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Saba-Ikhlas Malik, Muna Ahmed, Nour Khattab Faculty of Medicine, St George’s University of London, London, UKCorrespondence: Saba-Ikhlas MalikFaculty of Medicine, St George’s University of London, London, UKEmail m1400090@sgul.ac.uk As university students, we read with great interest the article by Aylie et al about the effect of the COVID-19 pandemic on university student mental health. The article highlighted that there has been an increase in depression, anxiety and stress levels and the need for governmental organisations to integrate psychological support into upcoming initiatives.1 View the original paper by Aylie and colleagues

This paper deals with an approach for an automated evaluation of the learners' state of knowledge when learning by doing. This approach is called ODALA for "Ontology-Driven Auto-evaluation for e-Learning Approach". It takes place in the context of Computer Based Human Learning Environment (CBHLE) in a self-learning by doing mode. ODALA is based on the teaching domain ontology and on errors classification and detection. The evaluation process is composed of four stages: (1) form analysis of learner's solutions, (2) semantic analysis, (3) marking, and (4) updating of the learner's model. We bring the approach into play in the context of relational databases teaching: we present the results of the relational databases self-learning system (RDB-E-LEARN) development, where the main stages of our evaluation approach are implemented.

Malaysian households have exhibited significant improvements in the standard of living and economic opportunities. However, a larger household income does not always translate into an economically comfortable household. Regional variations in income and expenditure levels need to be explored for better understanding on the diversity of experiences among Malaysian households. Therefore, this study aims to investigate the pattern and relationship between household income, household expenditure, and household size among states in Malaysia. Several methods have been used such as the Pearson correlation coefficient, paired t-test, and multiple regression model using IBM Statistical Package for the Social Sciences (SPSS) version 27 and Microsoft Excel for the year 2016, 2019 and 2020. Descriptive results showed that despite the significant increase in household median income, households seemed unable to allocate the income increment to their expenses, possibly due to higher living costs requiring adjustments in expenditure. Results also showed that the expenditure growth rate outpaces the income growth rate drastically in a few states such as Negeri Sembilan and Putrajaya. The inferential results have shown that there is a significant difference in the mean monthly household median income and the mean monthly household median expenditure across states in Malaysia between 2016 and 2019. Multiple regression revealed that household median income significantly predicted household median expenditure, while household size is not significant. This study suggests government to regularly review the prices of essential goods and services to ensure they remain affordable for all households. This is crucial for improving the living standards and well-being of Malaysians.

Category: Ankle Arthritis; Hindfoot Introduction/Purpose: Total Ankle Replacement (TAR) have a potential advantage of protecting further degradation of hindfoot joints by maintaining ankle joint motion. However, there is no study to our knowledge that directly compares hindfoot outcomes between TAR and Ankle Arthrodesis (AA) in the long term. Sokolowski et al. found that 68% of TAR patients had no radiological progression of subtalar arthritis after TAR, and 4% went on to fusion. Other studies have looked at 5 year outcomes finding higher hindfoot fusion rates post AA. However, no evaluation of the other hindfoot joints was made and no comparison made to other treatment. This study aimed to analyze the long-term rates of symptomatic hindfoot arthritis resulting in further procedures following TAR versus AA. Methods: We performed a retrospective review of all patients at our centre who had a TAR or AA since 2002. Case notes and imaging were reviewed and all instances of hindfoot treatment (injections or surgical procedures) noted. Patient were excluded who had no documentation, were followed up at other hospitals, had prior hindfoot fusion, or were having staged surgeries at the time of index treatment. Chi squared analysis was used to compare the cohorts. Results: Analysis revealed 428 eligible cases (275 TAR, 153 AA). TAR patients were older (mean age: 62 vs. 52 years, p=0.00001). Average follow up was 12.6 (1 – 21) years for TAR and 12.1 (1-21) years for AA. TAR showed lower rates of overall further hindfoot procedures compared to AA (14% vs. 24%, p=0.01), with significantly fewer hindfoot fusions (4% vs. 14%, p=0.0002). Revision rates were similar between groups (6% TAR vs. 4% AA, p=0.99). Conclusion: This study highlights higher rates of symptomatic hindfoot arthritis requiring intervention in AA compared to TAR. TAR appears to offer advantages in hindfoot preservation, with similar revision rates. Prospective studies integrating patient-reported outcomes are warranted to assess TAR versus AA efficacy on hindfoot function and overall well-being. Our findings advocate for TAR as the primary treatment for end-stage ankle arthritis, if appropriate, when considering symptomatic progression in management decisions.

There is an increasing demand for high-performance data center networks with resilient connectivity to support modern applications. Current approaches often lack robustness, particularly when seamlessly integrating wired and wireless technologies. To address this challenge and enhance flexibility, resilience, and programmability in data center architecture protocols, we propose the Versatile Resilience Packet Ring (VRPR) protocol. VRPR leverages a dual-connectivity approach to manage network traffic efficiently. It is implemented alongside P4-enabled network adapters on servers, allowing them to seamlessly utilize both wired and wireless links. Servers can choose the optimal link type based on load and potential interference. In case of a wired link failure, servers can seamlessly transition to wireless links, minimizing downtime and ensuring application availability. VRPR’s rapid recovery times further enhance network robustness. The protocol integrates seamlessly with P4, a programmable network architecture. This enables efficient packet duplication, rerouting, and fault tolerance mechanisms within the VRPR framework. The P4-based approach allows for the integration of security measures like flow entry verification and additional security checks, ensuring robust protection of sensitive data within the network. VRPR signifies a significant advancement in data center networking, supporting data rates up to 100 Gbp/s and sub-microsecond latencies. VRPR, with its focus on resilience and security, positions itself as a potential cornerstone technology for future data center networks. As VRPR evolves, its adoption holds the promise of reshaping data center networking paradigms by offering unparalleled performance and resilience.

Objective: To evaluate and compare the preventive role of Nebivolol and Alpha Tocopherol on testosterone-induced benign prostatic hyperplasia in rats. Study Design: Laboratory-based experimental study Place and Duration of Study: Department of Pharmacology and Pathology, Army Medical College, Rawalpindi, in collaboration with National Institute of Health (NIH), Islamabad Pakistan, from Dec 2021 to Jun 2022. Methodology: One hundred fifty healthy male Sprague-Dawley rats were procured from the NIH, Islamabad. They were placed into five groups, each with 30 rats. Results: Out of a total 150 sample of five groups, the mean prostatic index in Group-A, Group-B, Group-C, Group-D, and Group-E were 1.49±0.09, 2.35±0.48, 1.87±0.11, 1.72±0.04 and 1.68±0.08 respectively (p-value< 0.001). Mean Prostate Specific Antigen in Group-A, Group-B, Group-C, Group-D and Group-E was 0.19±0.02, 0.23±0.01, 0.18±0.02, 0.18±0.02 and 0.16±0.02 respectively (p-value< 0.001). On gross examination, in Group-A, all (100%) prostate samples were normal-sized. In Group-B, all (100%) prostate samples were enlarged. In Group-C, 53.3% were mild, and 47.7% of samples were moderately enlarged. In Group-D, 73.3% of samples were mildly enlarged, and 26.7% were moderately enlarged. In Group E, 26.7% of samples were normal, and 73.3% were mildly enlarged (p-value< 0.001). Conclusion: Prostatic index is markedly declined following treatment with the combination of Nebivolol and Alpha-Tocopherol. There is also a declining trend in Prostate Specific Antigen following treatment with a combination of Nebivolol and Alpha-Tocopherol.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total Ankle Replacement (TAR) is an established treatment option for end-stage ankle arthritis. We analysed at minimum, 10-year patient-reported and clinical outcomes of 156 TARs from a single centre. We specifically compared outcomes between patients under 60 and over 60 at time of surgery. Methods: Data was collected retrospectively from our departmental patient database. It included all patients who underwent a TAR by a single surgeon between 2006 and 2010 and patients were divided into those under 60 and those over 60 at the time of surgery. Patient reported outcomes (PROMs), including WOMAC, SF-36 and patient satisfaction scores and complications were analysed preoperatively and at one, two, five and over 10 years postoperatively. Results: There were 156 patients included in this analysis, 61 were under 60 (mean age 50.29) and 95 were over 60 (mean age 69.12). A total of 12 patients had revision surgery, (nine in the under 60 group) and 52 patients were deceased at the time of analysis (10 in the under 60 group). At one year the over 60 group had less pain and better functional scores (p=0.02, p=0.017). At two, five and ten years there was no statistical difference in pain and function between groups. At two years the over 60s reported less stiffness and quicker return to activities of daily living (p=0.007, p=0.001). However, at five and 10 years there was no statistical difference in any domain. Conclusion: This study demonstrates that age does not correlate with a significant difference in pain or functional outcomes in patients who have TAR, at over 10 years follow up. The higher revision rates in the younger group may correlate with higher functional demand and lower mortality rate.

Category: Ankle Arthritis; Ankle Introduction/ Purpose: There is paucity of literature comparing foot and general health status including quality of life between patients presenting with Ankle/ Hindfoot, Midfoot and 1st MTPJ arthritis. The aim of this study is to compare foot specific patient reported disability and quality of life satisfaction scores between patients presenting with arthritis of either the ankle/hindfoot, midfoot or 1st MTPJ. Methods: Patients who presented between 2020 and 2021 with a diagnosis of primary Osteoarthritis (OA) in either the ankle/hindfoot (AHA), midfoot (MA) or first MTPJ (MTPJA) were included in this study. Patients with associated foot problems, bilateral presentations, previous reconstructive surgery, or underlying neurological conditions were excluded. Differences in preoperative Patient Reported Outcome Measures (PROMs) including, MOX-FQ (Domains: Pain, Walking/Standing, Social activities), EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) (Domains: Pain, symptoms, ADL, sport, Recreation, Quality of Life) were analysed. Results: 94 patients (2020-2021) were included in this study (mean age 58.50). There were 45 patients with AHA, 21 with MA and 28 with MTPJA. The AHA group reported worse pain compared to the MTPJA group (p=0.03), and the MA group (p=0.004). AHA patients had more difficulty with Sports & Recreational Activities (p=0.029). Quality of Life scores was not significantly different between the groups. MTPJA patients had more difficulty with engaging in social activities compared the AHA patients (p=0.049). Conclusion: AHA patients suffer more pain that patients with arthritis in other areas of the foot. They appear to struggle with walking and standing and have difficulty participating in sports and recreational activities. Interestingly, MTPJA patients experience the most difficulty taking part in social activities. Patients with any type of foot or ankle arthritis experience similar difficulties with their mental health and their ability to carry out activities of daily living.

Category: Ankle Arthritis; Ankle Introduction/Purpose: Total ankle replacement (TAR) is gaining popularity as a treatment option for end stage arthritis. We analysed whether the underlying pathology leading to the arthritis has any bearing on patient reported or clinical outcomes. Methods: Patient-reported outcome measures (PROMs) for TAR performed from 2006 to 2010 by a single surgeon were reviewed. This included WOMAC score, SF-36 and patient satisfaction scores. Data was collected preoperatively and post- operatively at 1, 2, 5 and 10 year. The indications for TAR were obtained by review of clinical notes and radiographs and these included osteoarthritis (OA), inflammatory arthritis (IA), pilon fracture (PF), ankle fracture (AF), and post-traumatic arthritis without previous fracture (PTOA).PROMs were available for 156 TARs: 81 (51.9%, mean age 65.29) for OA, 28 (17.9%, mean age 65.29) for AF, 23 (14.7%, mean age 64.28) for IA, 11 (7%, mean age 55.01) for PF, and 13 (8.3%, mean age 51.08) for PTOA. Results: At 1 year WOMAC score showed significant worsening pain and stiffness on PTOA group (p=0.023, p=0.001) and worse general health and vitality for the IA group (p=0.0025, p=0.005). At 5 years The PTOA group showed significant worsening stiffness (p=0.048), social and emotional domains (p=0.004, P=0.029) and worsening pain, return recreational activities and surgery dissatisfaction (p < 0.05, p=0.032, p=0.023). At 10 years 50% of IA patients were unhappy with return to ADLs but no other difference were found between groups. There was a higher revision rate at 10 years in the PTOA group with 30.7% of patients being revised (4/13) compared to other groups (OA-6.17%, AF-3.57%, IA-4.35%, PF-9%) Conclusion: Similar outcomes in all groups were seen at 10 years but higher revision rates were present in PTOA group. In patients with PTOA careful consideration and counselling is needed prior to proceed with TAR.

Category: Other Introduction/Purpose: Steroid injection is a common treatment for Plantar fasciitis (PF) but has high recurrence rates. Platelet- rich plasma (PRP) injections have been used as an alternative treatment. Our aim was to review the effectiveness of PRP injection. Methods: All patients who underwent PRP injection for PF between 2015 and 2021 were included in this study. Clinical results and patient reported outcomes (MOX-FQ scores, EQ-5D and FAOS scores) were collected pre and post-operatively. Results: A total of 34 patients underwent PRP injection between 2015 and 2021 (mean age 34 years). There was a 71% PROMs response rate (80% female with, mean age 53). The mean duration of symptoms was 4 years and the median follow up time was 4.2 years. 77.1% were satisfied with overall outcomes of treatment with PRP injections (p < 0.05). 68.1% of patients reported satisfaction with pain relief. 74.6% were satisfied with return to activities of daily living. 72.6% were satisfied with return to recreational activities. 59% reported improvement in quality-of-life post treatment. 64% were happy to receive the same treatment again; 13.6% would not have the procedure again. 2 patients had severe pain within 2 weeks following the injection but symptoms settled. No other complications. Conclusion: PF is considered to be a self-limiting condition but can be debilitating whilst awaiting resolution of symptoms which can take upwards of 12 months to fully resolve. PRP injection provides effective pain relief for PF at 4 years follow up.

Category: Ankle Arthritis Introduction/Purpose: Step count and activity monitoring are objective tools to measure improvement in functional ability in patients undergoing Total ankle replacement (TAR); this area is underexplored in literature. Activity monitoring sensors provide additional information on physical activity and energy expenditure in addition to step counts. These carried out in a real-life environment helps us to understand the impact of intervention in improving physical activity. The aim of this study was to study physical activity patterns in the community in patients who underwent TAR surgery. Methods: 10 patients who underwent a TAR between 2017 and 2019 were recruited. Exclusion criteria included previous reconstructive surgery, h/o infection, PVD, neurological disease and other joint replacements. Written consent was obtained. Patients were provided with ActivPAL TM activity monitor to wear over a 7-day period along with a self-reported diary to record activity patterns. This was carried out pre-operatively and 2 years. Data from sensors were downloaded and activity patterns were analysed with SPSS IBM 28 statistical package. Results: 10 patients (7 males, 3 females) were recruited. Mean age of patients were 65.16 years (52.4 to 78.1yrs).there was a trend for improvement in Sitting / Lying (hours) from 121.36 to 132.56 (p=0.367) and Standing (hours) 25.53 to 33.23 (p=0.411), although this did not achieve statistical significance. Step count (in hours) improved from 8.8 hrs to 10.8 hrs (p=0.05); Step count increased from 38544 to 47074 (p=041) from pre-op to 2 years. Energy expenditure (metabolic equivalents) improved from 192.3 to 219.5 (p=0.033). Conclusion: At 2 years post-operatively, TAR patients showed considerable improvement in step count and energy expenditure compared to pre-operative levels. The results of this novel study helps us to understand the functional improvements in terms of physical activity and energy expenditure gained from TAR surgery

Category: Basic Sciences/Biologics; Ankle Introduction/ Purpose: The aim of this study was to investigate plantar pressures changes with gait in patients presenting with ankle arthritis pre and post TAR. Methods: Patients who were listed for a primary TAR with a 3 component mobile bearing prosthesis were included. Exclusion criteria included refusal of consent, previous surgery to foot, h/o infection, peripheral vascular disease, neurological disease and other LL joint replacements. Gait analysis was carried out using TekscanTM plantar preasure (PP) analysis system and PP) were recorded pre- operatively and 1 year post-operatively. Gait asymmetries were recorded in Percentage for ST parameters. 11 patients were recruited to this study. Mean age were 70.5 years. Results: Improvement centre of pressure pattern restoration and Force percentage curve (FP) patterns from pre-op to 1 Year. Improvement in foot progression angle was seen in 6 out of 11 patients (54.5%). Plantar pressure analysis showed deviation from reference ranges for 1) differences in centre of pressure (COP) 2) changes to hindfoot vs. forefoot loading ratio 3) change in loading pattern at heel in KPa (p < 0.05) 4) differences in gait parameters (reduction in cadence, walking velocity, increase in active propulsion time; p< 0.05) 5) changes to foot progression angles. These findings correlate with MOX-FQ scores (p>0.565) for pain, difficulty with walking/standing and difficulty with social activities. Gait asymmetries improved at 1 year for step velocity (76.1 to 93.4%) and mid stance time (76.04 to 93.5% in 8/11patients)(p < 0.05). Conclusion: This study shown that TAR surgery helps in restoring centre of pressure, force percentage curve patterns and reduces asymmetries in step velocity and mid stance times during gait at 1 year post surgery. Plantar pressure analysis is a useful tool to study improvement in function in this patient group.

Category: Ankle Arthritis Introduction/Purpose: Pilon fractures are challenging to manage and have poor functional outcomes and high complication rates. A significant proportion of these patients go on to develop post-traumatic ankle arthritis. Our aim was to assess the long term patient reported outcomes following pilon fracture fixation and how this compares to patients with end stage ankle osteoarthritis requiring surgical intervention in the form of total ankle arthroplasty. Methods: We retrospectively identified all patients who underwent pilon fracture fixation between April 2012 and December 2015 (Group A). Group B consisted of patients with primary ankle osteoarthritis awaiting elective total ankle replacement between 2015 and 2017. Patients completed a Patient Reported Outcome Measures questionnaire (MOX-FQ, EQ-5D and FAOS scores) pre and post-operatively. The average follow up was 8 years. Results: There were 18 patients in Group A and 22 in Group B. Ankle arthritis patients reported significantly worse score for MOXFQ Pain (P vs. AA; 39.0 ±29.5 vs. 68.0 ±27.1; p=0.001), Difficulty with Walking/ Standing (38.3±26.0 vs. 56.4±26.5; p=0.037) and difficulty with social activities (24.0 ±25.6 vs. 49.4 ±31.3; p=0.007) and FAOS domains of symptoms (68.7 vs. 52.1; p=0.005), ability to do Activities of Daily Living (18.9 vs. 27.5; p= 0.003) and Quality of life (56.6 vs. 32.5; p=0.012). There was no difference between groups for EQ-5D general health scores (78.8 vs. 68.8; p=0.156). Ankle arthritis group patients reported worse scores for mobility, ability to self-care and performed activities of daily living (p=0.012) compared to the pilon fracture group. Conclusion: Our 8 year follow up demonstrate good long term outcomes for patients following pilon fracture fixation. Patients did not develop symptomatic arthritis comparable to end stage ankle arthritis requiring surgical intervention and we therefore recommend primary treatment with fixation, irrespective of fracture severity.

Category: Ankle; Hindfoot Introduction/Purpose: There is paucity of literature reporting outcomes in patients who undergo subtalar joint fusion surgery before vs. after having a Total Ankle Replacement (TAR). We aimed to study the PROMs in patients who underwent a staged approach of Subtalar arthrodesis (STJA) followed by TAR vs patients who underwent TAR followed by further STJA surgery. Methods: All patients who underwent a STJA surgery and TAR surgery (in either order) between 2006 and 2010 included in this study. patient reported outcomes including WOMAC (Western Ontario McMasters Osteoarthritis score), SF-36 general health score and patient satisfaction scores were compared between groups. They analysed pre-operatively and at 1, 2, 5 and 10 years post-operatively. Out of 210 TARs performed, 14 patients underwent a two staged procedure between 2006 and 2010 by a single surgeon. 5 patients had STJ fusion after TAR (Group A) and 9 patients had STJ fusion before TAR (Group B). Results: Mean age of Group A and B was 52.5 years and 62.1 years respectively. 1 patient in Group A and 3 patients in Group B were deceased. Both groups reported improvement in scores for WOMAC, SF -36 from pre-op to 1 year post operatively (p < 0.05) and the results plateaued to 5 years with slight decline in scores from 5 to 10 years. At 2 years, Group B reported lower scores for stiffness (9.6±11.7 vs. 64.3 ±27.4) p=0.002, At 5 years, Group A reported lower scores than group B for General health and mental health components of SF-36 scores (p=0.044); however, there was no differences between groups for WOMAC, SF-36 and patient satisfaction outcomes at 10 years post-operatively. Conclusion: There were similar outcomes reported by patients who underwent STJA either before or after TAR at average of 10 year follow up in this series

Wireless Body Area Network (WBAN) is a special purpose wireless sensors network designed to connect various self-autonomous medical sensors and appliances located inside and outside of human body. Interests in human Healthcare Monitoring System (HMS) are based on WBAN due to the increasing aging population and chronically ill patients at home. HMS is expected to reduce healthcare expenses by enabling the continuous monitoring of patient’s health remotely in daily life activities. This research focuses on routing protocols in WBAN. The major problems in routing protocols are maximum energy consumption, path loss ratio, packet delivery ratio and maintaining stable signal to noise ratio. Real time analysis is required in HMS to support the patients through doctors, caregivers and hospital systems. Collected data is relayed by using existing wireless communication schemes towards the access point for further retransmission and processing. In this research, an Improved Quality of Service aware Routing Protocol (IM-QRP) is proposed for WBAN based HMS to remotely monitor the elderly people or chronically ill patients in hospitals and residential environments. The proposed protocol is capable to improve 10% residual energy, 30% reduction in path loss ratio, 10% improvement in packet transmission (link reliability) and 7% improvement in SNR as compared to existing CO-LEEBA and QPRD routing protocols. Convolutional Neural Network is used outside the WBAN environment to analyze the medical health records for healthcare diagnosis and intelligent decision-making.

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Aims: A multicentre, randomized, clinician-led, pragmatic, parallel-group orthopaedic trial of two surgical procedures was set up to obtain high-quality evidence of effectiveness. However, the trial faced recruitment challenges and struggled to maintain recruitment rates over 30%, although this is not unusual for surgical trials. We conducted a qualitative study with the aim of gathering information about recruitment practices to identify barriers to patient consent and participation to an orthopaedic trial. Methods: We collected 11 audio recordings of recruitment appointments and interviews of research team members (principal investigators and research nurses) from five hospitals involved in recruitment to an orthopaedic trial. We analyzed the qualitative data sets thematically with the aim of identifying aspects of informed consent and information provision that was either unclear, disrupted, or hindered trial recruitment. Results: Recruiters faced four common obstacles when recruiting to a surgical orthopaedic trial: patient preferences for an intervention; a complex recruitment pathway; various logistical issues; and conflicting views on equipoise. Clinicians expressed concerns that the trial may not show significant differences in the treatments, validating their equipoise. However, they experienced role conflicts due to their own preference and perceived patient preference for an intervention arm. Conclusion: This study provided initial information about barriers to recruitment to an orthopaedic randomized controlled trial. We shared these findings in an all-site investigators’ meeting and encouraged researchers to find solutions to identified barriers; this led to the successful completion of recruitment. Complex trials may benefit for using of a mixed-methods approach to mitigate against recruitment failure, and to improve patient participation and informed consent. Cite this article: Bone Jt Open 2021;2(8):631–637.

LHPP gene encodes a phospholysine phosphohistidine inorganic pyrophosphate phosphatase, which functions as a tumor-suppressor protein. The tumor suppression by this protein has been confirmed in various cancers, including hepatocellular carcinoma (HCC). LHPP downregulation promotes cell growth and proliferation by modulating the PI3K/AKT signaling pathway. This study identifies potentially deleterious missense single nucleotide variants (SNVs) associated with the LHPP gene using multiple computational tools based on different algorithms. A total of 4 destabilizing mutants are identified as L22P, I212T, G227R , and G236R , from the conserved region of the phosphatase. The 3-dimensional (3D) modeling and structural comparison of variants with the native protein reveals significant structural and conformational variations after mutations, suggesting disruption in the function of phospholysine phosphohistidine inorganic pyrophosphate phosphatase. The identified mutations might, therefore, participate in the cause of HCC.

Background: Patient-reported outcomes (PROMs) are an integral part of national joint registers in measuring outcomes of operative procedures and improving quality of care. There is lack of literature comparing outcomes of total ankle replacement (TAR) to total knee replacement (TKR) and total hip replacement (THR). The aim of this study was to compare PROMs between TAR, TKR, and THR patient groups at 1, 5, and 10 years. Methods: Prospective PROMs from patients who underwent a TAR, TKR, or THR procedure between 2003 and 2010 were studied. Patients were divided into 3 groups based on their index joint replacement (hip, knee, or ankle). Patient demographics (age, gender, body mass index), patient-reported outcome scores (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], 36-Item Short Form Health Survey [SF-36]) and patient satisfaction scores (4-point Likert scale) at follow-up were compared between the 3 groups. Results: Data was available on 1797 THR, 2475 TKR, and 146 TAR patients. TAR patients were younger and reported fewer number of comorbidities. All 3 groups improved significantly from preoperative to 10 years for WOMAC scores ( P < .001). For SF-36 scores at 10 years, the THR group (32.2% follow-up) scored the highest for 3 domains ( P = .031) when compared to the TKR group (29.1% follow-up). All 3 groups had similar outcomes for 5 of 8 domains; P < .05). For patient satisfaction, the THR group reported overall 95.1% satisfaction followed by 89.8% for the TKR group and 83.9% in the TAR group (42.4% follow-up). Conclusion: In this cohort with diminishing numbers over the decade of time the patients were followed up we found that patients are equally happy with functional and general health outcomes from total ankle replacement vs other major lower extremity joint replacement. TAR surgery should be considered as a viable treatment option in this patient group. Level of Evidence: Level III, retrospective case series.

Vitamin A deficiency (VAD) is a very common problem in developing countries and in extreme situations, it is responsible for vision impairment as well as death. To conduct a comprehensive cross-sectional evaluation of the deficiency of vitamin A and the associated risk factors responsible for its deficiency, a questionnaire based survey was conducted in District Gujrat, Punjab, Pakistan. In order to evaluate the data related to VAD and its relationship with different variables, a cross-sectional survey was conducted of 400 female students from three different schools in District Gujrat. The schools were situated in both rural and urban areas. A questionnaire eliciting personal information, family status and diet related information was used to collect the required data for the survey. The results did not pertain with the participants’ gender. The results were based on the summer season routine of diet and physical activity. All information was sorted and the results were analyzed using the Microsoft Excel 2010 update and SPSS version 20. It was found that 39% girls (156 out of 400) were deficient in vitamin A. The main source of VAD was found to be inadequate dietary consumption. It was also found that children with poor socioeconomic standing, low fluid consumption, and from urban areas have more VAD than others. Moreover, the age group of 8-11 years carried a higher percentage of VAD, while physical activity had no impact on VAD. A large number of girls were reported as the victims of VAD due to poverty and related socioeconomic constraints prevailing among the school going children in District Gujrat. A crucial approach towards reducing VAD is to learn about the preventive measures to control VAD. In low-income countries, the use of vitamin A supplements with daily diet is required to reduce the impact of VAD. Copyright(c) The Authors

Spatial data infrastructures (SDIs) have been implemented for the last four decades in most countries. One of the key objectives of SDIs is to ensure the quick availability and accessibility of spatial data. The success of SDI depends on the underlying spatial datasets. Many developing countries such as Pakistan are facing problems in implementing SDI because of the unavailability of spatial data. Volunteered Geographic Information (VGI) is an alternate source for obtaining spatial data. Therefore, the question is what factors hamper the adoption of VGI for making it part of SDI in Pakistan. The intention behind this paper is to explore such factors as the key research question. To do so, we make use of the Technology–Organization–Environment (TOE) framework along with the partial least square structural equation model (PLS-SEM) to empirically analyze the factors impeding VGI from becoming part of SDI in the country. The study concludes that many technical, organizational, and environmental factors affect the adoption of VGI to be part of SDI in Pakistan.

Category: Bunion Introduction/Purpose: There is paucity of literature comparing foot and general health status including quality of life between patients presenting with Hallux Valgus and Hallux Rigidus and to compare the outcomes of people how had surgery in either one. We compared foot specific patient reported disability and general health status between patients presenting with Hallux Valgus and Hallux Rigidus pre and post-surgery. Methods: All patients operated between June 2016 and December 2017 with a diagnosis of primary Hallux Valgus or Hallux Rigidus were invited to the study. Patients were grouped based on diagnosis into Group A (Hallux Valgus) and Group B (Hallux Rigidus). All patients received a Pre-Operative and post-operative questionnaire with a minimum of 6 months follow up. Differences were studied between groups for scores of MOX-FQ, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) comparing both pre and post-operative. Results: There were 53 patients with Hallux Valgus and 46 patients with Hallux Rigidus of 1st MTPJ. Pre-operatively in MOX-FQ both groups reported similar level of pain (p=0.776), difficulty with walking/ standing (p= 0.960) and restriction with social activity because of foot symptoms (p=0.683). Following surgery both groups significantly improved in all domains (p< 0.001). Post- operatively there was no difference between both groups for MOX-FQ (pain, walking, social domains; p>0.05), EQ-5D general health score (p=0.404) and FAOS domains for pain (p=0.653), symptoms (p=0.230), ADL (p=0.587), and quality of life (p=0.876). But all scores improved significantly from pre-op to post-op for both groups (p

Category: Ankle, Ankle Arthritis Introduction/Purpose: Total ankle replacement as a valid treatment for end stage ankle arthritis, is gaining popularity and every year there is an increasing number of procedures. With revision rates as high as 21% at 5 years and 43% at 10 years there is a need for understanding and reporting the outcome of revision ankle replacement. Our aim was to study the patient reported outcomes following revision TAR with a minimum of 2 year follow up. Methods: All patients that underwent a revision total ankle replacement between 2012 and 2016 were included in the study. All patients received a post-operative questionnaire comprising of MOX-FQ score, EQ-5D (UK) and Foot and Ankle outcomes scores (FAOS) and patients satisfaction questionnaire with a minimum of 2 years follow up. Results: 32 patients had a revision total ankle replacement between 2012 and 2016. 2 patients were deceased therefore 30 patients were included in the study. 5 patients declined participation for completing questionnaires. We received 21 (66%) completed questionnaires. The mean MOX-FQ average domain score for pain was 58.8, walking/standing 65.8 and social function was 48.2. The mean FAOS scores were 50.7 for pain, 50.6 for symptoms, 54.9 for ADL and 28.2 for quality of life. The mean overall health score today for EQ-5D was 67.8/100. 45% of patients were satisfied with the pain relief and return to sports and recreation obtained following the operation, 48% were satisfied with the improved in daily activities. 52% were overall satisfied with the results from surgery. Conclusion: Revision total ankle replacement gives overall satisfactory results demonstrated from patients reported outcomes at a minimum of 2 years following surgery.

Category: Ankle Arthritis Introduction/Purpose: Juvenile idiopathic arthritis is a broad term that describes a clinically heterogeneous group of arthritides of unknown cause, which begin before 16 years of age persist for more than 6 weeks. It is one of the main diseases affecting Paediatric age group Joints in a form of a chronic, long standing and debilitating disease. It is estimated that 1 in 1000 children present with JIA in the UK alone. Radiographic progression of the disease occurs early, and if not addressed may result in permanent joint destruction and poor functional outcomes. The ankle is frequently involved, but it is unclear whether this is due to synovitis, tenosynovitis. To date, no evidence of combined therapies or integrated care for juvenile idiopathic arthritis patients with F&A problems exists. Methods: JIA patients with ankle involvement presented to orthopedic foot and ankle services between 2012-2017 were include. All patients had weight bearing x-rays ankle measuring Tibio talar angle, also underwent Ankle MRI following standard hospital MRI protocols. The MRI scans were used to measure the affected areas in talus. Talus was divided into 4 anatomical regions (Anterio-medial, Anterio-lateral, posterior-medial, posterolateral). lesion involving wider areas were recorded as two or more regions accordingly, i.e.: AM and PM involvement at the same time were given yes for area of involvement in both region and recorded separately. Bilateral Ankles involvement were also recorded. Tibial growth plate involvement in these patients on the MRI scan was recorded. Demographic data was collected along with side, disease pattern, age at diagnosis and age at presentation to F&A speciality and patients requiring surgical intervention. Measurements were carried out by two in dependent orthopaedics F&A surgeons. Results: 14 patients were included in this study with a total of 17 ankles. 12 were females (N=12, 85.7%). Mean age was between 8-21 years (15.0 ± 4.08, M±SD). Time to presentation was 2.9 to 8.4 years (5.1 ± 1.4 years). 5 had Oligo-articular involvement (37.5%),9 patients had polyA (64.2%). 11/17 Right Ankles (64.7%), 3 left (21.4%). 3 bilateral (21.4%). 11/17 Ankles in Varus (64.7%), 1/17 valgus (5.8%), 5/17 neutral (29.4%). Mean Tibiotalar angle was 80° ± 13.5° (Range 49° - 100°). 12/17(70.5%) had involvement of the antero-medial part of the talus,1/17(5.8%)antero-lateral, 8/17 postero-medial(47.06%), 3/17(17.6%) postero-lateral . All the patients with postero-lateral involvement, they also had postero-medial involvement. (p=0.043). 13/17 ankles (76.4%) had tibial growth plate involvement. 5 patients (35.7%) had subsequent operations. Conclusion: This study shows a pattern of involvement in the talus and the effect this disease has on Tibiotalar alignment. This needs to be confirmed on a larger number of patients. And highlights the need for an earlier presentation of these patients to F&A surgeon to prevent the disease sequela. Further research is required to study the tibial growth plate involvement for its contribution to the varus / valgus deformity in a chronological method. Further research is also required to quantify the time frame for disease and deformity progression in the Tibiotalar Joint.

Category: Ankle, Ankle Arthritis Introduction/Purpose: Bone strength about the components is an important factor in Arthroplasty survival. This importance has been studied in total hip & knee replacement. However, there is paucity of literature Where little has been published regarding the quality of the bone and bone mineral content postoperatively surrounding Ankle Arthroplasty and circumstances surrounding the development of stress fracture. This prospective study used a method to quantify Bone Mineral Density BMD in different regions of the surrounding bones adjacent to tibia and talar components of uncemented Mobility ankle prosthesis, and to study the effect of loading on local ankle bone in the presence of un-cemented three components ankle replacement, by analyzing the BMD of the areas around tibia and talus before and after Mobility total ankle replacement. Methods: Twenty three Ankles (7Females, 15 Males) who underwent a Mobility Total Ankle Arthroplasty (TAA) between March 2008 and April 2009 were included prospectively in this study. They underwent a Bone Density Scan using the DEXA HOLIGIC Scanner with the specific method designed for measuring BMD. Seven areas (R1-R7) around the prosthesis were studied (Please see attached figure). Scans were carried out pre-operatively and repeated at 1 and 2 years post-operatively. The results were also compared with clinical outcomes, using (AOFAS scores) both pre, 1 and 2 years post-op. Results: Mean age of patients was 63.3 years (SD 9, range 43 to 80). AOFAS scores showed significant improvement (from 28.8 pre-op to 78.7,76.9 at 12 and 24 months post-op respectively; p

Category: Service improvement Introduction/Purpose: The foot and ankle services at NUTH incorporates both elective and trauma services. The elective service carries out on average 10,500- 11,000 review appointments/ year and 4000-4500 new patient appointments/year. The waiting times for new out-patient appointments were 8-14 weeks. A new pathway was designed with the aim to improve 18 week national target compliance, improve departmental efficiency, and improve patient satisfaction. Methods: A new initial assessment clinic pathways was designed were all new patients are seen in a one hour slot one stop clinic by a dedicated Extended Scope Practitioner. History and clinical examination are taken as well as initial Proms questionnaire, x-ray assessment followed by gate analysis including pain map, treadmill assessment and plantar pressure analysis. A consultant led MDT review of the finding is performed the same week where plan for treatment or further investigations is formulated. Results: A total of 1792 patients had the initial assessment through the new clinic pathway between March 2016 and March 2018. The average waiting time for the initial assessment has been gradually reduced from 14 to 3 weeks. We obtained over 96% patient satisfaction in enhancing patient experience. Conclusion: Our new clinic model has shown to improve efficiency, patient satisfaction and reduce waiting times.

Category: Hindfoot Introduction/Purpose: Arthrodesis is a safe and effective treatment for a number of hind and midfoot conditions. However, non-union rates have historically been reported as high as 41%. A number of factors have been identified that increase non-union rates, the most notable and readily modifiable is a patient’s smoking status. Smoking rates in the UK in 2015 were 19.3% for men and 15.3% for women. We have examined the effect of smoking status (current, ex-smokers and non-smokers) on union rates for a large cohort of patients undergoing hind or midfoot arthrodesis. Methods: This is a single surgeon, retrospective cohort study of consecutive cases. The surgeon’s logbook was used to identify patients undergoing any hind and midfoot arthrodesis procedures from January 2010 until September 2016. Revision procedures and charcot arthropathy cases were excluded along with cases with insufficient records available. Demographic data was collected along with: joints involved, surgical implant used, bone grafting, the use of ultrasound bone stimulation (EXOGEN, Bioventus LLC, Durham, USA) therapy, complications and final outcome with regards to union. Patients were divided according to self-reported smoking status at pre-operative assessment; current smokers, ex-smokers and non-smokers. Union outcome was based on clinical notes and included patient symptoms and radiographic evidence. Delayed union was classed as union occurring after 6 months. The effect of smoking status on deep infection rates and the need for EXOGEN therapy was also analysed. Results: 381 joints were included (see image). The smoking prevalence was 14.0% (accounting for 12.3% of joints) and 32.2% ex-smokers (35.4%). The groups were comparable with regards to gender, diabetes status and BMI. Smokers were younger, had less co-morbidities and were less likely to have had multiple joints fused (p

Category: Hindfoot Introduction/Purpose: Prevalence of degenerative disease of the joints of the foot is likely to be very low in the general population, as demonstrated by a previous cadaveric study (Muehleman et al. Osteoarthritis and Cartilage, 1997; 5 (1): 23-37). We hypothesised that the prevalence of these changes may be higher in patients presenting with ankle arthritis and we report the prevalence of these additional findings and their effect on patient-reported outcomes (PROMS) at presentation. Methods: 247 patients presented to our unit with ankle arthritis, which later went on to require total ankle replacement and were therefore included in our local joint replacement registry. Of these, 125 had available pre-operative MRI imaging. These images were reviewed by an orthopaedic resident and consultant radiologist. Results: 93 patients had evidence of degenerative change to other joints in the foot. The mean number of other joints affected was 1.25. The most common joints affected were the subtalar (67), talonavicular (32), tarsometatarsal (28), naviculocuneiform (21) and calcaneocuboid (5) joints. 92 patients had completed pre-operative FAOS scores. Multiple ANOVA of this data demonstrated no significant difference between the group with only ankle arthritis and those with other degenerative joints in terms of pre-operative FAOS score (p >0.05). In a subset of 19 patients who had pain diagrams available, most patients did not indicate areas of pain in the regions of their other degenerative joints. Pain drawings suggested 0% TMTJ, 25% TNJ and 78% subtalar joints were symptomatic at presentation. Conclusion: Most patients presenting with ankle arthritis will have at least one additional area of significant degenerative joint disease somewhere in the foot. Many of these will not be overtly symptomatic at the time of presentation and number and location of other degenerative joints in the foot does not result in significant differences in pre-operative PROMS, from those reported in patients with only ankle arthritis.

Category: Ankle Arthritis Introduction/Purpose: Total ankle arthroplasty (TAA) has been shown to be an effective treatment for end stage ankle arthritis. Achieving normal anatomical alignment has been shown to be important in long term outcomes and revision rates. Recent data from the British NJR has shown that revision rates are higher in patients with pre-operative fixed equinus. Although there is literature about surgical techniques to deal with pre-operative equinus we are not aware of any papers presenting patient outcomes. We present patient reported outcomes for our cohort of patients with pre-operative fixed equinus compared to those able to achieve a plantigrade ankle. Methods: This is a single surgeon, retrospective cohort study of consecutive cases. A mobile bearing prosthesis was used (Mobility TAA system, DePuy, Raynham, Massachusetts, USA). Cases were identified from a locally held joint registry which routinely records PROMS data pre-operatively and at annual intervals post-operatively. Patients undergoing primary TAA between March 2006 and June 2014 were included, revision procedures along with those with inadequate PROMS data were excluded. PROMS scores used were FAOS (WOMAC Pain, Function and Stiffness), SF-36 scores and patient satisfaction. All pre-operative lateral weight bearing xrays were reviewed to screen for potential fixed equinus deformity (tibia-sole angle >90 degrees). Clinical records were then reviewed to confirm clinical diagnosis of fixed equinus deformity. Results: 259 cases were identified, 95 cases were excluded based on our criteria leaving 164 cases for analysis (mean follow up 61.6 months). 144 were classified as neutral and 20 as fixed equinus. The fixed equinus group were significantly younger (neutral 64.2 vs equinus 53.9, p=0.0002), there was no difference in BMI or length of follow up. There was no difference in baseline scores except WOMAC stiffness, with the fixed equinus group significantly worse (36.9 vs 25.6, p=0.0014). Final PROMS score, change from baseline and patient satisfaction was the same in all domains for both groups. There was no difference in revision rates. Conclusion: A pre-operative fixed equinus deformity does not negatively impact on clinical outcomes in patients undergoing TAA. We are not aware of any previous studies to compare results. As expected the equinus group showed higher levels of stiffness pre-operatively. Contrary to the British NJR dataset we did not find a difference in revision rates.

Category: Midfoot/Forefoot Introduction/Purpose: There is paucity of literature comparing foot and general health status including quality of life between patients presenting with Hallux Valgus and Hallux Rigidus. We aimed to compare foot specific patient reported disability and general health status including higher functional activities and quality of life reported between patients presenting with Hallux Valgus and Hallux Rigidus. Methods: All patients who presented at our hospital foot and ankle clinics (between June 2016 and December 2017) with a diagnosis of primary Hallux Valgus or Hallux Rigidus were included in this prospective study. Patients with associated foot problems, bilateral presentations, h/o previous reconstructive surgeries, and underlying neurological conditions were excluded. These patients were grouped based on diagnosis into Group A (Hallux Valgus) and Group B (Hallux Rigidus). In these patients, differences were studied between groups for scores of MOX-FQ Manchester-Oxford foot questionnaire (Domains: Pain, Walking/Standing, Social activities), EQ-5D EuroQol (UK) and Foot and Ankle outcomes scores (FAOS) (Domains: Pain, symptoms, ADL, Recreation, Quality of Life). Statistical tests between groups included tests for normality, student t’tests and chi square tabulation tests using SPSS software. Results: MOX-FQ differences: - Both groups reported similar level of pain (59.6 ± 22.6 vs. 58.2 ± 23.3); p=0.776; Difficulty with walking/ standing (61.6 vs. 61.4 ); p= 0.960; and restriction with social activity because of foot symptoms (61.6 vs. 59.7 ); p=0.683 EQ-5D: - For mobility, both groups reported no (21.7% vs. 26.8); slight (28.2% vs. 29.2%) or moderate (34.7% vs. 31.7%) problems; p=0.931. For self-care, pain/discomfort, anxiety/ depression levels, there was no differences between groups; p>0.05. Mean overall general health scores was (71.3 ± 22.8) and (69.5 ± 20.8); p=0.663 FAOS: - There was no difference in mean pain score (59.6 vs. 58.2; p=0.776), symptoms (70.3 vs. 63.8; p=0.104), ADL score (p=0.587), difficulty with sport/ recreation (p=0.907) or Quality of Life (p=0.662) between groups Conclusion: - There is no difference in foot related quality of life, general health status and higher functional disability levels between patients presenting with Hallux Valgus vs. Hallux Rigidus. - The impact of these conditions on disability levels remain the same, amidst the difference in pathology

Category: Trauma Introduction/Purpose: The purpose of this study was to compare functional outcome at minimum 2 years follow up post fixation of pilon fractures to that of patients undergoing elective procedure (in the form of TAR or ankle arthrodesis) for primary osteoarthritis of the ankle to assess whether pilon fracture patients would benefit from tibio-talar arthrodesis as a primary procedure rather than fixation to avoid significant functional disability between primary fixation and subsequent arthrodesis. Methods: This is a retrospective study of prospectively collected data of patients operated between April 2012 and December 2015. All patients with primary osteoarthritis undergoing elective TAR/arthrodesis (Group A) had pre-op functional scores recorded (MOX-FQ, EQ-5D and Foot and ankle outcome score FAOS). Patients with bilateral ankle arthritis, previous reconstructive surgery, inflammatory arthritis, hip and knee arthritis, spinal pathology and underlying neurological conditions were excluded from Group A. Patients in Group B (post Pilon fracture fixation with a minimum 2 year follow up) completed a postal questionnaire with the above scores. Outcomes between groups were compared using inferential statistical tests using SPSS. Results: Mean age of patients in Group A and Group B were (62.6 ± 10.9 years) and (46.4 ± 15 years) respectively; p

Category: Ankle Arthritis Introduction/Purpose: There is paucity of literature on quantitative gait changes in patients with increased coronal plane deformity along with end stage ankle arthritis. We aimed to study the difference in spatial temporal parameters of gait and patient reported functional measure in patients with end stage arthritis and no coronal plane deformity vs. varus deformity of >10? Methods: All patients diagnosed with end stage arthritis between April 2016 and December 2017 underwent an objective gait assessment using Tekscan system (BioSense Medicals, UK) as part of routine clinical practice. Of this cohort, patients with bilateral ankle arthritis, previous reconstructive surgery, inflammatory arthritis, hip and knee arthritis, spinal pathology and underlying neurological conditions were excluded. Patients with unilateral ankle arthritis for a diagnosis of osteoarthritis or post traumatic arthritis were included in this study. These patients were grouped into Group A (no coronal plane deformity) vs. Group B (varus deformity of more than 10?). In these patients differences were studied between the groups for temporal spatial parameters of gait and functional disability levels measured by MOX-FQ scores. Statistical tests included normality tests, student t’tests, chi square evaluation and analysis of variance tests with SPSS. Results: Of 33 patients, 22 were in Group A (N=22) and 10 in Group B (N=10). There was no difference in mean age between groups (61.5 vs. 65.07; p=0.335; diagnosis was predominantly OA in both groups MOX-FQ: - There were similar levels of pain (p=0.570), difficulty with walking / standing (p=0.492) and restriction in social activities (p=0.869) reported Quantitative gait measures: - For spatial parameters, there was no difference between groups; p>0.05. - For temporal parameters, there was decreased step time(s) (0.67 vs. 0.61) and mid stance times (0.38 s vs. 0.30 s) in Group B; borderline statistical significance (p=0.052). - There was increase in stride velocity measured in Group B (79.1 ± 22.7 m/s) compared to Group A (64.0 ± 18.1 m/s), (p=0.05). Conclusion: - Although there were no differences in functional levels of pain, difficulty with walking / standing and restriction in social activities, measured by MOX-FQ, there were differences observed in objective gait parameters. - Patients in both groups demonstrated antalgic gait patterns; this was slightly increased in varus group. - There is a trend for reduction in temporal parameters and stride velocity in patients with end stage ankle arthritis and coronal plane deformity >10?, when compared to patients with end stage arthritis and no coronal plane deformity - Larger clinical study with increased sample size is required to confirm these findings.

Category: Ankle Arthritis Introduction/Purpose: There is increasing evidence that outcomes for total ankle arthroplasty (TAA) are not adversely affected by pre-operative varus deformity. There is a sparsity of evidence relating to outcomes in valgus ankle arthritis. We present our outcomes using a mobile bearing prosthesis (Mobility TAA system, DePuy, Raynham, Massachusetts, USA) with a comparison of neutral, varus and valgus ankles. Methods: This is a single surgeon, retrospective cohort study of consecutive cases. Cases were identified from a locally held joint registry which routinely records PROMS data pre-operatively and at annual intervals. Patients undergoing primary TAA between March 2006 and June 2014 were included. Rrevision procedures along with those with inadequate radiographic images for deformity analysis were excluded. Patients with inadequate PROMS data were included in the radiological analysis but not the PROMS analysis. Data collected included FAOS (Womac Pain, Function and Stiffness), SF-36 scores and patient satisfaction. Radiological data was gathered from routinely taken AP weight bearing radiographs pre-operatively, immediately post-operatively and at final follow up. Pre-operative deformity was measured between the tibial anatomical axis and a line perpendicular to the talus. Patients were classified as neutral, varus (≥10 degrees varus) or valgus (≥10 degrees valgus). Results: 230 cases (see image) underwent radiological classification (152 neutral, 60 varus, 18 valgus) and were included in the radiological analysis (mean follow-up 55.9 months). 164 cases were included in the PROMS analysis (mean follow-up 61.6 months). The groups were similar with regards to BMI and length of follow-up but neutral ankles were younger (P

Category: Ankle, Ankle Arthritis Introduction/Purpose: Topographic pain mapping has gained popularity during 20th century, providing opportunities for patients to demonstrate spatial distribution of pain. Despite this, evidence of clinical application in orthopaedics remains largely limited to spinal pathologies. We investigate how clinician interpretation of routine radiological studies compares to patient pain mapping in ankle arthritis. Methods: Between 2014 and 2016 we identified 21 patients ultimately diagnosed with ankle arthritis, who underwent comprehensive gait analysis (including topographic pain mapping) on referral to our institution. Patients were requested to map up to three pain areas, assigning a visual analogue score (VAS) of 0-10, to signify severity of pain in each area. A consultant orthopaedic foot and ankle surgeon, and orthopaedic trainees undertook blinded evaluation of relevant radiological studies, estimating patients’ mapping and VAS scores on the basis of radiological pathology. For the purpose of analysis findings were applied to five distinct regions around the ankle: three anterior (antero-medial; central; and antero-lateral), lateral and medial. Results were correlated between the different assessors, as well as to the patients’ pain mapping, using Spearman’s Rho & Kendall Tau correlation statistics, significance taken as p=0.05). Correlation to patient pain mapping was even poorer, with radiological assessment consistently over- estimating symptom severity (p=>0.05). Conclusion: There is a statistically strong correlation between topographic pain mapping and radiological evaluation of ankle arthritis. We strongly recommend that additional pathology around the ankle is excluded by use of pre-operative MRI imaging prior to surgery for ankle arthritis. Pain from ankle arthritis appears to mask additional soft tissue pathology surrounding the ankle noted on MRI scan.

Category: Ankle Arthritis, Midfoot/Forefoot Introduction/Purpose: There is wide array of outcome tools available for assessment of level of pain and symptoms in osteoarthritis, there are less disease and region specific outcome measures to evaluate the level of disability caused by arthritis in ankle, mid foot arthritis (including Talo-navicular joint, Calcaneo-cuboid joint and tarso metatarsal joints) and 1st Metatarso phalangeal joints. We aimed to measure the level of disability incorporating elements of physical, mental and social well-being using patient reported outcome measures as recommended by the International classification of Functioning, disability and health (ICF) Methods: This is a prospective data series, patients with arthritis of ankle, mid foot or 1st MTPJ who were diagnosed in new patient clinic were asked to take part in this survey. They completed a questionnaire consisting of MOX-FQ (Manchester Oxford Foot Questionnaire), EQ-5D (General Health Status) and FAOS (Foot and Ankle Outcome Scores). Patients were grouped in to 3 groups (Group A - ankle arthritis. Group B - midfoot arthritis (either Talo navicular, Calcaneo-cuboid or TMT joint); Group C - arthritis of 1st Metatarso-phalangeal joint of the foot). The results of summary scores were calculated for responses to individual questions and compared between the groups. Demographic factors were included in the statistical analysis carried out using SPSS Version 22, Illinois. Results are reported as follows Results: There were 26 patients in (Group A); 12 patients in (Group B) and 19 patients in (Group C). There was no difference in mean age of patients between groups (p>0.05) For components in MOX-FQ, there was no difference in pain scores (p=0.353) between the groups. For difficulty with walking/standing, Group A patients reported significantly worse scores (77 ± 19.4) when compared to Group C (53.7 ± 35.5). There was no difference in scores between groups for social function component of MOX- FQ (p=0.487). For EQ-5D, although Group C patients reported higher scores they failed to achieve statistical significance (p>0.05). For FAOS, Group A patients reported significantly lower scores for pain and symptoms, ADL, ability to take part in Sports/Recreation (p=0.008) and Quality of Life (p=0.003). Conclusion: In conclusion, although patients with ankle arthritis, mid foot arthritis and 1st MTP joint arthritis report similar level of disability in terms of general health and social function, patients with ankle arthritis reported higher level of disability in terms of pain, difficulty with standing/ Walking, ability to do Activities of Daily living, ability to take part in recreational activities and overall Quality of Life.

Category: Ankle Arthritis Introduction/Purpose: Pilon fractures of the distal tibia are high energy injuries often occurring in a young patient cohort. Despite optimal acute fracture management, post traumatic osteoarthritis of the tibiotalar joint is a common corollary. Standard treatment is by way of tibiotalar arthrodesis, however the lack of motion at the ankle afforded by this treatment is often poorly tolerated by patients and can lead to arthrosis of adjacent joints. Total ankle replacement (TAR) offers an attractive pain relieving and motion preserving option for this patient subgroup. Here we report the two-year patient reported outcome measures for a cohort of patients undergoing TAR for osteoarthritis secondary to tibial pilon fracture and compare them to the outcomes for other indications for total ankle replacement. Methods: The results of patient-reported outcome measures (PROMs) for TAR performed between March 2006 and November 2014 by a single surgeon at a single institution in the United Kingdom were reviewed. Data collected included Foot and Ankle Outcome Scores (FAOS) (WOMAC pain/stiffness/function); SF-36 General Health Questionnaire; number of comorbidities; self- reported BMI and patient satisfaction scores. Time points for data collection were pre-operatively and then at one and two years post-operatively. Clinical notes and radiographs were reviewed to highlight the indication for TAR and were categorised into the following sub-groups: osteoarthritis (OA); rheumatoid arthritis (RA); arthritis following pilon fracture; arthritis following ankle fracture; and post-traumatic arthritis without previous fracture (PTOA). FAOS and SF-36 were analysed using a general linear model to assess variance and by way of repeated measures ANOVA. Demographic data was assessed using student t-test and chi- squared analysis. Patient satisfaction scores were evaluated using cross-tabulation and chi-squared examination. Results: The pilon fracture group had the youngest average age and highest BMI (56.5 years; mean BMI 31.6). There was no statistically significant difference in number of reported comorbidities between subgroups (p>0.05). Significant improvement in FAOS pain, function and stiffness scores was seen in all subgroups from pre-operatively to one year post-operatively (p=0.01, 0.05 and 0.03 respectively). No further statistically significant improvement in the same scores was seen at two years. SF-36 analysis demonstrated similar results for all subgroups. There was general improvement in all parameters except for general health (p=0.890 at one year) and reduction in physical function in the RA group from first to second post-operative years (p=0.046). Patient satisfaction survey showed similar results for all subgroups. Conclusion: Our study has demonstrated that statistically significant improvement is seen in FAOS pain, function and stiffness scores in all subgroups of patients undergoing TAR by one year post surgery and that this improvement is maintained by two year follow up. There was no major difference in any of the reported outcomes between subgroups by two years post-operatively, suggesting that TAR performed for arthritis secondary to pilon fracture is a realistic alternative to tibio-talar arthrodesis.

For children with drug-resistant epilepsy (DRE), seizure freedom relies on the delineation and resection (or ablation/disconnection) of the epileptogenic zone (EZ) while preserving the eloquent brain areas. The development of a reliable and noninvasive localization method that provides clinically useful information for the localization of the EZ is, therefore, crucial to achieving successful surgical outcomes. Electric and magnetic source imaging (ESI and MSI) have been increasingly utilized in the presurgical evaluation of these patients showing promising findings in the delineation of epileptogenic as well as eloquent brain areas. Moreover, the combination of ESI and MSI into a single solution, namely electromagnetic source imaging (EMSI), performed on simultaneous high-density electroencephalography (HD-EEG) and magnetoencephalography (MEG) recordings has shown higher source localization accuracy than either modality alone. Despite these encouraging findings, such techniques are performed in only a few tertiary epilepsy centers, are rarely recorded simultaneously, and are underutilized in pediatric cohorts. This study illustrates the experimental setup for recording simultaneous MEG and HD-EEG data as well as the methodological framework for analyzing these data aiming to localize the irritative zone, the seizure onset zone, and eloquent brain areas in children with DRE. More specifically, the experimental setups are presented for (i) recording and localizing interictal and ictal epileptiform activity during sleep and (ii) recording visual-, motor-, auditory-, and somatosensory-evoked responses and mapping relevant eloquent brain areas (i.e., visual, motor, auditory, and somatosensory) during visuomotor task, as well as auditory and somatosensory stimulations. Detailed steps of the data analysis pipeline are further presented for performing EMSI as well as individual ESI and MSI using equivalent current dipole (ECD) and dynamic statistical parametric mapping (dSPM).

Background: Tuberculosis (TB) as a foremost infectious disease adds massive burden to morbidity and mortality rate, despite of well-structured TB control programs around the globe. Inappropriate health care management system and poor implementation on standard in relevance to TB, remain some reasons causative to TB prevalence and its rising antimicrobial resistance. Health Care Workers (HCWs) laboring as a part of TB control system, are the vital warriors in achieving the goals of TB End Strategy by 2035. Their performance is influenced by their knowledge, attitude, and practices (KAP) toward this infectious disease. This study aimed to signify the role of KAP score of health care Workers in the better control and prevention of TB in the Islamabad Capital Territory (ICT), Pakistan., Methods: A cross-sectional study on Knowledge, Attitude and Practice study of Tuberculosis (TB) among health care Workers, was done in ICT, which is the capital of Pakistan. The KAP of TB was collected for the 306 Health Care Workers from all the Islamabad TB referring health facilities which refer the TB patients for testing to the National Reference Laboratory, Islamabad Pakistan. Eligible health care workers were requested to respond on KAP questionnaire after informed consent. KAP questionnaire comprised of knowledge, attitude, and practices section including demographic information. All the data was analyzed using IBM SPSS statistics 21. One Way Analysis of Variance (ANOVA) was applied to calculate KAP mean score against different variables. On the significant data sets of ANOVA output, Tukey's Multiple Comparison Test was applied for pairwise comparison. Pearson correlation coefficient was utilized to explore the association between two qualitative variables. The non-parametric tests were applied to evaluate difference of KAP score in relation to demographic covariates individually., Results: From June to July 2023, we conducted TB KAP study among Health Care Workers of ICT, Pakistan. The average age was 33 years (range 26-30 years). Majority of the recruited subjects were not being trained for dealing with TB infection. The results demonstrated that Health Care Workers working were lacking their knowledge about mode of TB transmission, best diagnostic technique, and contraction of TB infections. The mean knowledge, attitude and practices mean scores were 15.05 (SD = 3.96), 83.68 (SD = 15.74) and 6.31 (SD = 2.21), respectively. Mean knowledge score of Health Care Workers were significantly related to their educational level and occupation while no significant association was declared with working experience as TB staff. Pearson coefficient of attitude score with knowledge of Health Care Workers was of weak level (0.28). Practice mean score was correlated to knowledge mean score at a moderate level (r = 0.40). On the other hand, practice score was r = 0.29 with attitude mean score had shown weak level correlation. A number of demographic factors were strongly linked to each of the mean score of knowledge, attitude, and practices., Conclusion: These findings highlighted the significant involvement of education, profession, and professional trainings in the better knowledge, attitude, and practices of the TB related health care Workers. For a better management system of infectious diseases like TB, a well-trained and professionally competent staff of Health Care Workers is important so as to achieve the goal of TB-End strategy by 2035 from Pakistan, which is the 5th highest burden country for TB., Competing Interests: Declaration of competing interest The authors affirm that the research was conducted in the absence of any commercial or financial assistance that could be taken as a potential conflict of interest., (Copyright © 2024. Published by Elsevier B.V.)