Bilateral STT Arthrodesis in a Young Patient with Occult Proximal Row Coalition

Background Carpal coalitions have an incidence of 0.1 to 1% in Caucasians and up to 8 to 9% in African populations. They rarely cause clinical problems requiring investigation or treatment, but are commonly identified on imaging obtained for other indications. Case Description We report a case of a 35-year-old male with progressive degenerative change of incomplete coalitions of the scaphotrapeziotrapezoid joint (STT) in the presence of bilateral complete osseous lunate–triquetral coalitions (Minnaar type 4). He was successfully treated with staged bilateral arthrodesis with excellent symptom resolution and preservation of function. Literature Review In patients with isolated STT coalition six reports of surgery exist, two of which were for arthrodesis. This is the first described case of STT arthrodesis in a patient with coexistent lunate–triquetral coalition. Clinical Relevance The STT arthrodesis remains a safe and effective treatment for STT pain even in cases of occult carpal coalition. Functional range of movement was well preserved. Level of evidence This is a Level V study.

Chyavanprash: A Multimodal Approach to COVID-19 Management

The word Chyavanprash (CP) comprises of ‘Chyawan’ and ‘Prasha’. Chyavan represents ‘degenerative change’ and Prasha symbolises a drug. Enhancement of immunity and longevity of life were the main reasons for which CP was consumed since ancient times. CP has about 50 herbs, spices and minerals along with a range of pharmacological activities on almost all organ systems of the human body. COVID-19 actually means coronavirus disease 2019. COVID-19 targets and affects multiple organs like lungs, heart, kidney etc, thus increasing the mortality and morbidity rates. The medication cost and side effects have made the allopathic system of medicine the least sought after. The rapid spread rate of the infection has urged mankind to look at alternative remedies to fight the novel coronavirus. AYUSH is a government organisation under the Ministry of Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy which aims to promote indigenous alternative medicine systems in India. AYUSH recommends various measures to fight the novel coronavirus infection. Chyavanprash is one such important formulation proposed by the AYUSH for COVID-19. The purpose of our review is to highlight the constituents and pharmacological activities of CP in the prophylaxis, manage and treatment of COVID-19 by collecting and compiling the published research on COVID-19. The review also focuses on understanding the mechanism behind the multimodal activity of CP. References relevant to our topic were screened based on relevance to our topic.

1301 Early MRI in the Diagnosis of Suspected Scaphoid Fractures – An Audit of a Redesigned Diagnostic Pathway

Introduction MRI is the gold standard for investigation of suspected scaphoid fractures, which can be missed on initial x-rays. This full cycle audit reports the impact of our new patient pathway, which changes repeat x-rays at 2 weeks to urgent limited sequence scaphoid MRI for those with normal initial x-rays, but clinical suspicion of fracture at initial clinic visit. Method A second cycle audited MRI requests for suspected scaphoid fractures at Southmead hospital following implementation of the new pathway in October 2020. We collected wait times from request to scan, and radiologist reports. Results were compared to our first cycle, 6-month time period. Results he results for 24 limited sequence MRIs via our new pathway were compared to 134 full wrist MRIs of the first cycle. Two scans (9.1%) were positive for scaphoid fracture versus 12% in the first cycle. 19 scans (86%) identified alternate pathology including sprain (6), bone bruise (5), non-scaphoid fractures (4) and degenerative change (3). 1 scan (4.5%) was reported as normal. 73% of MRIs were performed within 14 days, compared to 63% in previous cohort. Conclusions Our new pathway using limited sequence MRI identified similar rates of scaphoid fractures. Reduced time to MRI was observed compared to the previous cohort due to shorter scan durations and resulted in earlier diagnosis and fewer outpatient follow-up appointments. Our new pathway has benefits to patient experience and also reduces footfall in hospital, during a time of global Covid-19 pandemic, with no increase in costs.

A Prospective Observational Study on Prescription Pattern and Its Efficacy in the Management of Osteoarthritis at Multispecialty Teaching Care Hospital

Background: osteoarthritis is a severe clinical condition in elderly patients. Almost any bone can fracture as a result of the increased bone fragility of osteoarthritis. Aim and Objective of study: The principle aim of drug utilization research is to facilitate the rational use of drugs in an individualized patient. To Study current prescription pattern and its efficacy to manage osteoarthritis. Methodology: This study was a prospective observational study and conducted over a period of six month from October 2015 to March 2016. Patients diagnosed with arthritis with or without co-morbidities were enrolled in the Study considering the inclusion and exclusion criteria. The main sources of data collection were OPD file and case sheets of patients. Results: In this study 148 patients were enrolled, 105 (70.9%) female patients and 43 (29.1%) male patients were participated. Out of 148 study participants 60 (40.54%) patients from age group 51-65 years, followed by 54 (36.48%) patients from age group 36-50 years. In the study population 94 (63.51%) patient were suffering osteoarthritis of both knee, 29 (19.59%) patients were suffering osteoarthritis of right knee and 25 (16.89%) patients were having osteoarthritis of left knee. X-ray report were representing in study population, in 44 patient reports were shows degenerative change seen in both knee, 08 patient report were shows degenerative change seen in right knee. In our study out of 148 patients, 92 (62.16%) patients prescribed NSAIDs, 25 (16.89%) patients prescribed Analgesic, 05 (03.37%) patients were prescribed Opioid analgesic, 11 (07.43%) patients were prescribed supplements and 15 (10.13%) patients received other class of drugs. Among the study population 112 (75.67%) patients were received oral route of drugs and 36 (24.32%) Patients were prescribed topical preparation. The visual analogue scale has been categorized as follows 0-3 Mild pain, 4-7 Moderate pain and 8-10 severe pain. In visual analogue scale initially 16 patients were suffering mild pain, but after treatment it was 93 patients suffering mild pain. The facial pain scale has been categorized as follow 0 = very happy, no hurt, 2 = hurts just a little bit, 4 = hurts a little more 6 = hurts even more, 8 = hurts a whole lot, 10 = hurts as much as you can imagine. Among 148 study participants 14 patients were having final Facial pain score 0, 67 patients were having a final Facial pain score 2 and 3 patients having Initial Facial Pain score 2, 42 patients were having a final Facial pain score 4 and 42 patients having Initial Facial pain score 4, 19 patients were having a final Facial pain score 6 and 63 patients having Initial Facial pain score 6, 06 patients were having final Facial pain score 8 and 33 patients having Initial Facial pain score 8, 07 patients having Initial Facial score 10. Conclusion: The principal aim of drug utilization research is to facilitate the rational use of drugs in an individualized patient. For the individual’s patients, the rational use of a drug implies the prescription of the well documented drug at optimal dose, together with the correct information, at an affordable price.

Histomorphological spectrum of Leiomyoma – a one year retrospective study

Aims: To analyze the histomorphology of leiomyoma in specimens received in Pathology. Methods: This is a retrospective descriptive study of histopathology database of histomorphologic spectrum of leiomyoma at Pathology Laboratory of Nobel Medical College Teaching Hospital, Biratnagar, Nepal from April 2020 to April 2021. Data for the leiomyoma were analyzed descriptively. Ethical approval was obtained from the Institutional review committee. Results: A total of 1705 histopathology specimens were received in one year from April 2020 to April 2021 out of which 620 (37%) were from the Department of Gynecology and Obstetrics for histopathological analysis of various specimens. Total of 106 specimens of hysterectomy and myomectomy were included. Maximum number of leiomyoma was seen in the body 48 (45%) followed by fundus 34 (32%) and one from the lateral wall of the vagina 1 (0.9%). Mean age was 42 (24-70) years. Maximum size was 35 cm and minimum was 0.5 cm in diameter. Out of the rare ones one case of STUMP, Lipoleiomyoma and Mitotically active leiomyoma each were seen. Degenerative change was in 40 cases with hyaline type as the commonest one (33%); 61% were intramural; and 12% were multiple. Presentation was lower abdominal pain and abnormal uterine bleeding in 39.6%. Conclusions: Cases of leiomyoma may present with abdominal mass, pain and bleeding but the degenerative changes and malignant transformation can't be identified without histopathological examination.

TESSYS Technique With Small Grade of Facetectomy Has Potential Biomechanical Advantages Compared to the In-Out TED With Intact Articular Process : An In-Silico Study

Background: The facetectomy was reported as an important procedure in both in-out and out-in (i.e. transforaminal endoscopic spine system (TESSYS)) techniques in the transforaminal endoscopic discectomy (TED), and which was also related to the deterioration of postoperative biomechanical environment and related poor prognosis. Recently, the facetectomy was reported to be avoided in the modified in-out TED, but iatrogenic injury of annulus and related larger grades of nucleotomy can also be seen as risk factors for the prognosis deterioration. Meanwhile, above mentioned risk factors can be alleviated in TESSYS TED, and the grade of facetectomy can also be reduced in this surgery with the use of endoscopic dynamic drill. Methods: To evaluate the risk of biomechanical deterioration and related postoperative complications of these two surgical modified strategies in TED, an intact lumbo-sacral finite element model and the corresponding model with adjacent segments degeneration have been constructed and validated, modified in-out and TESSYS TED have been simulated in these models. Then, the change of biomechanical indicators have been computed to evaluate the risk of postoperative complications in the surgical segement. Results: Compared with intact FEA models, the tendency of biomechanical deterioration in TESSYS TED models was generally slight. By contrast, obvious biomechanical deterioration can be observed in models with modified in-out TED. The degenerative change in adjacent segments magnifies rather than alters the overall tendency of biomechanical change. Conclusions: Modified TESSYS TED with a small grade of facetectomy has potential biomechanical advantages compared with the in-out TED with intact articular process (i.e. without facetectomy). The iatrogenic injury of annulus and larger grade of nucleotomy can be seen as risk factors for postoperative biomechanical deteriorations and complications in the surgical segment.

Ankle Instability Patients Exhibit Altered Muscle Activation of Lower Extremity and Ground Reaction Force during Landing: A Systematic Review and Meta-Analysis

This review aimed to investigate characteristics of muscle activation and ground reaction force (GRF) patterns in patients with ankle instability (AI). Relevant studies were sourced from PubMed, CINAHL, SPORTDiscus, and Web of Science through December 2019 for case-control study in any laboratory setting. Inclusion criteria for study selection were (1) subjects with chronic, functional, or mechanical instability or recurrent ankle sprains; (2) primary outcomes consisted of muscle activation of the lower extremity and GRF during landing; and (3) peer-reviewed articles with full text available, including mean, standard deviation, and sample size, to enable data reanalysis. We evaluated four variables related to landing task: (1) muscle activation of the lower extremity before landing, (2) muscle activation of the lower extremity during landing, (3) magnitude of GRF, and (4) time to peak GRF. The effect size using standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for these variables to make comparisons across studies. Patients with AI had a lower activation of peroneal muscles before landing (SMD = -0.63, p < 0.001, CI = -0.95 to -0.31), greater peak vertical GRF (SMD = 0.21, p = 0.03, CI = 0.01 to 0.40), and shorter time to peak vertical GRF (SMD = -0.51, p < 0.001, CI = -0.72 to -0.29) than those of normal subjects during landing. There was no significant difference in other muscle activation and GRF components between the patients with AI and normal subjects (p > 0.05). Altered muscle activation and GRF before and during landing in AI cases may contribute to both recurrent ankle and ACL injuries and degenerative change of articular.

P043 Fascinating phosphate: seek and you will find

Background/Aims A 62-year-old accountant was referred to the metabolic bone clinic with a 2 year history of thoracic back pain and a persistently raised ALP. There were no associated red flags for her back pain. She had a history of a gluteal lump, thought to be benign, for which she had declined excision. She has hypertension and had a previous navicular fracture. Medications included bendroflumethiazide and Adcal D3. She had restriction in neck movements and was tender to percussion in the thoracic spine. There was no proximal weakness or focal neurology. Systems and joint exam were unremarkable. Methods The case is discussed below. Results Salient abnormal results on presentation were a raised ALP of 207 and corrected calcium of 2.34. PTH was elevated at 8.2 (NR:1.6-6.9), Vitamin D 79 and a low phosphate of 0.34 (NR:0.8-1.50). Alkaline phosphatase isoenzymes showed the raised level came from bone. Protein and urine electrophoresis were normal. A bone density scan was normal, and a recent thoracic MRI showed only degenerative change. An isotope bone scan was requested and was reported to show increased activity in the nasal bone, maxilla and both orbits, raising the possibility of Paget’s disease. However, when reviewed in the Radiology meeting with a skull x-ray, the appearances were not felt to be in keeping with Paget’s. Despite physiotherapy, hydrotherapy, acupuncture and neuropathic medication the patient’s back pain continued. Her phosphate remained low and her calculated tubular reabsorption of phosphate from a 24h urine collection (TmP/GFR) was low at 0.42mmol/l (NR 0.80-1.35). She was started on phosphate replacement and calcitriol, and Adcal D3 was continued. The Fibroblast Growth Factor (FGF) 23 levels were sent and came back significantly elevated at 1380 (NR &lt; 100). A 68Ga DOTA-TATE scan (whole body PET/CT scan), confirmed the right gluteal lump as the source of the FGF 23. The patient went on to have an excision biopsy and histology confirmed a mesenchymal tumour of the right buttock. Her phosphate replacement was gradually weaned, but on reducing the dose phosphate levels dropped and her symptoms returned. The repeat TmP/GFR was again low at 0.61, and FGF 23 levels were still raised at 204. A repeat 68Ga DOTA-TATE scan, 4 years after the first one, showed recurrence of the right gluteal lesion and a possible small lesion in the left gluteal muscle. She has been sent for further excision. Conclusion Tumour induced osteomalacia (TIO) is a rare condition and should be considered in cases of hypophosphataemia. Classical symptoms are proximal weakness and muscle and bone pain. They are typically associated with small benign tumours (most commonly mesenchymal tumours) which may be difficult to find. Excision is curative but if small amounts of tumour remain, relapses may occur. Disclosure J. Bakshi: None. C. Batten: None.

A Series of Pure Ankle Dislocations without Associated Fracture: Our Clinical Experience

Background: Pure ankle dislocation without associated fracture is extremely rare, thus the literature almost limited to case reports and small case series. The standardized treatment protocol is in controversy and the studies of mechanism and outcome of the injury are still deficient. We report a series of eight cases of pure tibiotalar dislocations managed with emergency reduction and other heterogenic procedures, hoping to add some material to the published data on this topic and present our clinical experience.Methods: We retrospectively reviewed the eight cases of isolated ankle dislocations without associated fracture that were treated in our department from 2015 to 2019. Results: The eight cases were all posteromedial dislocations with six open and two closed. Emergency reduction was performed for all patients followed by average 6 weeks’ immobilization with external fixators in five and short leg cast in three. The mean follow-up period was 33 (range, 12 to 61) months. None of the eight patients showed obvious instability though only one patient underwent ligaments repair. The average range of motion (ROM) loss of the ankles was 10 degrees for plantarflexion and 3 degrees for dorsiflexion. Two patients complained of moderate stiffness and three complained of persistent mild pain in whom degenerative change was found. Neurovascular sequela was presented in one patient with numbness. Only one patient developed superficial infection. The average AOFAS score was 90 (range, 78 to 100) points at the final follow-up with five ankles rated as excellent and three rated as good. All of the eight patients returned to their prior daily life and the two closed patients with sports injuries resumed sports activity.Conclusion: Pure ankle dislocation is a rare ligamentous ankle injury with complicated mechanism. Most of the injuries treated with emergency reduction and thorough debridement followed by a short period of immobilization and functional rehabilitation have good clinical outcomes. Ligaments repair should only be considered in cases of chronic ankle instability after failed conservative treatment.