Tibial Plateau Leveling Following Tibial Tuberosity Advancement: A Case Series

Persistent stifle instability is a recognized complication following tibial tuberosity advancement techniques (TTAT). The aim of this study is to report the feasibility and outcome of tibial plateau leveling techniques (TPLT) to treat dogs with persistent lameness, suspected to be secondary to persistent stifle instability, following (TTAT). Medical records of dogs presented for persistent lameness after TTAT were reviewed. Preoperative data included orthopedic examination, lameness score and radiographs. Inclusion criteria included performance of a surgery to address persistent lameness and suspected instability. Short-term follow up data included orthopedic examination and radiographs of the stifle. Long-term follow up was based on postoperative Liverpool Osteoarthritis in Dogs (LOAD) questionnaire. Seven dogs were included in the study. Mean subjective preoperative lameness score was 3 ± 1.53. Mean preoperative patellar ligament angle relative to the tibial plateau (PLATP) was 94° and mean tibial plateau angle (TPA) was 28°. Six dogs had tibial plateau leveling osteotomy and one had modified cranial closing wedge ostectomy. Mean postoperative PLATP was 79° and mean TPA was 5°. Mean subjective lameness score at follow up was 0.57 ± 0.49. Minor complications were present in 2 dogs and major complication in 1 dog. Mean LOAD questionnaire score was 6.6/52. TPLT can be performed after TTAT and may improve clinical function and stability in these cases in which persistent instability is suspected.

Central African Republic

Central African Republic (car) has been a theatre of instability for decades, especially following the 2013 coup, which saw crimes that have been found to be premeditated and systematic. This article identifies states collapse, persistent instability and impunity as key factors engendering atrocity crimes in car. Despite the overwhelming evidence of the risk of atrocity crimes, the international response has been inadequate if not passive, and interventions do not consider atrocity prevention in their execution. Thus, subsequent peacebuilding initiatives have not had real and visible impact on the prevention of atrocity crimes. To address this, the establishment of an accountable and functioning state is the overriding condition precedent to preventing and mangaging atrocity crimes in car. The international community should further engage local actors to promote inclusive governance and lay the foundations for stability and sustainable peace. Subsequent restoration of structures for justice and ensuring their effective functioning will help end structural impunity in the country and go a long way in averting future atrocity crimes.

Indications and outcomes of glenoid osteotomy for posterior shoulder instability: a systematic review

Background There is limited evidence examining glenoid osteotomy as a treatment for posterior shoulder instability. Methods A search of Medline, Embase, PubMed and Cochrane Central Register of Controlled Trials was conducted from the date of origin to 28th November 2019. Nine out of 3,408 retrieved studies met the inclusion criteria and quality was assessed using the Methodological Index for Non-randomized Studies tool. Results In 356 shoulders, the main indication for osteotomy was excessive glenoid retroversion (greater than or equal to approximately −10°). The mean preoperative glenoid version was −15° (range, −35° to −5°). Post-operatively, the mean glenoid version was −6° (range, −28° to 13°) and an average correction of 10° (range, −1° to 30°) was observed. Range of motion increased significantly in most studies and all standardized outcome scores (Rowe, Constant–Murley, Oxford instability, Japan Shoulder Society Shoulder Instability Scoring and mean shoulder value) improved significantly with high rates of patient satisfaction (85%). A high complication rate (34%, n = 120) was reported post-surgery, with frequent cases of persistent instability (20%, n = 68) and fractures (e.g., glenoid neck and acromion) (4%, n = 12). However, the revision rate was low (0.6%, n = 2). Conclusion Glenoid osteotomy is an appropriate treatment for posterior shoulder instability secondary to excessive glenoid retroversion. However, the high rate of persistent instability should be considered when making treatment decisions. Level of Evidence: Systematic review; Level 4

Comparable outcome for autografts and allografts in primary medial patellofemoral ligament reconstruction for patellofemoral instability: systematic review and meta-analysis

Purpose This study updates the current evidence on the role of allografts versus autografts for medial patellofemoral ligament (MPFL) reconstruction in patients with patellofemoral instability. Methods The study was performed according to the PRISMA guidelines. In March 2021, a literature search in the main online databases was performed. Studies reporting quantitative data concerning primary MPFL reconstruction using an allograft were considered for inclusion. The Coleman Methodology Score was used to assess the methodological quality of the selected articles. Results Data from 12 studies (474 procedures) were retrieved. The mean follow-up was 42.2 (15–78.5) months. The mean age was 21.1 ± 6.2 years. 64.9% (285 of 439) of patients were female. At the last follow-up, the Tegner (p < 0.0001), Kujala (p = 0.002) and the Lysholm (p < 0.0001) scores were minimally greater in the autografts. The similarity was found in the rate of persistent instability sensation and revision. The allograft group evidenced a lower rate of re-dislocations (p = 0.003). Conclusion Allografts may represent a feasible alternative to traditional autograft for MPFL reconstruction in selected patients with patellofemoral instability. Allograft tendons yielded similar PROMs, rates of persistent instability, and revision. Allograft reconstructions tended to have modestly lower re-dislocation rates. Level of evidence IV.

Need of additional iridotomies despite lens extraction in spherophakes

Spherophakes are known to have irregular anterior chamber (AC) depths due to their poorly supported zonules. This irregularity leads to an unstable AC, often resulting in angle closure glaucoma from anterior subluxation of globular lenses. A peripheral iridotomy may be helpful to encourage aqueous drainage in initial stages, however, is not often required once lens is extracted. But, we have observed persistent instability of AC in spherophakic eyes despite lens extraction, leading to frequent iridocorneal contact locally over some quadrants. The presumed aetiology in such scenarios could be constant anteroposterior instability of IOL-bag complex due to generalised zonulopathy and hence localised iris bombe in areas with previous iridocorneal contact. Timely identification and performing additional iridotomies during surgery at such sectors even after lens extraction facilitated symmetric deepening of the AC. Hence, we recommend use of additional iridotomies at areas with persistent iridocorneal contact even after lens extraction.

Contribution and Complications of Instability in the Lives of Street-Involved Youth

Unlike most emerging adults, for whom instability is new, for street-involved youth instability is a lifelong experience, beginning in early childhood. Chapter 3 portrays the experience of frequent changes in housing, frequent fluctuations in guardian arrangements, and adjustments related to parental mental health, addiction, and abuse and neglect. As a result of these unique circumstances, street-involved youth often embrace change and assume responsibility for themselves in the midst of instability. At the same time, persistent instability interferes with attachment to work and to education.

ACL reconstruction for all is not cost-effective after acute ACL rupture

ObjectivesTo conduct a cost-utility analysis for two commonly used treatment strategies for patients after ACL rupture; early ACL reconstruction (index) versus rehabilitation plus an optional reconstruction in case of persistent instability (comparator).MethodsPatients aged between 18 and 65 years of age with a recent ACL rupture (<2 months) were randomised between either an early ACL reconstruction (index) or a rehabilitation plus an optional reconstruction in case of persistent instability (comparator) after 3 months of rehabilitation. A cost-utility analysis was performed to compare both treatments over a 2-year follow-up. Cost-effectiveness was calculated as incremental costs per quality-adjusted life year (QALY) gained, using two perspectives: the healthcare system perspective and societal perspective. The uncertainty for costs and health effects was assessed by means of non-parametric bootstrapping.ResultsA total of 167 patients were included in the study, of which 85 were randomised to the early ACL reconstruction (index) group and 82 to the rehabilitation and optional reconstruction group (comparator). From the healthcare perspective it takes 48 460 € and from a societal perspective 78 179 €, to gain a QALY when performing early surgery compared with rehabilitation plus an optional reconstruction. This is unlikely to be cost-effective.ConclusionRoutine early ACL reconstruction (index) is not considered cost-effective as compared with rehabilitation plus optional reconstruction for a standard ACL population (comparator) given the maximum willingness to pay of 20 000 €/QALY. Early recognition of the patients that have better outcome of early ACL reconstruction might make rehabilitation and optional reconstruction even more cost-effective.

Building the ship in dry dock: The case for pre-independence constitution-building in Scotland

For newly independent states, constitution-building can be a defining moment: a time when national identities are asserted, values and norms articulated, and founding myths created. The constitution-building process is a critical juncture between the divergent paths of stable and well-functioning democracy, on one hand, or persistent instability, coups, repression, and state failure, on the other. But what is the proper relationship of constitution-building to state formation? Should constitution-building occur before or after state formation? Or should the two processes somehow proceed in parallel? To address these questions in a Scottish context, this article draws on state-formation and constitution-building processes in the Westminster-derived tradition. The article considers the advantages and disadvantages of these sequences, and discusses the circumstances in which they might be applicable. It concludes by making some tentative recommendations for a pre-independence constitution-building process in Scotland.

CAR faces challenging path towards peace and elections

Subject Outlook for the Central African Republic's peace process and elections in 2020. Significance After five years of persistent instability, a reduction in violence and humanitarian pressures finally arrived after a new peace agreement was agreed in Khartoum in early 2019. The state has moreover begun to extend its administrative reach and reconstruct its security forces. However, stability is far from restored and 2020 will offer a new set of challenges as elections approach at year-end. Impacts The UN will push to see elections held on time and a planned Truth, Justice, Reparation and Reconciliation Commission established promptly. Sporadic violent incidents will continue; conditions are particularly fragile in Bangui’s PK5 district and in the far north. Former President Francois Bozize’s return from exile and mooted presidential bid will raise political tensions.