bluuebunny/crossref_metadata_2025 huggingface dataset:
Ambient light exposure of photostimulable phosphor plates: is there a safe limit for acceptable image quality?
Authors: Sampaio-Oliveira Matheus , Marinho-Vieira Luiz Eduardo , Haiter-Neto Francisco , Freitas Deborah Q , Oliveira Matheus L
Published: July 2023

Objectives:

To subjectively assess radiographs obtained with photostimulable phosphor (PSP) plates exposed to clinical levels of ambient light prior to read-out to potentially set a safe limit for acceptable image quality.

Methods and materials:

Six dental regions of a dry human skull were X-rayed using PSP plates from VistaScan and Express under four exposure times: 0.1, 0.2, 0.32, and 0.4 s. Before read-out, the PSP plates were exposed to ambient light for 0, 5, 10, 30, 60, and 90 s. Six observers were asked to classify the 288 resulting radiographs as acceptable or unacceptable based on the identification of anatomical structures and global image quality. The number of answers classifying radiographs as unacceptable was used to calculate a rejection rate; a pairwise comparison for better image quality was further conducted among radiographs considered acceptable. Reproducibility was tested by having 25% of all experimental groups reassessed.

Results:

Intra- and interobserver agreement ranged from 0.87 to 1.00 and from 0.81 to 0.92, respectively. Exposure of PSP plates to ambient light increased rejection rates mostly as of 10 s. In the pairwise comparison, subtle differences were observed between radiographs obtained with PSP plates not exposed and those exposed to ambient light for 5 s.

Conclusions:

Ambient light exposure of PSP plates impairs the image quality of radiographs. A safe limit of ambient light exposure of 5 s for VistaScan and Express should be considered. Ambient light exposure of PSP plates within safe limits can avoid retakes and reduce unnecessary patient exposure to X-rays.
Co-existence of blaIMP, blaNDM-1, and blaSHV, genes of Pseudomonas aeruginosa isolated from Quetta: Antimicrobial resistance and clinical significance
Authors: Mohammad Din  , Awan Mohammad Arif , Sadeeq ur Rahman  , Mohammad Ali  , But Momina Aslam
Published: July 2023

Objective: Molecular detection and co-presence of carbapenem-resistant genes in the isolates of Pseudomonas aeruginosa are less commonly reported from Quetta. In the present study, we determined to highlight the antibiotic sensitivity profile and genetic mechanism of carbapenem resistance.

Methods: The cross-sectional study was conducted from May to September 2018 at the Hi-tech laboratory, Centre for Advance Studies in Vaccinology and Biotechnology, University of Baluchistan, Quetta. Biochemical and molecular methods were ascertained for the recognition of the isolates and minimum inhibitory concentration was performed using E-test and broth microdilution methods. The molecular basis of carbapenemase activity was determined by identifying carbapenemase genes in the isolates.

Results: Of the (n=23) P. aeruginosa isolated from pus aspirates obtained from surgical/burn units, we have detected blaIMP (n=7/8) 87.5%, blaNDM-1 (n=5/8) 62.5%, and blaSHV (n=4/8) 50%. The co-existence of multiple antibiotic-resistant genes, blaIMP, blaNDM-1 and blaSHV was found in (n=2/8) 25% isolates. These isolates displayed resistance against a range of antimicrobials from β-lactams, tetracyclines, cephalosporins, quinolones, monobactams, aminoglycosides, sulphonamides, phosphoric acid, macrolides, and polypeptide groups, suggesting extensive-drug resistance.

Conclusion: The emergence of MBL and ESBL producers is an alarming threat in the region. It is of great importance to determine the resistance mechanism of bacterial bugs. The lack of new antimicrobials particularly against gram-negative bacteria is quite alarming worldwide.

doi: https://doi.org/10.12669/pjms.39.5.7188

How to cite this: Din M, Awan MA, Sadeeq ur Rahman, Ali M, Aslam M. Co-existence of blaIMP, blaNDM-1, and blaSHV, genes of Pseudomonas aeruginosa isolated from Quetta: Antimicrobial resistance and clinical significance. Pak J Med Sci. 2023;39(5):---------.  doi: https://doi.org/10.12669/pjms.39.5.7188

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Burnout and Health Related Quality of Life among emergency physicians working at emergency at Tertiary Care Hospital in Lahore Pakistan
Authors: Sarwar Shahid , Mahmood Asma , Farooq Raja Mahnoor , Mahmud Yasir
Published: July 2023

Objective: To determine frequency of burnout in emergency physicians and to identify its impact on their health-related quality of life (HRQOL).

Methods: In this cross-sectional study, physicians from departments with emergency cover of Jinnah Hospital Lahore were included. Their burnout and HRQOL scores using Maslach Burnout Inventory (MBI) and Short Form (SF)-36 respectively were determined in March 2022. Burnout scores were graded as low, moderate and high and were correlated with domains of HRQOL using chi X2 and analysis of variance (ANOVA).

Results: One hundred fifty physicians were included with mean age 26.2 (±2.59), male to female ratio 0.78:1 (66/84) and House Officer (HO) to Postgraduate Resident (PGR) ratio 1.94:1 (99/51). High burnout was identified in 76 (50.7%) participants while 48 (32%) had moderate and 26 (17.3%) had low burnout. Males scored better than female physicians in vitality (0.008), general mental health (0.004), and mental component summary (0.01) domains of HRQOL. Doctors with high burnout had significantly lower scores in both physical component summary (p-value 0.004) and mental component summary (p-value < 0.0001) domains of HRQOL.

Conclusion: Physicians working in emergency settings have high frequency of burnout and it adversely affects their mental and physical health related quality of life.

doi: https://doi.org/10.12669/pjms.39.5.7560

How to cite this: Sarwar S, Mahmood A, Raja MF, Mahmud Y. Burnout and Health Related Quality of Life among emergency physicians working at emergency at Tertiary Care Hospital in Lahore Pakistan. Pak J Med Sci. 2023;39(5):---------. doi: https://doi.org/10.12669/pjms.39.5.7560

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Case Report: Case report: An unusual presentation of granulomatosis with polyangiitis
Authors: Bannour Ichrak , Ben Brahim Maroi , Arfa Sondes , Amor Soumaya ben , Ben Mabrouk Asma , Berrich Olfa , Hammemi Sonia
Published: July 2023

Aim: We are reporting a case of an unusual presentation of granulomatosis with polyangiitis (GPA) with liver involvement.

Case presentation: A 45-year-old male patient presented with erythematous plaques on the face and bilateral nasal obstruction. On physical examination, the patient had a ring-shaped squamous plaque on the face. The laboratory findings revealed an accelerated erythrocyte sedimentation rate at 100 mm/h, an elevated C-reactive protein at 66 mg/L, hyper gamma globulinemia 16 g/L and an elevated alkaline phosphatase (twice the upper normal limit). The craniofacial and thoracoabdominal computed tomography (CT) -scans showed ethmoid and maxillary sinusitis, low facial bone density, multiple mediastinal and hilar lymphadenopathy, diffuse small pulmonary nodules, and hepatomegaly. A cutaneous lesion biopsy, the nasal mucosa, and the liver showed a chronic inflammatory granulomatosis process with necrosis. Serum anti-neutrophil cytoplasmic antibody (ANCA) against PR3 was positive. The clinical, biological, radiological, and histological findings substantiated the diagnosis of GPA. The patient received systemic steroids combined with cyclophosphamide pulses on days 1, 14 and 28 and then he was lost to follow-up.  Two-years later, he presented with a cardiac failure and skin ulcer in the right lower limb. A nasal endoscopic exam showed nasal septum cartilage perforation with resorption of the middle and inferior nasal concha. Two weeks later, he developed a diffuse alveolar hemorrhage and was therefore transferred to the intensive care unit but died of respiratory failure 3 days later.

Conclusion: Clinicians should be aware of GPA atypical clinical manifestations.
The identification of high-performing antibodies for Apolipoprotein E for use in Western Blot and immunoprecipitation
Authors: Ayoubi Riham , Southern Kathleen , Laflamme Carl ,   NeuroSGC/YCharOS collaborative group
Published: July 2023

Apolipoprotein E is a secreted protein involved in mediating lipid distribution and metabolism among cells of specific tissues. The dysregulation of Apolipoprotein E can disturb cholesterol homeostasis, resulting in several diseases, including cardiovascular disease and Alzheimer’s disease. The therapeutic potential of Apolipoprotein E against these diseases demonstrates the importance of providing high-quality antibodies for this protein to the scientific community. In this study, we characterized fourteen Apolipoprotein E commercial antibodies for Western Blot and immunoprecipitation, using a standardized experimental protocol based on comparing read-outs in knockout cell lines and isogenic parental controls. We identified many high-performing antibodies and encourage readers to use this report as a guide to select the most appropriate antibody for their specific needs.
Age of first self-harm act in childhood and adolescence: A scoping review protocol
Authors: Wiggin Daisy , McMahon Elaine , McNicholas Fiona , Khan Almas , Griffin Eve
Published: July 2023

Background: Self-harm in young people is associated with adverse outcomes for many. The age of first self-harm is not often reported in the literature and there is considerable heterogeneity in how it is reported and in the methods used to estimate it. The objective of this study will be to examine the age of first self-harm act in childhood and adolescence and to identify the methods used to assess this.

Methods: This scoping review will follow JBI guidance. Five electronic databases, Medline, PsycInfo, CINAHL Plus, Embase, and Web of Science will be searched from inception. Grey literature will be searched via Google Scholar. Studies reporting the age of first act of self-harm in young people aged 17 years and younger are of interest. Any study design and methodology will be eligible for inclusion. Included studies may use any self-harm definition, any measures used to assess self-harm and the age of the first act. The focus can be in any context, including health services presenting or community samples. Title and abstract screening and full text screening will be carried out by two reviewers independently. The data extraction tool will be piloted by two reviewers independently, included studies will undergo data extraction by one reviewer and this will be checked by a second, independent reviewer.

Results: The resulting data will be presented using descriptive statistics, in tabular format, and accompanied with a narrative presentation of results. The results of this study will be distributed by publication in an academic journal.
Smart5Grid Solutions for enhanced TSO grid observability and manageability in massive RES penetration environment
Authors: Shangov Daniel , Vlachkov Krassimir , Rumenova Ralitsa , Hristov Georgi , Velkov Atanas , Antonopoulos Angelos , Cadenelli Nicola , Tzanis Nikolaos , Brodimas Dimitrios , Rantopoulos Michalis , Chochliouros Ioannis , Vlahodimitropoulou Vasiliki
Published: July 2023

This article presents the latency minimisation potential provided by the Smart5Grid Open Experimentation Platform (OEP) developed by the Horizon 2020 Smart5Grid Research and Innovation (R&I) project. It discusses the OEP performance and provides experimental data to substantiate its contribution to improving observability and manageability of distributed renewable generation in power grids. That experimental proof is delivered by two pilots running on the OEP: Demo 1 Millisecond Level Precise Distribution Generation Control, and Demo 2 Real-time Wide Area Monitoring (WAM) pilot of 5G virtual Phasor Data Concentrator v(PDC) capabilities for WAM of end-to-end electricity grids. This work reports  two Network Applications (NetApps) created to support both demos and provides experimental evidence that the OEP offers latency of comparable measure to well-established wire-bound communications in addition to availability and reliability on top of by-design flexibility, scalability and modularity, which are especially relevant to power systems with high shares of Distributed Renewable Energy Recourses (DRERs). The software and methods used for the OEP development and experimental testbeds applied to measure its latency performance in both tailored pilot demos are explained at length. The test results are presented and interpreted with a view to discussing potential contributions of the presented 5G-enabled solutions for power grid smartification in conditions of high rollout of distributed renewable generation. All pilot demos generate openly accessible data, except where specific security restrictions are applicable.
Staging enmity: reading populist productions of shame with Jelinek’s On the Royal Road
Authors: Prade-Weiss Juliane
Published: July 2023

Background: Populism is often perceived as a shamelessly loud segment of political discourse. However, Jelinek’s play On the Royal Road, written on the occasion of Trump’s 2016 election as US president, suggests that populism leads to societal silencing. Jelinek’s text expounds that when a society’s public sphere is marked by ubiquitous enmity against an imagined “we”, grounded in antagonism, then the possibility of speaking to one another disappears, because speaking to one another is based on the willingness to give one’s counterpart space and listen to them. In a public discourse that stages enmity, the counterpart vanishes. Therefore, populism, loud as it is, leads to the silencing of whole communities insofar as they are left with nothing in common but enmity.

Method: Critical discourse analysis is used to contextualise close readings of select passages of Jelinek’s play with recent social sciences and humanities research on global populisms to highlight what literary language and the dramatic form can contribute to understanding populism.

Results: The silencing populisms entail is fed, in large part, by a dynamics linking the interpersonal emotion of shame to its discursive exploitation in shamelessness and shaming: populist voices transgress rules of democratic debate in the public sphere to elicit outrage by mainstream politics, media, and civil society, which often retort populist shamelessness by shaming populist actors. The audience excitement populist leaders and supporters generate is an important factor in normalizing the emotional, moralizing populist polarization of “us” versus “them” that undermines differentiated discussion and a dispute of arguments.

Conclusion: While media and research commonly suggest that with the populist reduction of politics to a spectacle, citizens become a passive audience, the article expounds that audiences play a key role in the production of populist enmity. This insight offers an alley to counteract populism.
Checkpoint kinase interaction with DNA polymerase alpha regulates replication progression during stress
Authors: Hadjicharalambous Andreas , Whale Alex J. , Can Geylani , Skehel J. Mark , Houseley Jonathan M. , Zegerman Philip
Published: July 2023

Background: In eukaryotes, replication stress activates a checkpoint response, which facilitates genome duplication by stabilising the replisome. How the checkpoint kinases regulate the replisome remains poorly understood. The aim of this study is to identify new targets of checkpoint kinases within the replisome during replication stress.

Methods: Here we use an unbiased biotin proximity-ligation approach in Saccharomyces cerevisiae to identify new interactors and substrates of the checkpoint kinase Rad53 in vivo.

Results: From this screen, we identified the replication initiation factor Sld7 as a Rad53 substrate, and Pol1, the catalytic subunit of polymerase a, as a Rad53-interactor. We showed that CDK phosphorylation of Pol1 mediates its interaction with Rad53. Combined with other interactions between Rad53 and the replisome, this Rad53-Pol1 interaction is important for viability and replisome progression during replication stress.

Conclusions: Together, we explain how the interactions of Rad53 with the replisome are controlled by both replication stress and the cell cycle, and why these interactions might be important for coordinating the stabilisation of both the leading and lagging strand machineries.
The genome sequence of the White Satin, Leucoma salicis (Linnaeus, 1758)
Authors: Boyes Douglas , Holland Peter W.H. ,   University of Oxford and Wytham Woods Genome Acquisition Lab,   Darwin Tree of Life Barcoding collective,   Wellcome Sanger Institute Tree of Life programme,   Wellcome Sanger Institute Scientific Operations: DNA Pipelines collective,   Tree of Life Core Informatics collective,   Darwin Tree of Life Consortium
Published: July 2023

We present a genome assembly from an individual male Leucoma salicis (the White Satin; Arthropoda; Insecta; Lepidoptera; Erebidae). The genome sequence is 733.2 megabases in span. Most of the assembly is scaffolded into 30 chromosomal pseudomolecules, including the Z sex chromosome. The mitochondrial genome has also been assembled and is 15.73 kilobases in length. Gene annotation of this assembly on Ensembl identified 20,222 protein coding genes.
Decision-Making Delegation in Banks
Authors: Dlugosz Jennifer , Gam Yong Kyu , Gopalan Radhakrishnan , Skrastins Janis
Published: July 2023

Using natural disasters as shocks to local economies, we document that a bank branch’s ability to set deposit rates locally has real effects. Following disasters, branches with rates set locally increase deposit rates more and experience higher deposit volumes in affected counties. Consistent with imperfect insurance from internal capital markets, banks with more branches setting rates locally relatively expand mortgage lending in affected counties. House prices recover faster in local areas where more branches’ rates are set locally.

This paper was accepted by Tomasz Piskorski, finance.

Supplemental Material: The data files and online appendix are available at https://doi.org/10.1287/mnsc.2023.4856 .
The use of diagnostic criteria to diagnose and treat serotonin syndrome
Authors: Robinson Philip
Published: July 2023

This paper aims to explore the complexities surrounding the diagnosis of serotonin syndrome (SS), through the description of a real-life patient presentation. The management was initiated by a trainee advanced clinical practitioner with the support of a medical registrar. Following the event, six academic databases were searched, none of which yielded any relevant results specific to this case. Therefore, diagnostic criteria have been explored. Applying criteria to this case has demonstrated that the diagnosis of SS was unlikely, yet the treatment given was effective and the patient survived without the need for invasive management.
CIRCULAR EXTERNAL FIXATOR REMOVAL IN THE OUTPATIENT CLINIC USING REGIONAL ANAESTHESIA: A PILOT STUDY OF A NOVEL APPROACH
Authors: Williams Luke , Stamps Giles , Peak Helen , Singh Shiv , Narayan Badri , Graham Simon , Peterson Nicholas
Published: July 2023

Introduction

External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting.

Materials & Methods

This prospective case series evaluated the first 20 consecutive cases of EF removal in the outpatient clinic between 10/06/22 to 16/09/22. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirement, asked to evaluate their experience and perceived pain using the Visual Analogue Scale (VAS).

Results

Twenty patients were included in the study. The mean age was 46.6 years (range 21–85 years). Two thirds were male patients (N=13). Post procedure all patients indicated positive satisfaction ratings, each participant responding as either ‘satisfied’ (N=4), ‘very satisfied’ (N=15) or ‘highly satisfied’ (N=1). In addition, 85% of participants reported they would opt for this method of EF removal in future should it be necessary. VAS for pain immediately following completion of the procedure was low, with an average score of 0.45 (range 0–4), where a score of 0= ‘No pain’, and 10 = ‘worst pain possible’.

Conclusions

We present the first description of outpatient EF removal using sole regional anaesthesia, with a prospective case series of 20 EF removed in fully awake patients. This novel technique is cost-effective, reproducible, and safe. This not only reduces the burden of these surgical cases on an operating list but also improves patient experience when compared to other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this project demonstrates a method of improving environmental sustainability of surgery, anaesthesia and operating theatres.
RESULTS OF EXOGEN THERAPY FOR THE TREATMENT OF FRACTURE NONUNION OR DELAYED HEALING
Authors: Doherty Ciaran , McKee Christopher Madden- , Foster Andrew
Published: July 2023

Introduction

Non-union is an unfortunate outcome of the fracture healing process for some patients; with an estimated annual incidence of 17.4- 18.9 per 100,00. The management of these patients depicts a significant clinical challenge for surgeons and financial burden to health services. External ultrasound stimulation devices (ExogenTM) have been highlighted as a novel non invasive therapy to achieve union in cases of delayed and non-union. The aim of the current study was to assess the rate of union in patients using ExogenTM therapy for delayed fracture union in a district general hospital.

Materials & Methods

This is a single centre retrospective continuous cohort study. Patients were identified from a prospective database of all patients prescribed ExogenTM therapy between June 2013- September 2021 in a district general hospital. Patient data was collected retrospectively using electronic patient records. Fracture union was assessed both clinically and radiographically and recorded in patient records. Failure of treatment was defined as progression to operative treatment due to lack of progression with ultrasound therapy or established asymptomatic non-union. Patient were excluded from the study if ExogenTM therapy was prescribed within 6 weeks of injury.

Results

142 potential patient were identified from the database. 35 patients were excluded from the data set (17 patients due to insufficient data available, 9 lost to follow up, 4 died and 5 excluded due to early application of ExogenTM therapy). 58 Patients progressed to union with an average time to union of 41 weeks. 49 cases failed to progress to union, of which 7 cases had conversion to operative management prior to completion of single course of ExogenTM therapy and were excluded from all other data review. 12% of cases that failed to unite with ultrasound therapy required multiple operations to establish union.

Conclusions

A union rate of 58% was reported by the current study, which is lower than previously published. This likely reflects the heterogenous nature of the patient population and fracture distribution included. However, this is potentially a more reflective union rate for the general population than previously published. There were no adverse events associated with the use of ExogenTM therapy in the current study. Therefore supporting its use as a first line management to promote union in delayed fracture union in the general population. Additionally, failure to achieve fracture union with utilisation of ExogenTM therapy was associated with risk for requirement of multiple surgeries to achieve union. This could serve as an indicator for surgeon to consider the requirement additional measures at the initial surgical procedure.
LIMBDREAM: THE LIMB RECONSTRUCTION REGISTRY OF EXPERIENCE, ASPIRATION, AND MEASURES
Authors: Morrison Stewart , Formosa Melissa , Donnan Leo
Published: July 2023

Introduction

Patient-reported outcome measures (PROMs) has gained momentum in the orthopaedic literature. The GOAL-LD (Gait Outcomes Assessment List for Limb Deformity) incorporates the framework of The WHO International Classification of Functioning, Disability and Health and correlates highly with the Paediatric Outcomes Data Collection Instrument (PODCI) when applied in a limb reconstruction setting. The Royal Children's Hospital Melbourne, Australia, supported by The University of Melbourne is designing and implementing a Limb Reconstruction Registry, prospectively enrolling patients with a number of key conditions and provide a mechanism for capturing surgical data and PROMs at regular follow-up intervals. LimbDREAM (The Limb Reconstruction Registry of Experience, Aspiration and Measures) has begun recruiting participants, and this paper serves as a narrative review of our design and implementation process.

Materials & Methods

After provision of a research grant, audit was conducted to examine local case mix and estimate recruitment based on conditions selected. Literature review was focussed on (i) registries in the paediatric limb reconstruction domain and (ii) use of PROMs across conditions selected. A high-level process-flow chart was constructed in order to inform governance and staffing requirements in addition to REDCap Database structure. Local as well as scalable deployment was considered. Alpha and beta testing was performed by principal and associate investigators prior to participant recruitment.

Results

Audit identified 6 condition streams for inclusion: Congenital limb deficiencies, congenital pseudarthrosis of the tibia, bone dysplasias, bone tumours, amputation, and complex deformity of other etiology. Literature review identified 20 PROMs used across these conditions, with limited validation studies and significant implementation heterogeneity. REDCap database design took longer than anticipated (planned 10 months, actual 18 months) before being recruitment ready, due to the complexity of ensuring data collection logic would work across highly diverse patient journeys. Initial recruitment across all streams has been promising. Email and text message reminders have proved helpful in increasing survey return rates.

Conclusions

Prospective collection of PROMs as well as surgical data via a standardized dataset will provide the basis for future condition-specific research, with the ability to support nested trials. Implementation requires forethought with regard to time frames and staffing for non-automated steps as well as data integrity review. The next phase of the LimbDREAM project will be to integrate use of the Registry into our weekly Limb Reconstruction Meeting to ensure that operative plans and data are captured close to the point of care.
A CASE REPORT OF A RARE POST-TRAUMATIC INFECTED REGENERATE CORTICOTOMY FOR LENGTHENING FOLLOWING A FRAME ANKLE FUSION
Authors: Haq Labeeba , Thomson Lauren , Wright Sally , Bose Deepa
Published: July 2023

Introduction

We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy.

Materials & Methods

A systematic review of the literature was conducted searching EMBASE, MEDLINE and Cochrane library for all articles discussing infected bone regenerate- a paucity of information was found. Abstracts were independently reviewed by 2 authors (LH and LT). In total, there were 16 papers, and then subsequently analysed we identified two case reports regarding infected regenerate.

Results

Developing an infection in a regenerate is highly rare with very few reported cases within the published literature. The literature identified risk factors for an infected regenerate, with open fracture and smoking being the two consistent factors. The open fracture deep infection rate is cited at 10% in most publications, this is at the site of the open fracture and not within the regenerate.

Conclusions

Infection within the regenerate during distraction osteogenesis is highly unusual, with only two other published papers in the literature to the best of our knowledge. This should be borne in mind when managing patients with infection of unknown sources in cases of distraction osteogenesis.
THE ENVIRONMENTAL IMPACT AND SUSTAINABILITY OF TOTAL HIP AND KNEE ARTHROPLASTY
Authors: Prakash Rohan , Abid Husnain , Wasim Abdus , Sharma Akash , Agrawal Yuvraj
Published: July 2023

The National Health Service produces over 500,000 tonnes of waste and 25 mega tonnes of CO2 annually. Operating room waste is segregated into different streams which are recycled, disposed of in landfill sites, or undergo costly and energy-intensive incineration processes.

By assessing the quantity and recyclability of waste from primary hip and knee arthroplasty cases, we aim to identify strategies to reduce the carbon footprint of arthroplasty surgery.

Data was collected prospectively at a tertiary orthopaedic hospital, in the theatres of six arthroplasty surgeons between April – July 2022. Fifteen primary total hip arthroplasty (THA) and 16 primary total knee arthroplasty (TKA) cases were included; revision and complex primary cases were excluded.

Waste was categorised into non-hazardous waste, hazardous waste, recycling, sharps, and linens. Each waste category was weighed. Items disposed as non-hazardous waste were catalogued for a sample of 10 TKA and 10 THA cases. Recyclability of items was determined from packaging.

Average total waste generated for THA and TKA were 14.46kg and 17.16kg respectively, with TKA generating significantly greater waste (p < 0.05).

On average only 5.4% of waste was recycled in TKA and just 2.9% in THA cases. The mean recycled waste was significantly greater in TKA cases compared to THA, 0.93kg and 0.42kg respectively (p < 0.05).

Hazardous waste represented the largest proportion of the waste streams for both TKA (69.2%) and THA (73.4%). On average TKA generated a significantly greater amount (11.87kg) compared to THA (10.61kg), p < 0.05.

Non-hazardous waste made up 15.1% and 11.3% of total waste for TKA and THA respectively.

In the non-hazardous waste, only two items (scrub brush packaging and sterile towel packaging) were identified as recyclable based on packaging.

We estimate that annually total hip and knee arthroplasty generates over 2.7 million kg of waste in the UK. Through increased use of recyclable plastics for packaging, combined with clear labelling of items as recyclable, medical suppliers can significantly reduce the carbon footprint of arthroplasty. Our data highlight only a very small percentage of waste is recycled in total hip and knee arthroplasty cases.
ISCHIAL SCREW FIXATION CAN PREVENT CUP MIGRATION IN 3D-PRINTED CUSTOM ACETABULAR COMPONENTS FOR COMPLEX HIP RECONSTRUCTION
Authors: Madanipour Suroosh , Lemanu Daniel , Jayadev Chethan , Aston Will , Donaldson James , Miles Jonathan , Carrington Richard , McCulloch Robert , Skinner John
Published: July 2023

Custom acetabular components have become an established method of treating massive acetabular bone defects in hip arthroplasty. Complication rates, however, remain high and migration of the cup is still reported. Ischial screw fixation (IF) has been demonstrated to improve mechanical stability for non-custom, revision arthroplasty cup fixation. We hypothesise that ischial fixation through the flange of a custom acetabular component aids in anti-rotational stability and prevention of cup migration.

Electronic patient records were used to identify a consecutive series of 49 custom implants in 46 patients from 2016 to 2022 in a unit specializing in complex joint reconstruction. IF was defined as a minimum of one screw inserted into the ischium passing through a hole in a flange on the custom cup.

The mean follow-up time was 30 months. IF was used in 36 cups. There was no IF in 13 cups. No difference was found between groups in age (68.9 vs. 66.3, P = 0.48), BMI (32.3 vs. 28.2, P = 0.11) or number of consecutively implanted cups (3.2 vs. 3.6, P = 0.43). Aseptic loosening with massive bone loss was the primary indication for revision. There existed no difference in Paprosky grade between the groups (P = 0.1). 14.2% of hips underwent revision and 22.4% had at least one dislocation event.

No ischial fixation was associated with a higher risk of cup migration (6/13 vs. 2/36, X2 = 11.5, P = 0.0007). Cup migration was associated with an increased risk for all cause revision (4/8 vs. 3/38, X2 = 9.96, P = 0.0016, but not with dislocation (3/8 vs. 8/41, X2 = 1.2, P = 0.26).

The results suggest that failure to achieve adequate ischial fixation, with screws passing through the flange of the custom component into the ischium, increases the risk of cup migration, which, in turn, is a risk factor for revision.
IS VIRTUAL REALITY THE ANSWER? A STUDY TO VALIDATE THE USE OF HIGH-FIDELITY VIRTUAL REALITY SIMULATION IN HIP ARTHROSCOPY TRAINING
Authors: Schapira Benjamin , Spanoudakis Emmanuel , Jaiswal Parag , Patel Akash
Published: July 2023

Surgical trainees are finding it increasingly more challenging to meet operative requirements and coupled with the effects of COVID-19, we face a future of insufficiently trained surgeons. As a result, virtual reality (VR) simulator training has become more prevalent and whilst more readily accepted in certain arthroscopic fields, its use in hip arthroscopy (HA) remains novel. This project aimed to validate VR high-fidelity HA simulation and assess its functional use in arthroscopic training.

Seventy-two participants were recruited to perform two basic arthroscopic tasks on a VR HA simulator, testing hip anatomy, scope manipulation and triangulation skills. They were stratified into novice (39) and experienced (33) groups based on previous arthroscopy experience. Metric parameters recorded from the simulator were used to assess construct validity. Face validity was evaluated using a Likert-style questionnaire. All recordings were reviewed by 2 HA experts for blinded ASSET score assessment.

Experienced participants were significantly faster in completing both tasks compared with novice participants (p<0.001). Experienced participants damaged the acetabular and femoral cartilage significantly less than novice participants (p=0.011) and were found to have significantly reduced path length of both camera and instrument across both tasks (p=0.001, p=0.007), demonstrating significantly greater movement economy. Total ASSET scores were significantly greater in experienced participants compared to novice participants (p=0.041) with excellent correlation between task time, cartilage damage, camera and instrument path length and corresponding ASSET score constituents. 62.5% of experienced participants reported a high degree of realism in all facets of external, technical and haptic experience with 94.4% advising further practice would improve their arthroscopic skills. There was a relative improvement of 43% in skill amongst all participants between task 1 and 2 (p<0.001).

This is the largest study to date validating the use of simulation in HA training. These results confirm significant construct and face validity, excellent agreement between objective measures and ASSET scores, significant improvement in skill with continued use and recommend VR simulation to be a valuable asset in HA training for all grades.
CUP-CAGE RECONSTRUCTION FOR MAJOR ACETABULAR DEFECTS: TEN-YEAR UPDATE OF FULL AND HALF CAGE CONSTRUCTS
Authors: Berdis G. E. , Couch C. G. , Larson D. R. , Bedard N. A. , Berry D. J. , Lewallen D. G. , Abdel M. P.
Published: July 2023

Cup-cage constructs are one of several methods commonly used to treat severe acetabular bone loss during contemporary revision total hip arthroplasty. The purpose of this study was to provide a long-term results of the technique with emphasis on implant survivorship, radiographic results, and clinical outcomes for both full and half cup-cage reconstructions.

We identified 57 patients treated with a cup-cage reconstruction for major acetabular bone loss between 2002–2012. All patients had Paprosky Type 2B through 3B bone loss, with 60% having an associated pelvic discontinuity. Thirty-one patients received a full cup-cage construct, and 26 a half cup-cage. Mean age at reconstruction was 66 years, 75% were female, and the mean BMI was 27 kg/m2. Mean follow-up was 10 years.

The 10-year cumulative incidences of any revision were 14% and 12% for the full and half cup-cage construct groups, respectively. Of the 9 revisions, 3 were for dislocation, 2 for aseptic loosening and construct failure (both were pelvic discontinuities), 1 for adverse local tissue reaction, and 1 for infection with persistent pelvic discontinuity. The 10-year cumulative incidences of revision for aseptic loosening were 4.5% and 5% for the full and half cup-cage constructs, respectively. Of the unrevised cases, incomplete and non-progressive zone 3 radiolucent lines were observed in 10% of patients in each group. Three patients experienced partial motor and sensory sciatic nerve palsies (2 in the full and 1 in the half cup-cage group). Both the full and half cup-cage cohorts demonstrated significantly improved Harris hip scores.

Full and half cup-cage reconstructions for major acetabular defects were successful at 10 years in regards to acetabular fixation without appreciable differences between the two techniques. However, zone 3 radiolucent lines were not uncommon in association with discontinuities, and dislocation continues to be a problem.
LONG-TERM FOLLOW UP OF THE CUP-CAGE RECONSTRUCTION FOR PELVIC DISCONTINUITY
Authors: Gross A. , Safir O. , Kuzyk P.
Published: July 2023

Pelvic discontinuity is a separation through the acetabulum with the ilium displacing superiorly and the ischium/pubis displacing inferiorly. This is a biomechanically challenging environment with a high rate of failure for standard acetabular components. The cup-cage reconstruction involves the use of a highly porous metal cup to achieve biological bone ingrowth on both sides of the pelvic discontinuity and an ilioischial cage to provide secure fixation across the discontinuity and bring the articulating hip center to the correct level. The purpose of this study was to report long term follow up of the use of the cup-cage to treat pelvic discontinuity.

All hip revision procedures between January 2003 and January 2022 where a cup-cage was used for a hip with a pelvic discontinuity were included in this retrospective review. All patients received a Trabecular Metal Revision Shell with either a ZCA cage or TMARS cage (Zimmer-Biomet Inc.). Pelvic discontinuity was diagnosed on pre-operative radiographs and/or intraoperatively. Kaplan-Meier survival analysis was performed with failure defined as revision of the cup-cage reconstruction.

Fifty-seven cup-cages in 56 patients were included with an average follow-up of 6.25 years (0.10 to 19.98 years). The average age of patients was 72.09 years (43 to 92 years) and 70.2% of patients were female. The five year Kaplan-Meier survival was 92.0% (95% CI 84.55 to 99.45) and the ten year survival was 80.5% (95% CI 58.35 to 102.65). There were 5 major complications that required revision of the cup-cage reconstruction (3 infections and 2 mechanical failures). There were 9 complications that required re-operation without revision of the cup-cage reconstruction (5 dislocations, 3 washouts for infection and one femoral revision for aseptic loosening).

In our hands the cup-cage reconstruction has provided a reliable tool to address pelvic discontinuity with an acceptable complication rate.
VIRTUAL BIOMECHANICAL ASSESSMENT OF CUSTOM TRIFLANGE AND TRABECULAR METAL COMPONENTS TO TREAT LARGE ACETABULAR DEFECTS
Authors: Callary S. , Barends J. , Solomon L. B. , Nelissen R. , Broekhuis D. , Kaptein B.
Published: July 2023

The best treatment method of large acetabular bone defects at revision THR remains controversial. Some of the factors that need consideration are the amount of residual pelvic bone removed during revision; the contact area between the residual pelvic bone and the new implant; and the influence of the new acetabular construct on the centre of rotation of the hip. The purpose of this study was to compare these variables in two of the most used surgical techniques used to reconstruct severe acetabular defects: the trabecular metal acetabular revision system (TMARS) and a custom triflanged acetabular component (CTAC).

Pre- and post-operative CT-scans were acquired from 11 patients who underwent revision THR with a TMARS construct for a Paprosky IIIB defect, 10 with pelvic discontinuity, at Royal Adelaide Hospital. The CT scans were used to generate computer models to virtually compare the TMARS and CTAC constructs using a semi-automated method. The TMARS construct model was calculated using postoperative CT scans while the CTAC constructs using the preoperative CT scans. The bone contact, centre of rotation, inclination, anteversion and reamed bone differences were calculated for both models.

There was a significant difference in the mean amount of bone reamed for the TMARS reconstructions (15,997 mm3) compared to the CTAC reconstructions (2292 mm3, p>0.01). There was no significant difference between overall implant bone contact (TMARS 5760mm2 vs CTAC 5447mm2, p=0.63). However, there was a significant difference for both cancellous (TMARS 4966mm2 vs CTAC 2887mm2, p=0.008) and cortical bone contact (TMARS 795mm2 vs CTAC 2560mm2, p=0.001). There was no difference in inclination and anteversion achieved. TMARS constructs resulted on average in a centre of rotations 7.4mm more lateral and 4.0mm more posterior.

Modelling of two different reconstructions of Paprosky IIIB defects demonstrated potential important differences between all variables investigated.
THRESHOLD FOR ANTERIOR CUP OVERHANG CORRELATED WITH SYMPTOMATIC ILIOPSOAS IMPINGEMENT AFTER TOTAL HIP ARTHROPLASTY: A 268-PATIENT CASE CONTROL STUDY USING CT SCAN
Authors: Baujard A. , Martinot P. , Demondion X. , Dartus J. , Girard J. , Migaud H.
Published: July 2023

Mechanical irritation or impingement of the iliopsoas tendon accounts for 2–6% of persistent postoperative pain cases after total hip arthroplasty (THA). The most common trigger is anterior cup overhang. CT-scan can be used to identify and measure this overhang; however, no threshold exists for symptomatic anterior iliopsoas impingement. We conducted a case–control study in which CT-scan was used to define a threshold that differentiates patients with iliopsoas impingement from asymptomatic patients after THA.

We analyzed the CT-scans of 622 patients (758 CT-scans) between 2011 and 2020. Out of this population we identified 136 patients with symptoms suggestive of iliopsoas impingement. Among them, 6 were subsequently excluded: three because the diagnosis was reestablished intra-operatively (one metallosis, two anterior instability related to posterior prosthetic impingement) and three because they had another obvious cause of impingement (one protruding screw, one protruding cement plug, one stem collar), leaving 130 patients in the study (impingement) group. They were matched to a control group of 138 patients who were asymptomatic after THA. The anterior cup overhang (anterior margin of cup not covered by anterior wall) was measured by an observer (without knowledge of the clinical status) on an axial CT slice based on anatomical landmarks (orthogonal to pelvic axis).

The impingement group had a median overhang of 8 mm [IQR: 5 to 11] versus 0 mm [IQR: 0 to 4] for the control group (p<.001). Using ROC curves, an overhang threshold of 4 mm was best correlated with a diagnosis of impingement (sensitivity 79%, specificity 85%, PPV = 75%, NPV = 85%).

Pain after THA related to iliopsoas impingement can be reasonably linked to acetabular overhang if it exceeds 4 mm on a CT scan. Below this threshold, it seems logical to look for another cause of iliopsoas irritation or another reason for the pain after THA before concluding impingement is present.
INFLUENCE OF ACETABULAR AND FEMORAL MORPHOLOGY ON PELVIC TILT: A STUDY IN 388 PATIENTS
Authors: Heimann A. F. , Murmann V. , Schwab J. M. , Tannast M.
Published: July 2023

To investigate whether anterior pelvic plane-pelvic tilt (APP-PT) is associated with distinct hip pathomorphologies, we asked: (1) Is there a difference in APP-PT between symptomatic young patients eligible for joint preservation surgery and an asymptomatic control group? (2) Does APP-PT vary between distinct acetabular and femoral pathomorphologies? (3) Does APP-PT differ in symptomatic hips based on demographic factors?

IRB-approved, single-center, retrospective, case-control, comparative study in 388 symptomatic hips (357) patients (mean age 26 ± 2 years [range 23 to 29], 50% females) that presented to our tertiary center for joint preservation over a five year-period. Patients were allocated to 12 different morphologic subgroups. The overall study group was compared to a control group of 20 asymptomatic hips (20 patients). APP-PT was assessed in all patients based on AP pelvis X-rays using the validated HipRecon software. Values between overall and control group were compared using an independent samples t-test. Multiple regression analysis was performed to examine the influences of diagnoses and demographic factors on APP-PT. Minimal clinically important difference (MCID) of APP-PT was defined as >1 standard deviation.

No significant differences in APP-PT between the control group and overall group (1.1 ± 3.0° [−4.9 to 5.9] vs 1.8 ± 3.4° [−6.9 to 13.2], p = 0.323) were observed. Acetabular retroversion and overcoverage groups showed higher APP-PT compared to the control group (both p < 0.05) and were the only diagnoses with significant influence on APP-PT in the stepwise multiple regression analysis. However, all observed differences were below the MCID. Demographic factors age, gender, height, weight and BMI showed no influence on APP-PT.

APP-PT across different hip pathomorphologies showed no clinically significant variation. It does not appear to be a relevant contributing factor in the evaluation of young patients eligible for hip preservation surgery.