-
Social Science & Medicine (1982) Feb 2017Dengue is highly endemic in Peru, with increases in transmission particularly since vector re-infestation of the country in the 1980s. Pucallpa, the second largest city...
Dengue is highly endemic in Peru, with increases in transmission particularly since vector re-infestation of the country in the 1980s. Pucallpa, the second largest city in the Peruvian Amazon, experienced a large outbreak in 2012 that caused more than 10,000 cases and 13 deaths. To date, there has been limited research on dengue in the Peruvian Amazon outside of Iquitos, and no published review or critical analysis of the 2012 Pucallpa dengue outbreak. This study describes the incidence, surveillance, and control of dengue in Ucayali to understand the factors that contributed to the 2012 Pucallpa outbreak. We employed a socio-ecological autopsy approach to consider distal and proximal contributing factors, drawing on existing literature and interviews with key personnel involved in dengue control, surveillance and treatment in Ucayali. Spatio-temporal analysis showed that relative risk of dengue was higher in the northern districts of Calleria (RR = 2.18), Manantay (RR = 1.49) and Yarinacocha (RR = 1.25) compared to all other districts between 2004 and 2014. The seasonal occurrence of the 2012 outbreak is consistent with typical seasonal patterns for dengue incidence in the region. Our assessment suggests that the outbreak was proximally triggered by the introduction of a new virus serotype (DENV-2 Asian/America) to the region. Increased travel, rapid urbanization, and inadequate water management facilitated the potential for virus spread and transmission, both within Pucallpa and regionally. These triggers occurred within the context of failures in surveillance and control programming, including underfunded and ad hoc vector control. These findings have implications for future prevention and control of dengue in Ucayali as new diseases such as chikungunya and Zika threaten the region.
Topics: Dengue; Dengue Virus; Disease Outbreaks; Humans; Incidence; Peru; Population Surveillance; Risk Assessment; Seasons; Spatio-Temporal Analysis
PubMed: 28024241
DOI: 10.1016/j.socscimed.2016.12.010 -
The American Journal of Sports Medicine Dec 2023Medial patellofemoral ligament (MPFL) reconstruction is associated with high complication rates because of graft overloading from incorrect graft positioning. To improve...
BACKGROUND
Medial patellofemoral ligament (MPFL) reconstruction is associated with high complication rates because of graft overloading from incorrect graft positioning. To improve clinical outcomes, it is crucial to gain a better understanding of MPFL elongation patterns.
PURPOSE
To assess MPFL length changes in healthy knees from 0° to 90° of dynamic flexion and their relationship with anatomic parameters of the patellofemoral joint.
STUDY DESIGN
Descriptive laboratory study.
METHODS
Dynamic computed tomography scans of an active flexion-extension-flexion movement in 115 knees from 63 healthy participants were evaluated to construct knee joint models. Using these models, the MPFL length was measured as the shortest wrapping path from the Schöttle point on the femur to 3 insertion points on the superomedial border of the patella (proximal, central, and distal). MPFL length changes (%) relative to the length in full extension were calculated, and their correlations with the tibial tuberosity-trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination were analyzed.
RESULTS
The proximal fiber was the longest in full extension and progressively decreased to a median length of -6.0% at 90° of flexion. The central fiber exhibited the most isometric pattern during knee flexion, showing a median maximal decrease of 2.8% relative to the full extension length and no evident elongation. The distal fiber first slightly decreased in length but increased at deeper flexion angles. The median overall length changes were 4.6, 4.7, and 5.7 mm for the proximal, central, and distal patellar insertion, respectively. These values were either not or very weakly correlated with the tibial tuberosity-trochlear groove distance, Caton-Deschamps index, and lateral trochlear inclination when the anatomic parameters were within the healthy range.
CONCLUSION
The median MPFL length changed by approximately 5 mm between 0° and 90° of flexion. Proximally, the length continuously decreased, indicating slackening behavior. Distally, the length increased at deeper flexion angles, indicating tightening behavior.
CLINICAL RELEVANCE
In MPFL reconstruction techniques utilizing the Schöttle point to establish the femoral insertion, one should avoid distal patellar insertion, as it causes elongation of the ligament, which may increase the risk for complications due to overloading.
Topics: Humans; Knee Joint; Ligaments, Articular; Patellofemoral Joint; Femur; Patella; Tomography, X-Ray Computed; Patellar Dislocation
PubMed: 37960850
DOI: 10.1177/03635465231205597 -
Frontiers in Pediatrics 2022Although complex atresias, such as apple-peel and multiple atresias, comprise a smaller percentage, they are usually associated with a higher incidence of postoperative...
BACKGROUND AND OBJECTIVE
Although complex atresias, such as apple-peel and multiple atresias, comprise a smaller percentage, they are usually associated with a higher incidence of postoperative complications and mortality rate. Contrary to simple atresias where the surgical technique of choice usually entails bowel resection and anastomosis with or without enteroplasty, managing apple-peel atresia remains more sophisticated. Decompressive and functionalizing stomas are sometimes mandatory to overcome problems such as increased wall thickness and the wide disparity among the anastomotic ends. Few reports discussed using tube enterostomy in the management of apple-peel atresia; nonetheless, no previous prospective studies were conducted to discuss its efficacy on a larger population. In this study, we are describing our experience using this technique on 12 patients suffering from apple-peel atresia in our center.
METHODS
A prospective study was conducted from June 2015 to May 2020, where all children who were found to have apple-peel atresia were included in the study. T-tube was placed through an enterotomy through the dilated proximal bowel, around 10 cm before the anastomotic line, and was kept in place using a double suture (Stamm technique) before closing the anterior face of the anastomosis. The short distal limb of the T-tube was oriented toward the anastomotic line, while the long proximal limb was directed proximally. After finishing the anastomosis, the T-tube was delivered outside the abdominal wall, anchoring the enterostomy along with the proximal dilated jejunum against the anterior abdominal wall.
RESULTS
A total of 12 cases were encountered throughout the period of study. The mean age at operation was 4 days and the mean birth weight was 2700 g. The mean time for starting oral feeding postoperatively and T-tube removal was 8 and 10.5 days, respectively. Cases were discharged after a mean of 22 days. As regards morbidity and mortality, a single case developed skin excoriations at the site of tube insertion and was managed conservatively using topical ointments and another case died from overwhelming sepsis 3 days after the operation.
CONCLUSION
T-tube enteroplasty is a safe and feasible option in the surgical management of apple-peel atresia. The main strength of our study is its prospective nature and that it includes apple-peel atresia cases only. However, the main limitation is that a larger sample is needed.
PubMed: 36440335
DOI: 10.3389/fped.2022.1003508 -
Canadian Prosthetics & Orthotics Journal 2020Individuals with transtibial amputation (TTA) typically walk with an asymmetrical gait pattern, which may predispose them to secondary complications and increase risk of...
BACKGROUND
Individuals with transtibial amputation (TTA) typically walk with an asymmetrical gait pattern, which may predispose them to secondary complications and increase risk of fall. Gait asymmetry may be influenced by prosthesis mass.
OBJECTIVES
To explore the effects of prosthesis mass on temporal and limb loading asymmetry in people with TTA following seven days of acclimation and community use.
METHODOLOGY
Eight individuals with transtibial amputation participated. A counterbalanced repeated measures study, involving three sessions (each one week apart) was conducted, during which three load conditions were examined: no load, light load and heavy load. The light load and heavy load conditions were achieved by adding 30% and 50% of the mass difference between legs, at a proximal location on the prosthesis. Kinematic and ground reaction force data was captured while walking one week after the added mass. Symmetry indices between the prosthetic and intact side were computed for temporal (Stance and Swing time) and limb loading measures (vertical ground reaction force Peak and Impulse).
FINDINGS
Following seven days of acclimation, no significant differences were observed between the three mass conditions (no load, light load and heavy load) for temporal (Stance time: p=0.61; Swing time: p=0.13) and limb loading asymmetry (vertical ground reaction force Peak: p=0.95; vertical ground reaction force Impulse: p=0.55).
CONCLUSIONS
Prosthesis mass increase at a proximal location did not increase temporal and limb loading asymmetry during walking in individuals with TTA. Hence, mass increase subsequent to replacing proximally located prosthesis components may not increase gait asymmetry, thereby allowing more flexibility to the clinician for component selection.
PubMed: 37621951
DOI: 10.33137/cpoj.v3i2.34609 -
Plastic and Reconstructive Surgery.... Jul 2023The A2 and A4 pulleys are fibro-osseous structures that support the flexor tendon function. Injury to these pulleys can result in bowstringing and limited tendon...
UNLABELLED
The A2 and A4 pulleys are fibro-osseous structures that support the flexor tendon function. Injury to these pulleys can result in bowstringing and limited tendon excursion. Thus, having an understanding of the skin surface landmark of the A2 pulley is crucial to safeguard it during hand surgery.
METHODS
We performed cadaveric dissection of 62 hands. For 248 fingers, the measurement of distance A, which is half the distance between the palmar digital crease and proximal interphalangeal crease reflected in the palm, and distance B, which is the distance between the A2 pulley's starting point and the palmar digital crease, were taken by a caliber. Statistical analysis was performed using the paired sample test to determine whether there was a significant difference between distances A and B.
RESULTS
Our study revealed that there was no significant difference (p>0.05) between the measured starting point of the A2 pulley and its proposed surface landmark for the index, middle, and small fingers. Conversely, the ring finger showed a statistically significant difference of 1 mm more proximal.
CONCLUSIONS
By measuring the distance between the palmar digital crease and proximal interphalangeal crease and reflecting it proximally in the palms, one can anticipate the location of the A2 pulley's starting point for each digit, except for the ring finger. The ring finger's starting point is 1 mm more proximal than the other digits. Knowing the starting point of the A2 pulley will help hand surgeons limit incisions and avoid accidental injury during hand surgery.
PubMed: 37496981
DOI: 10.1097/GOX.0000000000005138 -
Orthopaedic Journal of Sports Medicine Dec 2022For skeletally immature patients, over-the-top (OTT) anterior cruciate ligament (ACL) reconstruction (ACLR) is preferred. However, increased anterior laxity at deep knee...
BACKGROUND
For skeletally immature patients, over-the-top (OTT) anterior cruciate ligament (ACL) reconstruction (ACLR) is preferred. However, increased anterior laxity at deep knee flexion angles remains concerning. We modified the procedure to proximally shift the graft fixation site on the femur to prevent graft loosening at higher knee flexion angles and named it the supra-OTT procedure.
PURPOSE
To compare anterior laxity and in situ forces of the ACL graft between conventional OTT and supra-OTT ACLR in a cadaveric model.
STUDY DESIGN
Controlled laboratory study.
METHODS
A total of 11 fresh-frozen cadaveric knee specimens underwent 4 robotic testing conditions: ACL intact, ACL resected, conventional OTT, and supra-OTT. For each condition, a 100-N load was applied at 0°, 15°, 30°, 60°, and 90° of knee flexion to simulate the Lachman test or anterior drawer test. In addition, a combined load of 5-N·m internal tibial torque and 10-N·m valgus torque was applied at 15° and 30° of knee flexion as a simulated pivot-shift test. Anterior tibial translation and in situ graft forces were recorded. The only difference between conventional OTT and supra-OTT ACLR was the graft fixation site on the femur. For conventional OTT ACLR, graft fixation was performed just on the proximal and lateral ends of the posterior condyle. For supra-OTT ACLR, the fixation point was around the proximal insertion of the lateral head of the gastrocnemius and the lateral edge of the posterior cortex, approximately 2 cm proximal to the conventional OTT position.
RESULTS
On the simulated anterior drawer test at 60° and 90° of knee flexion, anterior tibial translation after supra-OTT ACLR was significantly smaller than after conventional OTT ACLR ( < .01). However, no significant differences were noted at other flexion angles or on the simulated pivot-shift test between the conventional OTT and supra-OTT procedures. Some overconstraint and higher graft forces were noted with both techniques, but the supra-OTT technique caused even more overconstraint at higher flexion angles.
CONCLUSION
Supra-OTT ACLR showed better biomechanical performance to control anterior laxity than conventional OTT ACLR at higher knee flexion angles.
CLINICAL RELEVANCE
The supra-OTT procedure may improve anterior stability at deep knee flexion angles.
PubMed: 36545379
DOI: 10.1177/23259671221139876 -
JBJS Essential Surgical Techniques Mar 2019Ulnocarpal impaction is the most common reason to perform ulnar shortening osteotomy. There are 3 osteotomy techniques for ulnar shortening: transverse, step-cut, and...
BACKGROUND
Ulnocarpal impaction is the most common reason to perform ulnar shortening osteotomy. There are 3 osteotomy techniques for ulnar shortening: transverse, step-cut, and oblique cut.First described by Milch in 1941, extra-articular diaphyseal oblique or transverse shortening is the most frequently performed type of shortening. However, it is associated with a nonunion rate of up to 10%, and irritation by implants requiring removal occurs in up to 28% of cases. Intra-articular procedures such as the wafer procedure affect the distal ulnar joint surface, which can lead to stiffness of the distal radioulnar joint (DRUJ) due to scar tissue formation and adhesion of the triangular fibrocartilage complex (TFCC). Lapner et al. described increased pressure in the DRUJ after the wafer procedure, which may lead to an early onset of osteoarthritis. Complication rates between 8% for open wafer procedures and 21% for arthroscopic wafer procedures have been described.Intra-articular shortening has also been described by Slade and Gillon in 2007 and Hammert et al. in 2012 and was tested in cadavers by Greenberg et al. in 2013. This closing wedge technique preserves the distal joint surface of the ulna and also allows for easy correction of the inclination of the hub joint surface of the ulna.In contrast to the technique of Slade, our described osteotomy is steeper and longer proximally, which allows for fixation with >2 screws. Rapid healing of the metaphyseal bone compared with diaphyseal bone is described, and implant removal is necessary less often.With the described procedure, the interosseous membrane remains untouched, especially the distal oblique bundle, which additionally provides stability of the DRUJ in 40% of patients.
DESCRIPTION
A dorso-ulnar approach through the fifth extensor sheath is performed. The ulnocarpal joint and the DRUJ are accessed through an arthrotomy distal and proximal to the TFCC. The foveal attachment of the TFCC and the subsheath of the sixth extensor sheath are visualized. The osteotomy is intra-articular oblique from distal ulnar to proximal radial. Sliding the head of the ulna proximally achieves the desired shortening of up to 5 mm, and the head is fixed using 2, 3, or 4 cannulated headless screws. A slight correction of the axis of the ulnar head is also possible.
ALTERNATIVES
An alternative to this procedure is extra-articular osteotomy using a palmar or dorsal ulnar approach. If necessary, additional ulnocarpal procedures can be performed in an open or arthroscopically assisted manner.
RATIONALE
The shortening takes place only in the articular part of the distal aspect of the ulna. This procedure can easily be combined with TFCC repair, synovectomy of the DRUJ, or repair or reconstruction of the lunotriquetral ligament if needed. Shortening of up to 5 mm is possible.
PubMed: 31086725
DOI: 10.2106/JBJS.ST.18.00024 -
Hand (New York, N.Y.) Jan 2023The treatment of carpal tunnel syndrome (CTS) by sectioning the transverse carpal ligament (TCL) is not exempt from complications. Some nerve branches may be damaged by...
The treatment of carpal tunnel syndrome (CTS) by sectioning the transverse carpal ligament (TCL) is not exempt from complications. Some nerve branches may be damaged by the incision. The aim of this study is to identify and map the TCL nerve endings, serving as a guide for sectioning this structure in a zone with less nerve ending density. Ten TCLs were obtained from fresh frozen cadavers. The TCLs were measured, divided into 3 equal bands (radial, central, and ulnar), and submitted to cryostat sectioning. The sections were subjected to immunofluorescence with the protein gene product (PGP) 9.5 and confocal microscopy analysis. All the specimens contained type I and type IV mechanoreceptors. Neural elements occupied 0.695 ± 0.056% of the ligament area. The density of the neural elements was greater in the radial, followed by the ulnar and central bands, with 0.730 ± 0.083%, 0.686 ± 0.009%, and 0.669 ± 0.031%, respectively. The present findings suggest that the region with the least potential for neural element injury during TCL release is the central third near the transition with the ulnar third. When performed distally to proximally with a slight inclination from the radial to the ulnar, this release compromises the lowest nerve element density. Topographically, the proximal limit of the release is the distal wrist crease, while the distal limit is the intersection of Kaplan cardinal line and the axis of the third webspace.
Topics: Humans; Wrist Joint; Wrist; Ligaments, Articular; Mechanoreceptors; Nerve Endings
PubMed: 35034484
DOI: 10.1177/15589447211066974