laxity (grade 2 pivot shift or greater), and 215 (42.1%) were diagnosed as having GLL. There were 18 patients lost to follow-up and 11 who withdrew (~5%). In the ACLR group, 120/298 (40%) patients sustained the primary outcome of clinical failure, compared with 72/291 (25%) in the ACLR+LET group (relative risk reduction [RRR], 0.38; 95% CI, 0.21-0.52; P < .0001). A total of 45 patients experienced graft rupture, 34/298 (11%) in the ACLR group compared with 11/291 (4%) in the ACL+LET group (RRR, 0.67; 95% CI, 0.36-0.83; P < .001). The number needed to treat with LET to prevent 1 patient from graft rupture was 14.3 over the first 2 postoperative years. At 3 months, patients in the ACLR group had less pain as measured by the P4 ( P = .003) and KOOS ( P = .007), with KOOS pain persisting in favor of the ACLR group to 6 months ( P = .02). No clinically important differences in patient-reported outcome measures were found between groups at other time points. The level of sports activity was similar between groups at 2 years after surgery, as measured by the Marx Activity Rating Scale ( P = .11). Conclusion: The addition of LET to a single-bundle hamstring tendon autograft ACLR in young patients at high risk of failure results in a statistically significant, clinically relevant reduction in graft rupture and persistent rotatory laxity at 2 years after surgery. Registration: NCT02018354 ( ClinicalTrials.gov identifier)

Individuals who encounter disasters experience negative consequences across physical, mental and psychosocial domains. Impacts on mental health and psychosocial domains are more common, and last longer than physical health problems. In August 2018, the state of Kerala, India witnessed unprecedented floods that resulted in 483 deaths and significant loss of property and livelihood. Project “PARIRAKSHA” was implemented by the Government of Kerala, to mitigate the long-term psychosocial impact of the disaster. It has been one of the largest comprehensive post-disaster psychosocial project in India till date, aimed to benefit approximately 2 million people across 93 panchayats which experienced severe flooding and loss of life. This paper describes the detailed methodology of this project. In addition, the supplementary material includes the technical manuals that were prepared, and is freely accessible to personnel in disaster affected zones. Counsellors were newly appointed in all the primary health centres in affected panchayats to provide mental health and psychosocial support. Accredited Social Health Activists (community level health workers) undertook home-visits to ensure early case-detection. Medical officers’ in affected areas received booster training regarding pharmacological management of mental health issues. Multi-disciplinary mobile mental health teams were constituted to ensure availability of specialised mental health inputs locally. The project integrated additional mental health resource personnel, into the existing health care system. Existing health care personnel received training to improve competency in dealing with post-disaster psychosocial issues. This framework is expected to ensure early detection and intervention, thus facilitating timely psychosocial recovery of communities impacted by the floods.

Changes in cell surface glycosylation are a key feature of cancer initiation and progression. Sialic acid is a major glycan attached to extracellular proteins and lipids. Altered sialylation in cancer can impact at many levels and may result in improved cancer cell survival and spread. Here we focus on sialic acid-dependent interactions of tumour cells with sialic acid-binding Ig-like lectins (siglecs). These proteins are expressed broadly in the immune system and can modulate cellular functions in diverse ways. We discuss changes in sialylation commonly observed in tumours and the emerging role of siglecs in modulating both host immune responses and tumour responses.