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Introduction: Open tendoachilles injuries are rare and associated with significant soft tissues complications. The objective of the present study was to assess the clinical outcome and safety of a simple and minimally invasive technique, with a goal to assess if it may help minimise flap and wound related complications in open tendoachilles injuries. Materials and methods: This prospective study of four years duration included 20 patients with open tendoachilles injuries managed with a simple minimally invasive tunnel technique. The primary outcome variable was occurrence of a major soft tissue complication. The secondary outcome variables included functional outcome measured using AOFAS Ankle hind foot score, re-rupture of tendoachilles and need for revision surgery. Results: None of the patients in the present series developed a serious soft tissue complication. Based upon the AOFAS hind foot scoring system, good to excellent outcome was achieved in 19 (95%) patients. All the patients were able to perform tip toe walking at six months post-surgery. None of the patients had a re-rupture of the tendoachilles and no patient needed a revision surgery. The complications encountered include thickening of the tendon at the repair site (15%), superficial wound infection (5%), stitch granuloma (5%) and hypertrophic scar (5%). Conclusion: This technique seems to be promising in reducing the soft tissue complications associated with the surgical management of open tendoachilles injuries. Most patients had a good final clinical outcome. The technique is safe, simple and reproducible. However, further randomised control studies with a larger sample size assessing the technique are recommended.

Mohsin Faysal Butt,1,2 Louise Salmon,3 Fahira Mulamehic,4 Avelyn Hixon,2 Abdul Rehman Moodambail,5 Sandy Gupta2 1Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AJ, UK; 2Cardiology Department, Whipps Cross University Hospital, Barts Health NHS Trust, London E11 1NR, UK; 3Refugee Assessment and Guidance Unit (RAGU), London Metropolitan University, London, UK; 4British Refugee Council, London, UK; 5Paediatrics Department, Newham University Hospital, Barts Health NHS Trust, London E13 8SL, UKCorrespondence: Mohsin Faysal ButtBarts and the London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AJ, UKEmail mohsinfaysalbutt@doctors.org.ukPurpose: Refugee healthcare professionals (RHPs) may encounter several barriers to employment upon moving to the UK, such as conversion of professional qualifications and a lack of familiarity with the recruitment process. The Building Bridges Programme (BBP) is a London-based multi-agency collaboration which helps refugee healthcare professionals seek employment in the UK National Health Service (NHS).Methods: We have kept an electronic database of all RHPs who have participated in the BBP from October 2009 to March 2018. Data collected include gender, language spoken, country of initial medical qualification, immigration status, religion, ethnicity and professional work experience. In this paper, we focus on employment outcomes and determine the proportion (%) of RHPs joining the BBP who enter employment in the NHS.Results: Between October 2009 and March 2018, the BBP supported 372 refugee doctors, 42 refugee pharmacists, 69 refugee dentists, 25 refugee biomedical scientists, 4 refugee physiotherapists and 83 refugee nurses. The following are the results for the RHPs who settled into a registered NHS position appropriate to their (home country) professional qualifications: 98/372 (26%) doctors, 4/42 (10%), pharmacists, 17/69 (25%) dentists, 1/25 (9%) biomedical scientists, 1/4 (25%) physiotherapists and 2/83 (2%) nurses. The following are the results for the RHPs who settled in associated healthcare profession positions: 109/372 (29%) doctors, 16/42 (38%) pharmacists, 12/69 (17%) dentists, 10/25 (40%) biomedical scientists, 3/4 (75%) physiotherapists and 34/83 (41%) nurses.Conclusion: The BBP provides a useful model that is transferable to other countries. Future studies assessing the utility of such programmes should ensure that the long-term employment outcomes of RHPs are more closely tracked. A key limitation of this paper is the absence of a control group of participants who did not join the BPP, which would help to conclusively demonstrate whether participants who joined our programme had a statistically significant improvement in employment outcomes.Keywords: refugees, curriculum development, education, employment

Mohsin Faysal Butt,1 Kabir Matwala,2 Rakin Rownak Choudhury1 1Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AT, UK; 2Department of Medicine, Imperial College London, London SW7 2AZ, UK We read with interest the study by Bilello et al,1 which assessed the utility of a cardiac case-based simulation scenario to investigate the physical examination performance of fourth-year medical students. As medical students, mannequins have granted us useful practical skills, but we recognize that they do not command the same feeling of dread nor the adrenaline surge that comes with managing a real-life cardiac arrest. This is a unique study design, and we respect the authors’ description of its limitations, but for the educator who wishes to utilize mannequins in a similar investigation, we propose slight alterations to the study protocol. Authors’ reply Leslie A Bilello,1 Nicole M Dubosh,1 Jason J Lewis,1 Matthew M Hall,1 Jonathan Fisher,2 Edward A Ullman,1 1Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; 2Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ, USA We appreciate the Letter to the Editor from Butt et al regarding our study and recent publication entitled, “Fourth-year medical students do not perform a focused physical examination during a case-based simulation scenario.” This study sought to assess the physical examination performance of medical students in the simulation laboratory during a high-acuity cardiac case that later evolved into a cardiac arrest. View the original paper by Bilello and colleagues.

Aims: To evaluate the effectiveness and safety of anterior tension band wiring technique using two cannulated cancellous screws in patients with transverse (AO34-C1) or transverse with mildly comminuted (AO34-C2) patellar fractures. Materials and Methods: This is a prospective study of 25 patients with transverse fracture or transverse fracture with mildly comminuted patella fractures. All the patients were treated with open reduction and internal fixation using two parallel cannulated screws and 18G stainless steel wire as per the tension band principle. Results: There were eighteen males (72%) and seven females (28%). The age group ranged from 24 to 58 years, with mean age of 38 years. The most common mode of injury was fall (72%) followed by road traffic accident (20%) and violent quadriceps contraction (8%). Transverse fracture was present in 60% and transverse fracture with mild comminution in 40% of patients. Mean time to achieve union was 10.7 weeks (range 8-12 weeks). Mean ROM at three months was 113.8 degree (90-130) and at final follow up this improved to 125.4 degrees (range 100-140). There was one case of knee stiffness and no case of implant failure was observed. Patients were evaluated using Bostman scoring, the mean score at three months being 26.04 which improved to 27.36 at the end of final follow up at one year. Conclusion: Cannulated cancellous screws with anterior tension band wiring is a safe, reliable and reproducible method in management of transverse patellar fractures, with less chances of implant failure and soft tissue irritation.

Purpose. To analyze the outcome of the management of pediatric elbow trauma referred to our hospital after initial intervention by traditional bone setters. Method. Retrospective study of 73 patients, presenting to the hospital with a complication attributable to the initial mismanagement of their injuries. Results. The mode of presentation was directly related to the type of initial intervention on the basis of which we were able to quantify bone setters into two groups. The first group using a rather rough method of trauma treatment involving the application of tight local bandages, massage and manipulation and a second group having a relatively less rough approach, applying splints to the injured extremity without tight bandages and manipulation. The result of treatment of these injuries was determined by the delay in presentation and the type of injury. Conclusion. This study highlights the importance of dealing with the unchecked and unsupervised practice of bone setting in the developing world. We believe that training these people on the pattern of traditional birth attendants can at the very least lower the occurrence, if not entirely eliminate the problem of mismanaged trauma in this part of the world. [ABSTRACT FROM AUTHOR]

Polytrauma cases in mass disasters present several challenges to the orthopaedic surgeon. Delayed referral, multisystem involvement and the requirement to manage coexisting injuries by interhospital transfer often make infection an inevitable risk. 28 patients with polytrauma were studied after being referred after being recovered from the debris of their homes in the Kashmir earthquake. All patients were referred more than 24h after sustaining their injuries. The lower limb fractures were fixed by external fixators in all these cases before interhospital transfer for the management of their co existing injuries. Return referral to the orthopaedic facility occurred after an average of 25 days. All cases were converted to Ilizarov fixation. The results bear out the fact that the Ilizarov method may be well suited for conversion osteosynthesis of lower limb fractures in polytrauma cases. [ABSTRACT FROM AUTHOR]

Transition services-programs that support adolescents and young adults (AYAs) as they move from a child-centered to a more autonomous, adult-orientated healthcare system-have been associated with improved short- and long-term healthcare outcomes. Unfortunately, there is a paucity of evidence exploring transition services within the neurogastroenterology and motility (NGM) field. The overall aim of this article, endorsed by the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility, is to promote a discussion about the role of transition services for patients with NGM disorders. The AYAs addressed herein are those who have: (a) a ROME positive disorder of gut-brain interaction (DGBI), (b) a primary or secondary motility disorder (including those with motility disorders that have been surgically managed), or (c) an artificial feeding requirement (parenteral or enteral tube feeding) to manage malnutrition secondary to categories (a) or (b). The issues explored in this position paper include the specific physical and psychological healthcare needs of patients with NGM disorders; key healthcare professionals who should form part of a secondary care NGM transition service; the triadic relationship between healthcare professionals, caregivers, and patients; approaches to selecting patients who may benefit most from transition care; methods to assess transition readiness; and strategies with which to facilitate transfer of care between healthcare professionals. Key areas for future research are also addressed, including the construction of NGM-specific transition readiness questionnaires, tools to assess post-transfer healthcare outcomes, and educational programs to train healthcare professionals about transition care in NGM., (© 2024 The Author(s). Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Current biomarkers do not adequately predict the behaviour of neuroendocrine neoplasms (NENs). This study assessed the NETest, a multianalyte blood biomarker, in patients with small intestinal NENs (Si-NENs). We studied two patient groups: Group 1: metastatic Si-NENs ( n = 102) and Group 2: post-operatively disease-free according to 68Ga-DOTATATE PET ( n = 16). NETest scores were ≤20% (normal), 21-40% (low), 41-79% (intermediate), or ≥80% (high). Overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method. Univariate and multivariate analyses were performed using the Cox proportional hazards model. In Group 1, the median NETest score was 40% (IQR: 33.3-46.7%). The NETest value (HR: 1.032, 95% CI: 1.003-1.062, p = 0.033) and high-risk NETest category (HR: 10.5, 95% CI: 1.35-81.7, p = 0.025) were independent predictors of PFS, along with presence of lung metastases, CgA levels > 10 × ULN, and tumour growth rate (TGR). Independent predictors of OS were the NETest value (HR: 1.035, 95% CI: 1.005-1.066, p = 0.024) and high-risk NETest category (HR: 15.2, 95% CI: 1.52-151, p = 0.02), along with presence of lung metastases and CgA levels > 10 × ULN. In Group 2, ROC analysis identified an AUC of 0.909 (95% CI: 0.75-0.100) for prediction of local or metastatic recurrence. Blood NETest scores were associated with PFS and OS in patients with metastatic Si-NENs, along with TGR, CgA > 10 × ULN, and presence of lung metastases.

Disorders of gut-brain interaction (DGBI), previously referred to as functional gastrointestinal disorders, affect 40.3% of adults in the general population and are diagnosed in 34.9% of new adult referrals to secondary care gastroenterology services. Despite their high prevalence, studies published in this issue of Neurogastroenterology and Motility by investigators based in Germany, the UK, and the USA demonstrate a mismatch between the clinical burden of DGBI and their representation in medical school and postgraduate curricula. This review outlines the salient findings of these studies and explores why and how negative perceptions toward DGBI exist, including factors related to misinformation and internalized stigma. The authors propose a selection of strategies to ameliorate physicians' attitudes toward and knowledge of neurogastroenterology and motility including linking trainees with dedicated clinician mentors with an interest in motility, exposing trainees to expert patients who can enhance empathy, extending Balint groups into gastroenterology training, and offering motility apprenticeships in specialist units. Urgent improvements to medical school and postgraduate curricula are required to ensure the longevity of this subspecialty field in gastroenterology, and to ensure the needs of a sizeable proportion of gastroenterology patients are appropriately met., (© 2023 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Background: Acute-on-chronic liver failure (ACLF) is a clinically and pathophysiologically distinct condition from acutely decompensated cirrhosis and is characterised by systemic inflammation, extrahepatic organ failure, and high short-term mortality., Aims: To provide a narrative review of the diagnostic criteria, prognosis, epidemiology, and general management principles of ACLF. Four specific interventions that are explored in detail are intravenous albumin, extracorporeal liver assist devices, granulocyte-colony stimulating factor, and liver transplantation., Methods: We searched PubMed and Cochrane databases for articles published up to July 2023., Results: Approximately 35% of hospital inpatients with decompensated cirrhosis have ACLF. There is significant heterogeneity in the criteria used to diagnose ACLF; different definitions identify different phenotypes with varying mortality. Criteria established by the European Association for the Study of the Liver were developed in prospective patient cohorts and are, to-date, the most well validated internationally. Systemic haemodynamic instability, renal dysfunction, coagulopathy, neurological dysfunction, and respiratory failure are key considerations when managing ACLF in the intensive care unit. Apart from liver transplantation, there are no accepted evidence-based treatments for ACLF, but several different approaches are under investigation., Conclusion: The recognition of ACLF as a distinct entity from acutely decompensated cirrhosis has allowed for better patient stratification in clinical settings, facilitating earlier engagement with the intensive care unit and liver transplantation teams. Research priorities over the next decade should focus on exploring novel treatment strategies with a particular focus on which, when, and how patients with ACLF should be treated., (© 2023 The Authors. Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd.)

AIS is a heterogeneous 3D spinal deformity with Cobb angle ≥10°. It affects children in the age group of 10-16 years globally with 2-3% prevalence and significant female predominance. The exact etiology of AIS is not known however, it is supposed to be associated with factors such as anthropometric, metabolic, neuromuscular abnormalities and genetics., Objectives: To determine the prevalence of AIS and association of anthropometric factors with AIS in the studied population group., Methodology: Scoliosis screening of 9,500 individuals was carried out at different educational institutions of Jammu region in Jammu and Kashmir, India using a scoliosis-meter. The subjects were later examined radiologically., Results: In population of the region, AIS was most prevalent among all types of scoliosis with overall prevalence of 0.61%. The prevalence was observed to be lower in females (0.31%) than males (0.88%). Based on angle of trunk rotation (ATR), lumbar curves were more prevalent than thoracic curves. Average Cobb angle in males and females were 24.9° and 22.6°, respectively. BMI showed significant association with AIS in the age group of 12-16 years ( P value =0.028). Furthermore, height was significantly associated with AIS in the overall screened population ( P -value =0.029)., Conclusions: The AIS patients in the Jammu region of India have unique clinical features. In contrast to the global prevalence data, the prevalence of AIS in females in the region was less in comparison to males. Based on epidemiological literature and our findings, we hypothesized that genetic factors might be a major contributor in the AIS pathogenesis along with other confounding factors such as height, BMI, ethnicity, etc., Competing Interests: None., (AJTR Copyright © 2022.)

In this article, I detail my rapport-building trial and error exercise and outline why addressing a patient's occupation at the beginning of a consultation worked during my history taking. Context permitting, addressing occupation can be useful when setting the tone and rhythm of a conversation, helping to focus explanations on the back of a patient's everyday experiences, and allowing a history-taker to address a patient's ideas, concerns and expectations more comfortably. Broaching occupation can also be a useful way to extrapolate information about disease risk factors and baseline understanding from the start. Whatever the rapport-building technique used, self-awareness seems to be a critical skill in this exercise, and an approach used with one patient may not necessarily be useful with another., (© Royal College of Physicians 2021. All rights reserved.)

Unilateral pleural effusions are uncommonly reported in patients with SARS-CoV-2 pneumonitis. Herein, we report a case of a 42-year-old woman who presented to hospital with worsening dyspnoea on a background of a 2-week history of typical SARS-CoV-2 symptoms. On admission to the emergency department, the patient was severely hypoxic and hypotensive. A chest radiograph demonstrated a large left-sided pleural effusion with associated contralateral mediastinal shift (tension hydrothorax) and typical SARS-CoV-2 changes within the right lung. She was treated with thoracocentesis in which 2 L of serosanguinous, lymphocyte-rich fluid was drained from the left lung pleura. Following incubation, the pleural aspirate sample tested positive for Mycobacterium tuberculosis This case demonstrates the need to exclude non-SARS-CoV-2-related causes of pleural effusions, particularly when patients present in an atypical manner, that is, with tension hydrothorax. Given the non-specific symptomatology of SARS-CoV-2 pneumonitis, this case illustrates the importance of excluding other causes of respiratory distress., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pakistan ranks amongst the top 20 highest burden tuberculosis (TB) countries in the world. Approximately 369,548 cases of TB (all forms) were notified in 2018, with an estimated incidence of 265 per 100,000 people per year. In other settings, TB has been shown to demonstrate seasonal variation, with higher incidence in the spring/summer months and lower incidence in the autumn/winter; the amplitude of seasonal variation has also been reported to be higher with increasing distance from the equator., Methods: Notifications of newly-diagnosed pulmonary and extrapulmonary TB cases were obtained for 139 districts in Pakistan from 2011 to 2017. Data were provided by the Pakistan National TB Control Programme, Islamabad, Pakistan. Statistical analyses were performed to determine whether there was seasonal variation in TB notifications in Pakistan; whether the amplitude of seasonal variation in TB notifications varied according to latitude; whether the amplitude of seasonal variation of TB in Pakistan differed between extrapulmonary TB vs. pulmonary TB. To assess the quarterly seasonality of TB, we used the X-13-ARIMA-SEATS seasonal adjustment programme from the United States Census Bureau. The mean difference and corresponding 95% confidence intervals of seasonal amplitudes between different latitudes and clinical phenotype of TB were estimated using linear regression., Results: TB notifications were highest in quarter 2, and lowest in quarter 4. The mean amplitude of seasonal variation was 25.5% (95% CI 25.0 to 25.9%). The mean seasonal amplitude of TB notifications from latitude 24.5°N- < 26.5°N was 29.5% (95% CI 29.3 to 29.7%) whilst the mean seasonal amplitude of TB notifications from latitude 34.5°N - < 36.5°N was 21.7% (95% CI 19.6 to 23.9%). The mean seasonal amplitude of TB notifications across Pakistan between latitudes 24.5°N to 36.5°N reached statistically significant difference (p < 0.001). The amplitude of seasonal variation was greater for extrapulmonary TB (mean seasonal amplitude: 32.6, 95% CI 21.4 to 21.8%) vs. smear positive pulmonary TB mean seasonal amplitude: 21.6, 95% CI 32.1 to 33.1%), p < 0.001., Conclusion: TB notifications in Pakistan exhibit seasonal variation with a peak in quarter 2 (April-June) and trough in quarter 4 (October-December). The amplitude of seasonality decreases with increasing latitude, and is more pronounced for extrapulmonary than for pulmonary TB.

The array of end organ innervations of the vagus nerve, coupled with increased basic science evidence, has led to vagus nerve stimulation (VNS) being explored as a management option in a number of clinical disorders, such as heart failure, migraine and inflammatory bowel disease. Both invasive (surgically implanted) and non-invasive (transcutaneous) techniques of VNS exist. Transcutaneous VNS (tVNS) delivery systems rely on the cutaneous distribution of vagal afferents, either at the external ear (auricular branch of the vagus nerve) or at the neck (cervical branch of the vagus nerve), thus obviating the need for surgical implantation of a VNS delivery device and facilitating further investigations across a wide range of uses. The concept of electrically stimulating the auricular branch of the vagus nerve (ABVN), which provides somatosensory innervation to several aspects of the external ear, is relatively more recent compared with cervical VNS; thus, there is a relative paucity of literature surrounding its operation and functionality. Despite the increasing body of research exploring the therapeutic uses of auricular transcutaneous VNS (tVNS), a comprehensive review of the cutaneous, intracranial and central distribution of ABVN fibres has not been conducted to date. A review of the literature exploring the neuroanatomical basis of this neuromodulatory therapy is therefore timely. Our review article explores the neuroanatomy of the ABVN with reference to (1) clinical surveys examining Arnold's reflex, (2) cadaveric studies, (3) fMRI studies, (4) electrophysiological studies, (5) acupuncture studies, (6) retrograde tracing studies and (7) studies measuring changes in autonomic (cardiovascular) parameters in response to auricular tVNS. We also provide an overview of the fibre composition of the ABVN and the effects of auricular tVNS on the central nervous system. Cadaveric studies, of which a limited number exist in the literature, would be the 'gold-standard' approach to studying the cutaneous map of the ABVN; thus, there is a need for more such studies to be conducted. Functional magnetic resonance imaging (fMRI) represents a useful surrogate modality for discerning the auricular sites most likely innervated by the ABVN and the most promising locations for auricular tVNS. However, given the heterogeneity in the results of such investigations and the various limitations of using fMRI, the current literature lacks a clear consensus on the auricular sites that are most densely innervated by the ABVN and whether the brain regions secondarily activated by electrical auricular tVNS depend on specific parameters. At present, it is reasonable to surmise that the concha and inner tragus are suitable locations for vagal modulation. Given the therapeutic potential of auricular tVNS, there remains a need for the cutaneous map of the ABVN to be further refined and the effects of various stimulation parameters and stimulation sites to be determined., (© 2019 Anatomical Society.)

Study Design: Prospective clinical study., Purpose: The present study aimed to examine the neurological recovery pattern in cervical spondylotic myelopathy (CSM) after anterior cervical decompression and compare it with the existing reports in the literature., Overview of Literature: Neurological recovery and regression of myelopathy symptoms is an important factor that determines the outcomes of surgical decompression. The present findings contribute to the literature on the pattern of neurological recovery and patient prognosis with respect to the resolution of myelopathy symptoms after surgery., Methods: This prospective study was conducted in Government Medical College in Jammu, North India between November 2012 and October 2014, a total of 30 consecutive patients with CSM were included and treated with anterior decompression and stabilization. They were prospectively followed up for 1 year and were evaluated for their neurological recovery pattern. The postoperative outcome was evaluated using the modified Japanese Orthopaedic Association (mJOA) score. The recovery rate was calculated using Hirabayashi's method. The JOA score was assessed before the operation and postoperatively at 1 week, 2 weeks, 1 month, 3 months, 4 months, 6 months, and 1 year., Results: The postoperative mJOA score was 0 in the 1st month, 12.90±3.57 in the 3rd month, 13.50±3.55 in the 4th month, 14.63±3.62 in the 6th month, and 14.9±3.24 at the final follow-up of 1 year. The average recovery rate during the 1st month followup was 0%, and that during the 3rd month follow-up was 12.91% with a range of 0%-50%. The average recovery rate during the 4th month was 32.5%, with a range of 0%-60%, while that during the 6th month was 72.83%, with a range of 0%-100%. The average recovery rate during the final follow-up of 1 year was 54.3%., Conclusions: Neurological recovery after surgical decompression starts from the 3rd postoperative month and progresses until the 6th postoperative month; thereafter, it gradually plateaus over the subsequent 6 months until it steadies. Symptom duration is an important factor that requires consideration while determining postoperative neurological recovery.

Aims and methodThe Tower Hamlets Crisis House (voluntary sector), in partnership with the local home treatment team, offers a brief residential alternative to psychiatric hospital admission. Here, we review clinician-reported (Health of the Nation Outcome Scales; HoNOS) and patient-reported (DIALOG) outcome scores collected from successive admissions between June 2015 and December 2016, to assess the effectiveness of the service model. We identified 153 successive admissions, and of these, 85 (55.6%) and 91 (59.5%) patients completed both admission and discharge DIALOG and HoNOS questionnaires, respectively. We analysed ten out of twelve HoNOS domains and eight patient-reported outcome measure DIALOG domains. RESULTS: We found a statistically significant improvement in nine out of ten domains of HoNOS and three out of eight domains of DIALOG.Clinical implicationsA partnership between a home treatment team and crisis house can result in positive outcomes for patients, as determined by both clinicians and patients.Declaration of interestNone.

Introduction: Open reduction and internal fixation using plates is the gold standard for the treatment of displaced forearm bone fractures in adults. The ulna being subcutaneous throughout has a constant approach. However, the radius is approached from either the dorsal or the volar side. Both the dorsal and the volar approaches to the radial shaft involve meticulous dissection and preservation of important neurovascular structures. The posterior interosseus nerve is at risk in the dorsal approach and the radial artery and its branches in the volar approach. Dissection of these structures also adds to the operative time. The possibility of a third alternate approach was perceived, which could decrease the potential risks of the conventional approaches., Patients and Methods: Sixteen patients with radial shaft fractures in the middle third were operated on using the lateral approach: 6 of them had isolated radius fracture and 10 had both-bone fractures. There were 13 males and three females with a mean age of 37.9 years. Limited contact dynamic compression plate or locking compression plate of 3.5 mm was used to fix all fractures. All patients were operated on within 36 h of injury and then followed up till union. Union was assessed using serial radiographs and functional outcome using Anderson et al.'s criteria. The final functional outcome was assessed at an average 6 months after surgery and the results compiled., Results: The mean operative time in isolated radius fractures was 37.5 min and that for plating of both bones was 80.7 min. Primary bone grafting of the radius was done in one case and secondary bone grafting in another patient with delayed union of the radius. Union was achieved in all cases at a mean time of 17.25 weeks. The functional outcome was excellent in 10 patients, satisfactory in 5 patients, and unsatisfactory in 1 patient., Conclusion: The lateral approach is a simple approach with low operative complexity and complications. We found this approach to provide a reliably good exposure of the middle third of the radius, enabling lateral plating without complications.

Introduction: Use of autologous fat grafting (AFG) for breast reconstructive surgery is gaining acceptance, but concerns regarding its efficacy and safety remain. We present a protocol for a systematic review that aims to update the findings since our previous systematic review on a number of outcomes of AFG., Methods: The systematic review has been registered a priori (UIN: reviewregistry308). All study designs, including randomised controlled trials, cohort studies, case-controlled studies and case reports/series, reporting original data, on women undergoing AFG for breast reconstruction following mastectomy or breast conserving surgery, will be included. Six categorical outcomes will be assessed: oncological; clinical; aesthetic/functional; patient-reported; process; and radiological.The search strategy will be devised to investigate 'fat grafting and breast reconstruction'. Electronic databases will be searched, 01 April 2014 to 21 August 2017: PubMed, MEDLINE®, EMBASE, SCOPUS, CINAHL, PsychINFO, SciELO, The Cochrane Library, including the Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effect (DARE), the Cochrane Methodology Register, Health Technology Assessment Database, the NHS Economic Evaluation Databases and Cochrane Groups, ClinicalTrials.gov, Current Controlled Trials Database, the World Health Organisation (WHO) International Clinical Trials Registry Platform, UpToDate.com, NHS Evidence and the York Centre for Reviews and Dissemination. Grey literature will be searched. Two trained, independent teams will screen all titles and abstracts, and relevant full texts, for eligibility. Data will be extracted under standardised extraction fields into a preformatted database., Ethics and Dissemination: The systematic review will be published in a peer-reviewed journal and presented at national and international meetings within fields of plastic, reconstructive and aesthetic surgery, and surgical oncology. The work will be disseminated electronically and in print. Brief reports of the review and findings will be disseminated to interested parties through email and direct communication. The review aims to guide healthcare practice and policy., (© 2017 The Authors.)

Introduction: Fracture fixation has become advanced with the advent of new and custom metal implants for each type of bone/fracture. After union though, the implant ceases to be important and may be removed. Routine removal is advocated by some and opposed by others. Nevertheless, some patients require removal of the hardware because of various implant-related problems. Our study was aimed at identifying the most common causes for implant removal., Objective: To investigate the common indications of orthopedic implant removal surgeries., Methods: Adult patients admitted for implant removal in our department were included in the study. They were operated in the next OT list. They were then followed for an average 4 months for resolutions of symptoms or appearance of new problems., Results: A total of 83 patients were studied. 71 of them were males. The mean age was 38 years. The reasons for removal of implants were found to lie in five categories: Pain/discomfort/prominent hardware, infected hardware, implant failure, elective (patient's insistence), and other reasons. Overall, the most frequently removed implants in our series were distal tibial/ankle plates (14.45% of implants removed), femoral intramedullary (IM) nails (13.25%), olecranon wires and plates (12.04%), and tibial IM nails and patellar tension band wirings (9.53% each)., Discussion and Conclusion: The clinical indications of implant removal are not well established, and few definitive data exist to guide whether routine implant removal is appropriate. Symptomatic hardware frequently needs removal. We found that pain and implant prominence (mechanical symptoms) are the most common indications. Infection is the next most common, followed by hardware failure. Other indications are implant failure, bone resorption due to excessive stress shielding and patient's will. Removal is, however, not an easy surgery, and several factors such as bone ingrowth and wear of the implant may make its removal difficult.

Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.

Objectives: Diabetes mellitus (DM), is affecting an ever increasing number of people worldwide. Diabetes is associated with several musculoskeletal manifestations. These may involve, the upper as well as the lower limb. We conducted this study to find out the prevalence of musculoskeletal problems in type 2 diabetics in the Kashmiri population., Methodology: The study was conducted on 403 patients with diabetes and 300 controls. All patients underwent screening for any musculoskeletal abnormalities. The patients with musculoskeletal abnormalities were further assessed to find the exact diagnosis according to predefined criteria., Results: The hand was involved in 80 patients [19.8%] in the diabetic group and 15 (5%) patients of the control group. The elbow was affected in 56 patients [14%] in the diabetic group and 24 patients [5.9%] in the non-diabetic group. The shoulder involvement was diagnosed in 61 patients [15%] on the diabetic cohort and 15 patients in the non-diabetic cohort. All the upper limb figures showed a statistically significant difference i.e. P value <0.05., Conclusion: The prevalence of musculoskeletal complications in type 2 diabetics in Kashmir is quite high.

Percutaneous tenotomy of the Achilles tendon is an integral part of the Ponseti technique of clubfoot correction. Although originally described by Ponseti as an office procedure that was performed under local anaesthesia, serious neurovascular complications that include iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation have been reported. We describe a new tenotomy technique, the posterior to anterior controlled technique, that may decrease the possibility of neurovascular damage, does not require exposure of the Achilles tendon and can be performed as an office procedure under local anaesthesia.

Tuberculosis of the talus is a rare condition, and the diagnosis can be difficult to make because of inconclusive laboratory and ancillary testing. In such cases, accurate diagnosis and appropriate treatment may require the use of a transmalleolar osteotomy to gain access to the involved portion of the talar body. In the case described in this article, a transmalleolar approach was used to gain access to a lytic lesion of the talar body so as to obtain microbiological and histopathological specimens for diagnostic purposes, and to thoroughly debride the lesion. After 6 years of postsurgical follow-up, the patient was leading a normal life with a full range of ankle and subtalar motion. The rarity of the diagnosis, and the use of the transmalleolar approach to a lytic and likely infected lesion in the body of the talus, makes this case worthy of public discussion., (Copyright © 2011 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: A Monteggia facture dislocation is not an uncommon injury, and the diagnosis can often be missed. Long-term follow-up of untreated Monteggia fracture dislocations reveals development of premature arthritis, pain, instability, and loss of pronation and supination. Methods involving annular ligament reconstruction require post-operative immobilization and use of transcapitellar pinning for maintenance of reduction, and thus a delay in rehabilitation. The literature reports satisfactory results with methods that involve ulnar osteotomy and open reduction of the radial head without annular ligament reconstruction. We used the Ilizarov method in two cases with neglected Monteggia fracture dislocations to stably reduce the radial head without open reduction and annular ligament reconstruction., Case Presentation: We report two cases of neglected Monteggia fracture dislocation, in two Kashmiri boys aged four and six years. Using ulnar osteotomy with distraction osteogenesis, we were able to relocate the radial head gradually and maintain the reduction without a requirement for open reduction and annular ligament reconstruction., Conclusion: Distraction lengthening and hyperangulation in different planes by use of the Ilizarov technique effectively reduces the radial head without open reduction and annular ligament reconstruction.

Penetrating injuries of the foot are a common presenting complaint in the emergency department. The residents of the underdeveloped world are especially prone to suffer such injuries as barefoot walking is still common. However, a relatively common injury that occurs in the shod feet is the "Nail-Slipper injury". A metal nail penetrates through the rubber sole of the footwear introducing the rubber piece into the soft tissue of the foot. As the nail is removed the piece remains behind often leading to delayed manifestations. This article describes the various delayed manifestations of this injury. A leading question for the antecedent injury of this kind should be asked from all patients with such presentations, especially in the urban setting.

Purpose: To determine the impact of a substantial delay in providing surgical treatment on the final outcome in transcervical femoral neck fractures in children., Methods: Data on all pediatric patients with transcervical fractures of the femoral neck that were fixed by reduction and internal fixation after a delay of ≥7 days in our department between 2000 and 2008 were collected both retrospectively and prospectively., Results: The medical records of 14 patients (15 fractures) were analyzed. The results after an average of 43 months of follow-up showed that the complication and avascular necrosis rates were higher in cases in which treatment had been delayed compared to those in comparable fractures that had been treated promptly after the event in other series. Nine of the 15 fractures had developed avascular necrosis at final follow-up. Overall, there were four excellent, three good, and eight poor results (based on the Ratliff criteria)., Conclusions: Children whose transcervical fractures of the femoral neck were surgically treated after a delay of 1 week or longer had a high avascular necrosis rate and a relatively poor outcome. Reduction and internal fixation as the initial treatment should be implemented shortly after injury in order to enhance treatment outcome.

Purpose: To describe a technique that preserves anterior and posterior alternate ledges in a closing wedge osteotomy., Methods: Five patients aged 14 to 19 years underwent a closing wedge osteotomy for genu valgum in 8 limbs using a reciprocating ledge technique. A unicortical wedge of bone was removed, with the anterior and posterior cortices spared. The anterior cortex at the proximal level and the posterior cortex at the distal level were cut through. With a wobbling action, the osteotomy site was rotated, and the distal fragment externally rotated. Manual force was applied to close the osteotomy site ensuring overlapping of the reciprocal ledges. The distal fragment was translated laterally to prevent club deformity. The osteotomy site was held with one or 2 staples. Stability was tested by flexion and extension of knee., Results: All 8 limbs attained bone union within 12 weeks, and full range of motion within a mean of 13 (range, 12-15) weeks. The mean correction of the tibiofemoral angle was 13 degrees. At a mean follow-up of 12 months, all patients were pain-free and none developed club deformity., Conclusion: Sparing reciprocal ledges in a closing wedge osteotomy for genu valgum may increase stability in the flexion-extension axis, enable early range-of-motion exercises, and facilitate early bone union.

Background: The distal third of the tibia is unique in the sense that it has a minimal muscle cover and consequently the blood supply is easily compromised after a fracture in this area. Infected non union in this area provides a challenge to the orthopaedic surgeon. These difficulties are especially profound in the geriatric age group., Material and Methods: 12 cases with an infected non union of the distal third of the tibia were managed with acute docking over a distance of up to 2.5 cms. The age of these patients was more than 55 years., Results: The average shortening at final follow up was 1.8 cms. The bone results were assessed according to the protocol laid down by the association for the study and application of the method of Ilizarov. Accordingly we had 3 excellent, 8 good and 1 fair result. The functional result was calculated as per the Ilizarov criteria [1]. On this basis we had 7 excellent, 4 good and 1 fair result., Conclusion: The acute docking modality is applicable to the distal tibia in such situations even in the geriatric population with predictable results.

This is a retrospective review of paediatric elbow trauma, which was initially treated by bonesetters and subsequently reported to the hospital for management. This paper describes the pattern of trauma and the complications of unscientific management. The report also recommends a basic training program for the bonesetters so as to make them aware of the potential complications involved in managing paediatric elbow trauma.

Background: To assess the pattern of mass casualty incidents managed at our hospital over the last eight years, and evolve a differentiating classification based on this pattern. A combination of retrospective and prospective assessment was made., Material and Methods: All patients receiving injuries in mass casualty incidents and managed at our hospital. Patients with an injury severity score above 9. Management of injuries as per the trauma management protocol. Classification based on the data collected during the study and application of this classification to the subsequent mass casualty incidents to allow comparison between similar incidents in different settings., Results: A classification system that mainly differentiates mass casualty incidents on the hospital basis, the criteria being: the time interval between the first information to first reception, and the percentage of admission above the maximum normal intake., Conclusions: The Barzullah classification system is the first attempt at developing a hospital based differentiation in mass casualty incidents. It provides a valid and easy method of comparing such incidents between hospitals and perhaps a basis for developing protocol for mass disaster management.

One of the recommended methods for the management of displaced unstable proximal humeral fractures is the unilateral external fixator. In polytrauma cases this method may be especially useful for the stabilisation of these fractures. However, problems may arise if the fracture is fixed in a malaligned or distracted position. Conversion of the treatment concept to other modalities is difficult because of the problem of pin tract infection. The Ilizarov apparatus provides an useful method in such situations, as it allows distraction, translation and compression without the need for further anaesthesia and additional fixation.

Purpose: To assess the efficacy of acute invaginating docking for infected non-unions of the humerus., Methods: Eight men and 3 women aged 17 to 59 years with infected non-unions of the humerus underwent acute invaginating docking with shortening and Ilizarov fixation., Results: The mean shortening was 2.9 cm owing to additional debridement. The mean time to external fixator removal was 14.9 (range, 8-28) weeks. The final bone result was excellent in 1, good in 8, and fair in 2. The functional result was excellent in 7 and good in 4., Conclusion: This modality enables simultaneous treatment of infected non-unions, axial alignment, vascularity, stability, and function.