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Background: Common peroneal nerve palsy (CPNP) is a rare complication of total knee arthroplasty (TKA). It may lead to impaired function and pain. The purpose of this study was to determine the frequency and outcome of CPNP in a single orthopedic unit and to identify potential risk factors., Methods: This is a single-center study using the hospital's prospectively collected quality registry. All TKAs from 2002 to 2022 were included and followed up from 3 to 24 months with a follow-up rate of 98.4%. The local joint register was reviewed to identify patients with CPNP and used to extract data regarding the operation and the patients with and without CPNP. The groups were compared to identify possible risk factors for nerve injury. The medical records of the patients with CPNP were reviewed to determine the CPNPs' severity and outcome, and their preoperative radiographs were analyzed and compared to a control group with no nerve injury., Results: A total of 7704 TKAs were included, and 25 CPNPs were identified (0.32%). Complete palsies occurred in 18 cases, and partial palsies in 7. Postoperative epidural anesthesia, preoperative excessive valgus, and female sex were significant risk factors. Body mass index and age were not associated with CPNP. Two-thirds of the complete palsies had complete recovery, and four-fifths of the partial palsies recovered., Conclusions: The incidence of CPNP was 0.32%, and risk factors were epidural anesthesia, excessive valgus, and female sex. Most patients with CPNP recovered completely. Partial palsies had better outcomes than complete palsies in our cohort., (© 2024 The Authors.)

There is little data on long-term persistence/continuation of methotrexate among Indian Rheumatoid arthritis patients. We assembled a retrospective single-center cohort consisting of RA patients (fulfilling 1987 ACR criteria) started on methotrexate as part of three academic studies (including two RCTs) from 2011 to 2016. Oral methotrexate was started at 7.5 or 15 mg per week with a target dose of 25 mg per week. Between August and December 2020, all patients were contacted (telephonically) and data were obtained from clinic files to evaluate self-reported continuation/persistence of methotrexate and reasons for discontinuation. Survival analysis using Kaplan-Meier and cox-regression were used to assess methotrexate continuation rates and factors associated with its discontinuation. This study included 317 patients with rheumatoid arthritis, with mean age and disease duration (at enrollment) of 43 years and 2 years; And positive rheumatoid factor and anti-CCP in 69 and 75%. At follow-up, 16 patients (5%) had died, whereas 103 (32.5%) had discontinued methotrexate. On Kaplan-Meier survival analysis, the mean survival (continuation) time for methotrexate was 7.3 years (95% CI 7-7.6 years). The actuarial continuation/persistence of methotrexate at 3, 5 and 9 years was 92, 81 and 51%, respectively. Among those who discontinued methotrexate, common reasons were remission of disease, symptomatic adverse effects (intolerance), perceived lack of efficacy and socioeconomic reasons. On multivariable cox-regression, symptomatic adverse effects during the first 12-24 weeks (Hazard ratio, 95% CI 1.8 (1.2-2.8)) and anti-CCP positivity (Hazard ratio, 95% CI 0.6 (0.3-1.0)) were significantly associated with hazard of discontinuation. Persistence or continuation of methotrexate was found to be good and comparable to reports in other centers world-wide. Apart from remission, the most important cause of methotrexate discontinuation was symptomatic adverse effects (intolerance)., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Rotator cuff (RC) tear is one of the most common injuries of the shoulder. Patients with RC tears often report a trauma initiating shoulder pain and impaired function. The aim of this retrospective analysis of a prospectively registered cohort was to elucidate whether the time interval between the trauma and RC repair, using a cut off of 3 months, affects the functional outcome after 2 years., Methods: In a single orthopedic unit, 819 consecutive patients were treated with rotator cuff repair during the period from 2010 to 2014 and 733 of the patients completed the Western Ontario Rotator Cuff (WORC) index preoperatively and at 2-year follow-up. The Constant-Murley (CM) score was completed by trained physiotherapists after a clinical examination both preoperatively and at 2-year follow-up. Preoperative magnetic resonance imaging (MRI) was performed in all patients and postoperatively in 65% of the included patients. Re-tears and partial repairs were excluded, as were patients with pseudoparalysis who were given high priority and underwent surgery during the first 3 weeks after trauma., Results: Of the 733 treated patients, 437 (60%) reported having had a shoulder trauma in their medical history initiating their shoulder symptoms, and of these, 358 met the inclusion criteria. 296 patients with non-traumatic tears, 9 repairs done within 3 weeks after trauma, 25 partial repairs, 33 re-tears and 12 others were excluded. At 2-year follow-up there was no significant difference in WORC index (n.s.) or CM score (n.s.) between patients who had their RC repaired within or more than 3 months after trauma. In patients where RC repair was performed within 3 months, the WORC index improved by 42.9%, and in the group of patients operated later than 3 months, the increase was 38.7%. This difference between the groups was neither statistically significant (n.s.) nor clinically relevant. On postoperative MRI, 80% of the repairs were healed in both groups., Conclusion: In this retrospective cohort study, no differences in clinical outcome were found when RC repair was performed between 3 weeks and 3 months or later than 3 months after injury in patients describing their onset of symptoms as traumatic., Level of Evidence: III., (© 2022. The Author(s).)

Background: Optimum venous thromboembolism (VTE) prophylaxis for patients undergoing total hip or knee arthroplasty remains undefined. The purpose of this study is to compare complication rates among total joint arthroplasty patients using either low-dose aspirin (75 mg once daily) or low-molecular-weight heparin (LMWH; Fragmin/dalteparin 5000 U) for VTE prophylaxis., Methods: This is a prospective observational study. All total hip or knee arthroplasties from 2014 to 2020 were included. One thousand eighty-four patients already taking aspirin 75 mg as primary or secondary prophylaxis for cardiovascular disease continued their daily aspirin dose throughout their hospital stay and after discharge without any other kind of thromboprophylaxis. Five thousand ten patients not already taking aspirin were given LMWH for 12-14 days starting the day of surgery. Both groups consisted of patients undergoing either primary or revision total hip or knee arthroplasty. The aspirin group was older (73 ± 7.8 vs 66 ± 10.2 years, P < .01, 95% CI -7.6, -6.3) with more comorbidities but otherwise did not differ from the LMWH group. Outcome measures were recorded at 3-month follow-up and included the following complications: clinically deep venous thrombosis (DVT), pulmonary embolism (PE), deep infection, blood transfusion, and death., Results: The aspirin group had 0.28% DVT and 0.28% PE, and the LMWH group had 0.24% DVT and 0.16% PE (P = .42 and .74, respectively). No difference in deep infection, allogenic blood transfusion, or mortality was found., Conclusion: No statistically significant difference in complication rates was found between aspirin 75 mg and LMWH used for VTE prophylaxis. Aspirin 75 mg daily is safe for VTE prophylaxis after total hip or knee arthroplasty., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Although shoulder function is reported to be generally good after rotator cuff repair, limited knowledge exists regarding which prognostic factors predict functional outcomes., Purpose: To identify pre- and perioperative predictors of functional outcomes after arthroscopic rotator cuff repair., Study Design: Case-control study; Level of evidence, 3., Methods: A cohort of 733 consecutive patients treated with rotator cuff repair between 2010 and 2014 in a single orthopaedics unit was included. Data were collected prospectively and included pre- and perioperative variables. Univariate and multivariable linear regression analyses were used to predict shoulder function at 2-year follow-up, as measured by the Western Ontario Rotator Cuff Index (WORC)., Results: In total, 647 (88%) patients were followed for 25 ± 5 months (mean ± SD; range, 17-66 months). In the multivariable regression model, the adjusted R 2 was 0.360, indicating that 36% of the variation in the WORC at final follow-up could be explained by this statistical model. The multivariable linear regression analysis revealed that the strongest positive independent predictors of shoulder function at 2 years were preoperative WORC and Constant-Murley score in the contralateral shoulder. The model also indicated that activities of daily living, age, subacromial decompression, and biceps surgery had independent positive associations with better shoulder function at 2 years. In addition, previous surgery in the ipsilateral or contralateral shoulder, smoking, partial rotator cuff repair, preoperative pain, and atrophy in the infraspinatus were all independent factors negatively associated with shoulder function after 2 years. The overall healing rate of complete repairs per magnetic resonance imaging was 80%., Conclusion: The most important finding of the present study was that the strongest prognostic factors for better WORC at 2-year follow-up were better preoperative WORC and Constant-Murley score in the contralateral shoulder. Although not all the prognostic factors identified in this study are modifiable, they can still be useful for guiding patients in shared decision making with the surgeon. This cohort study shows that if selection of patients is performed properly, it is possible to obtain a successful outcome.

Purpose: The aim of this study was to compare clinical and radiologic results among patients with 3 versus 6 weeks of immobilization after arthroscopic rotator cuff (RC) repair in a prospective randomized controlled non-inferiority trial., Methods: One hundred twenty patients were included after RC surgery for a small- to medium-sized tear of supraspinatus and upper infraspinatus tendons. Group A was immobilized in a simple sling for 3 weeks, and group B had a brace with a small abduction pillow with the arm in neutral position for 6 weeks. All patients started active range of motion when they removed the sling/brace. One hundred eighteen (98%) patients were assessed at 1-year follow-up. They underwent magnetic resonance imaging (MRI) of the shoulder, filled out the Western Ontario Rotator Cuff (WORC) index, and were evaluated with a Constant Murley (CM) score., Results: Statistical non-inferiority was demonstrated for the 2 groups on the basis of the WORC index, the primary endpoint at 1 year. The objective for the non-inferiority test was to determine whether the expected mean WORC index for group A was at most 13% worse than standard treatment (Group B). The WORC index at 1 year was similar in both groups, with mean percent scores of 83% in group A and 87% in group B (mean difference = -4; 95% one-sided CI -9, -4). Age-adjusted CM scores were also similar, with means of 86 in group A and 90 in group B (mean difference = -4; 95% CI -13, 5; P = .37). MRI after 1 year showed 50 (89%) patients in each group with healed RC repair. Four patients in group A had complications: 1 acute postoperative infection, 2 cases of postoperative capsulitis treated with corticosteroid injections, and 1 repeat operation because of a loose anchor and subacromial pain. No patients in group B had complications., Conclusion: RC repair resulted in improved postoperative shoulder function, regardless of whether the shoulder was immobilized for 3 or 6 weeks. Three weeks of postoperative immobilization with sling use was non-inferior to the commonly used regimen involving 6 weeks of immobilization in a brace with regard to the WORC index at 12 months' follow-up. MRI indicated similar degrees of healing between the groups. Based on these findings, it is safe to immobilize patients in a simple sling for 3 to 6 weeks after repair of small to medium RC tears., Level of Evidence: Level I, high-quality randomized controlled trial with statistically significant differences., (Copyright © 2018 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Purpose: The primary goal of this retrospective review of a prospective database was to document the functional results after acute postoperative deep infection following rotator cuff repair in a single orthopaedic unit over a period of 5 years. Secondary goals were to document the effect of infection on healing of the cuff repair and to describe its incidence, diagnostic challenges, pathogens and management., Methods: Patients undergoing arthroscopic rotator cuff repair were prospectively registered from 2010 to 2014. Eleven out of 1072 repairs developed an acute postoperative infection. The patients were examined with an MRI scan, Constant-Murley (CM) score and the Western Ontario Rotator Cuff Index (WORC) at final follow-up (median of 22 months)., Results: All 11 patients who developed acute postoperative deep infections were males. Median age was 56 years (range 41-68). All patients underwent arthroscopic debridement and biopsies were collected at a median of 26 days (range 14-50) after primary surgery. In ten patients, Propionibacterium acnes was cultured, six of these patients also had positive cultures for coagulase-negative staphylococci. In the remaining patient, only coagulase-negative staphylococcus was cultured. Five patients were treated with one arthroscopic debridement, five had two arthroscopic debridements and one required arthroscopic debridement four times before the infection was eradicated. Two patients had their implants removed due to loosening of the suture anchors. All patients were treated with parenteral antibiotics for 1-4 weeks, followed by oral treatment for 1-5 weeks. At median 22 months (range 11-28) follow-up the median CM score was 84 and median WORC index was 81%. Ten patients had a postoperative MRI scan after a median of 23 months (range 3-49), with eight presenting a healed cuff repair., Conclusion: The findings of this study support the rapid, targeted intervention of acute postoperative infection after RC repair with immediate arthroscopic debridement, irrigation and biopsies for bacteriological diagnostics followed by parenteral antibiotics. Furthermore, repeated arthroscopic debridement and irrigation are recommended if signs of infection persist. Removal of the implant is rarely needed. Despite the postoperative acute infection, these patients presented good functional results at final follow-up., Level of Evidence: Level III.

Cyclic vomiting syndrome (CVS) is a functional disorder characterized by stereotypical episodes of intense vomiting separated by weeks to months. Although it can occur at any age, the most common age at presentation is 3-7 years. There is no gender predominance. The precise pathophysiology of CVS is not known but a strong association with migraine headaches, in the patient as well as the mother indicates that it may represent a mitochondriopathy. Studies have also suggested the role of an underlying autonomic neuropathy involving the sympathetic nervous system in its pathogenesis. CVS has known triggers in many individuals and avoiding these triggers can help prevent the onset of the episodes. It typically presents in four phases: a prodrome, vomiting phase, recovery phase and an asymptomatic phase until the next episode. Complications such as dehydration and hematemesis from Mallory Wise tear of the esophageal mucosa may occur in more severe cases. Blood and urine tests and abdominal imaging may be indicated depending upon the severity of symptoms. Brain magnetic resonance imaging and upper gastrointestinal endoscopy may also be indicated in certain circumstances. Management of an episode after it has started ('abortive treatment') includes keeping the patient in a dark and quiet room, intravenous hydration, ondansetron, sumatriptan, clonidine, and benzodiazepines. Prophylactic treatment includes cyproheptadine, propranolol and amitriptyline. No mortality has been reported as a direct result of CVS and many children outgrow it over time. A subset may develop other functional disorders like irritable bowel syndrome and migraine headaches.

Objective: To report the autosomal dominant inheritance of the Jervell and Lange-Nielsen syndrome in a highly inbred family, the initiation of Torsades de Pointes, and the natural history of the syndrome based on a 16-year follow-up of the kindred., Method: A family tree was constructed that included 66 blood relatives from three successive generations. Electrocardiograms were obtained from 59 living members including the proband, four members from a nuclear family, and 54 from the extended family. Evoked response audiometry was recorded for the proband and the nuclear family. All 59 family members were followed up regularly for 16 years., Results: A total of 24 living members were affected--QTc: 480-680 ms. The proband had long QTc, bilateral high-tone sensorineural deafness, recurrent syncope, and Torsades de Pointes. The asymptomatic father had long QTc and unilateral high-tone sensorineural deafness that involved specifically the left ear. One asymptomatic sibling of the proband had long QTc and normal hearing. The mother and another sibling were asymptomatic; QTc and hearing were normal in both. A total of 21 affected members from the extended family had only long QTc, and all were asymptomatic. There were three congenitally deaf first cousins who had recurrent syncope and adrenergic-triggered sudden death. In all, seven of 10 parents had consanguineous marriage to a first cousin. Each affected offspring had at least one affected parent. The severely symptomatic proband who received only β-blocker therapy and the 23 affected members without antiadrenergic therapy, all remained asymptomatic throughout the 16-year follow-up period., Conclusion: Jervell and Lange-Nielsen syndrome was inherited as autosomal dominant in this kindred. The majority of the affected members had a mild phenotype. The severity of auditory and cardiac phenotypes corresponded.

The effect of 2- pyridine aldoxime methyl chloride (2-PAMCl) and atropine with or without curcumin was investigated in dichlorvos (2,2-dichlorovinyl dimethyl phosphate; DDVP) induced toxicity in rats. Rats were exposed to DDVP (2 mg/kg sub-cutaneously) once daily for the period of 21 days. Post DDVP exposure, rats were further treated with 2-PAMCl (50 mg/kg intramuscular, once daily) + atropine (10 mg/kg, i.m. once daily) with or without curcumin (200 mg/kg; oral; once daily) for further 21 days. We observed a significant increase in lipid peroxidation (LPO), reactive oxygen species (ROS), oxidized glutathione (GSSG), while there was a significant decrease in antioxidant enzymes, brain acetylcholinesterase (AChE) and 5-hydroxy tryptamine (5-HT) activity on DDVP exposure of rats. These alterations were restored significantly by co-administration of 2-PAMCl + atropine in DDVP exposed rats. Curcumin when co-supplemented with 2-PAMCl + atropine also significantly protected serum aspartate aminotransferase (AST) and restored brain AChE activity and 5-HT level in animals sub-chronically exposed to DDVP. Histopathological observations along with biochemical changes in rat blood and tissues revealed significant protection offered by 2-PAMCl + atropine against DDVP. The results indicate that DDVP-induced toxicity can be significantly protected by co-administration of 2-PAMCl + atropine individually, however, curcumin co-supplementation with 2-PAMCl + atropine provides more pronounced protection, concerning particularly neurological disorders.

Culturally appropriate techniques for monitoring child psychosocial development were prepared and tested in China, India and Thailand on a total of 28,139 children. This is the largest study of its kind ever undertaken. Representative groups aged between birth and 6 years were examined and the results were used to produce national development standards-separately for rural and urban children in China and India, and for all children combined in Thailand-which are considered to be more satisfactory than foreign-based standards. In each country, between 13 and 19 key milestones of psychosocial development were selected for a simplified developmental screening operation and these have been incorporated on a home-based record of a child's growth and development. Between 35 and 67 tests have been devised in each country to test the children at first-referral level.

Measurements of weight and height of 21,638 Saudi boys and girls ages six to 16 years from the Eastern Province were taken. It was observed that the occurrence age of children could only be made out in Hegira years, as age is recorded by parents and at schools by the Hegira calendar. Age is a crucial factor in studies such as this and for valid comparison with any international reference standard, the latter must be adapted to the Hegira calendar year. Curves for weight and height percentiles for age have been constructed and compared with the Hegira adaptation of the NCHS growth standard.

The ages of Saudi children are recorded and based on the Hegira calendar. When charted on the National Center for Health Statistics (NCHS) weight and height charts, children will be at disadvantage since the Hegira year is shorter than the Gregorian year. In this paper, centiles for the NCHS reference population are estimated for age in Hegira years from 2-18 for height and weight for both sexes using mathematical interpolation. Charts are prepared for use in hospitals and health centers for children whose ages have been reported based on the Hegira calendar.

A comparison of mortality and morbidity pattern of hospital admissions of children under 14 years during 1966-68 and 1977-81 has been made. Annual admission rate has increased from 1515 to 2515, which is in proportion to the population increase of 3 lacs from 1966 to 1981. Recently more than 70% were discharged within a week as against 52% during 1966-68, indicating a faster turnover and a need for more beds. Protein energy malnutrition, infections and diarrhoea with dehydration were main killers. The pattern of mortality and morbidity has not much changed from 1966 to 81 but mortality rates at all ages have considerably declined in recent years (neonatal, post neonatal, preschool and school). Measures to decline it further have been discussed. The data should be of interest to those engaged in planning health strategies and to teachers in defining priorities in Medical education.