COGNITIVE ADVERSE EFFECTS OF LACOSAMIDE IN PATIENTS WITH LOCALIZATION RELATED EPILEPSY - A PROSPECTIVE OBSERVATIONAL STUDY

More than 30% of epilepsy patients remain refractory to pharmacotherapy. Combined administration of AEDs or the application of novel AEDs is a therapeutic option especially when surgical treatment cannot be offered. The newer AEDs offer new mechanisms of action and more favourable safety profiles than the older AEDs. Lacosamide (LCM) is one of the third generation AEDs approved for adjunctive use in partial-onset seizures. Patients with epilepsy frequently experience cognitive dysfunctions. Because antiepileptic drugs (AEDs) are the major therapeutic modality for epilepsy, the adverse effects of AEDs on cognition are important. Objectives: This study was conducted to obtain reliable data on the cognitive adverse effects of lacosamide in Indian population. METHODOLOGY : An open labelled prospective observational study in 22 patients who suffered from localization related epilepsy. Results: Average Initial seizure frequency per month was 3.56 (SD 2.58) and median frequency 2.5 seizures per month. Range being 1-8 per month. At the final followup at 6months, only 2 persons experienced seizure and that too only single episodes. The difference in frequency is statistically significant (Wilcoxon Signed Ranks TestP <0.001). All the pre and post lacosamide cognition scores showed statistically significant positive correlation in this study. Conclusion: Excellent seizure control is observed in patients with refractory localization related epilepsy treated with lacosamide. Also, lacosamide has no serious adverse effects or drug interactions. In this study, it is observed that unlike many AEDs, lacosamide contributed to significant improvement in cognition and can improve the quality of life in such patients.

Surgical treatment for persistent second carpometacarpal joint pain

The purposes of this study were to demonstrate the clinical characteristics of patients with persistent second carpometacarpal (CMC) joint pain without bony abnormalities known as the carpal boss, and to assess the clinical efficacy of surgical stabilization of the second CMC joint. Eleven patients had persistent wrist pain with characteristic symptoms, including tenderness over the second CMC joint, increased symptoms when the involved hand was placed on the ground or gripped strongly with the involved hand, a positive metacarpal stress test and temporary pain relief with the intra-articular injection of the lidocaine. The patients underwent arthrodesis of the second CMC joint. All cases showed radiologically confirmed fusion of the second CMC joint. At the final followup examination, 10 of 11 patients resulted in satisfactory clinical outcomes, excepting one patient with remnant pain and restricted range of wrist motions. This report highlights the importance of conducting a careful assessment of patients who present with persistent second CMC joint pain without the bony abnormalities, such as carpal bossing. Surgery to stabilize the second CMC joint may be an option to improve their symptoms when conservative treatment fails.

Salvage Arthrodesis with Femoral Head Allograft for Failed Total Ankle Arthroplasty

Category: Ankle Introduction/Purpose: Failed total ankle arthroplasty (TAA) often results in significant bone loss and requires salvage arthrodesis. The aim of this study was to investigate the outcomes of Salvage arthrodesis with allo-bone block for failed TAA. Methods: This study included 8 patients who underwent salvage arthrodesis with femoral head allograft for failed TAA from August 2012 to March 2018 because of loosing of TAA implant. The mean age of the patients was 71 years (range, 54-81 years), and the mean follow-up period was 32 months (range, 12 to 84 months). Allograft problem and alignment of joint were evaluated radiographically. American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Outcome Score (FAOS), and visual analogue scale (VAS) pain scores were recorded preoperatively and at the time of final followup. Functional questionnaires were used to assess the duration for which the patient could walk continuously, use of walking aids, consumption of pain medication, and the patient’s subjective assessment of the percentage of overall improvement compared with before the salvage arthrodesis. Results: The allograft was retained without collapse for a mean of 24 months (range, 12 to 36 months) in four patients. Collapse of the allograft was observed in four patients at a mean of 11 months (range, 9 to 16 months), 1 of 4 patients were conserved to retrograde intramedullary nail at postoperative 12 months because of with implant failure and nonunion. The mean AOFAS and VAS pain scores improved from 12 (range, 8 to 40) preoperatively to 63 (range, 38 to 75) postoperatively (p = 0.001) and from 7 (range, 6 to 10 to 3 (range, 2 to 8) (p = 0.001), respectively. At the final follow-up evaluation, 6 of 8 patients were able to walk continuously at least 30 minutes with walking aid. Conclusion: The successful rate of salvage arthrodesis with femoral head allograft was 75% (Six of total 8 patients). The incidence rate of allograft collapse was 50% (Four of total 8 patients).

Long-term anatomical and functional outcomes after autokeratoplasty

BackgroundTo evaluate the anatomical and functional outcomes of autologous contralateral penetrating keratoplasty (autokeratoplasty).MethodsKaplan-Meier survival analyses were retrospectively performed. Anatomical failure was defined as regraft or graft permanently cloudy at any time during follow-up. Functional failure was defined as the final best-corrected visual acuity (BCVA) <20/400.ResultsThirty-one eyes of 31 patients (19 men), with a mean age of 52±18 years (range 15–81 years) were studied during a mean follow-up of 11.3 years (from 13 months to 48 years). At 12 months postoperatively, all the recipient eyes showed a transparent cornea, but 23% showed functional failure. At the final followup, 16 recipient eyes (52%) showed anatomical and functional success. Twenty-three eyes (74%) showed a clear cornea and 68% reached a better BCVA when compared with preoperative measurements. Nevertheless, 13/31 eyes (42%) displayed functional failure. The accumulative probabilities for anatomical success were 100%, 72% and 48% and 77%, 59% and 29% for functional success at 1, 10 and 40 years, respectively. The most common risk factor for failure was progression of previous glaucoma in 50% of the anatomical failures and in 77% of the functional failures.ConclusionsAutokeratoplasty could be a successful long-term option in patients having one eye with a clear cornea but with irreversible visual dysfunction and the contralateral eye having favourable visual potential limited only by a completely opacified cornea. Progression of previous glaucoma was the most important risk factor for long-term cornea decompensation and visual functional failure in the sample.

Does zero-profile anchored cage accompanied by a higher postoperative subsidence compared with cage-plate construct? A meta-analysis

Background Zero-profile anchored cage (ZP) has been widely used for its lower occurrence of dysphagia. However, it is still controversial whether it has the same stability as the cage-plate construct (CP) and increases the incidence of postoperative subsidence. We compared the rate of subsidence after anterior cervical discectomy and fusion (ACDF) with ZP and CP to determine whether the zero-profile device had a higher subsidence rate?Methods We performed a meta-analysis of studies which compared the subsidence rate of ZP and CP. An extensive and systematical search covered Medline, Embase and Web of Science databases according to PRISMA guidelines and identified ten articles that satisfied our inclusion criteria. Relevant clinical and radiological data were extracted and analysed by RevMan 5.3 software.Results Ten trials involving 626 patients were included in this meta-analysis. The incidence of postoperative subsidence in ZP group was significantly higher than with CP group [15.1% (89/588) vs. 8.8% (51/581), OR = 1.97 (1.34, 2.89), P = 0.0005]. In subgroup analysis, we found that the definition of subsidence did not affect the higher subsidence rate in the ZP group. Considering the quantity of operative segments, there was no significant difference in the incidence of subsidence between the two groups after single-level fusion (OR 1.43, 95% CI 0.61-3.37, P = 0.41). However, the subsidence rate of the ZP group was significantly higher than the CP group (OR 2.61, 95% CI 1.55-4.40, P = 0.0003) after multi-level surgery. There were no significant differences in intraoperative blood loss, JOA score, NDI score, fusion rate and cervical aligment in the final followup between the two groups. In addition, the CP group had a longer operation time and a higher incidence of dysphagia at each follow-up time than the ZP group.Conclusion ZP had a higher risk of postoperative subsidence than CP. Although there was a high occurrence of swallowing discomfort, we are more agreed that the anterior plate should be used in multi-level surgery as far as possible to reduce the subsidence and adverse clinical symptoms in the long term.

The Effects of Lateral Ligaments Augmentation Using Suture-tape on Functional Ankle Instability

Category: Sports Introduction/Purpose: Although lateral ligaments augmentation using suture-tape has been effective for restoration of mechanical ankle stability, few data are available regarding changes of peroneal strength, proprioception and postural control. The aim of this study was to determine effects of suture-tape augmentation on functional ankle instability (FAI). Methods: Twenty-four patients that underwent suture-tape augmentation were eligible and were followed more than two years postoperatively. Functional outcomes were evaluated with the Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM). Changes of peroneal strength, proprioception and postural control were analyzed with an isokinetic dynamometer and a modified Romberg test. Results: CAIT and FAAM significantly improved to average 27.2 points, 86.7 points at final followup. Peak torque for eversion in 60º/sec angular velocity significantly improved to 10.6 Nm at final followup. Deficit ratio of peak torque for eversion significantly improved from mean 39.5% to 20.9%, and significant side to side difference was revealed (P < .001). There were no significant differences in joint position sense. A significant improvement in balance retention time was revealed at final followup and relative deficit ratio compared to unaffected side was 30.9%. Conclusion: Patient-reported functional outcomes significantly improved after lateral ligaments augmentation using suture-tape. Although this procedure demonstrated significant effects on FAI based on improvement of isokinetic peroneal strength and postural control, recovery rates compared to the unaffected side were insufficient at the intermediate-term followup. In addition, there was no significantly positive effect on proprioception of the ankle.

Long-term Results after Repair of Isolated Meniscus Tears in Patients 18 Years and Younger: An 18-Year Follow-up Study

Objectives: Meniscus repair is desirable over resection to prevent post-meniscectomy arthritis, especially in young and active patients. However, long-term data is currently lacking following isolated meniscus repair, particularly in the pediatric population. The purpose of this study was to report long-term follow-up of isolated meniscus tears treated by meniscus repair in a pediatric population, and to compare those results to previous mid-term follow-up data reported. We hypothesized that these patients would have satisfactory function and reoperation rates at long-term follow-up. Methods: Patients less than 18 undergoing repair of an isolated (without concomitant ACL injury) meniscus tear performed between 1990 and 2005 were included. At the time of final followup, recurrent tear, reoperations, and IKDC and Tegner scores were determined. With logistic regression, the overall failure between different tear types was calculated. Wilcoxon signed ranks tests were performed to calculate the differences in clinical outcome for different time-points, and Spearman coefficients were calculated for Tegner and IKDC with different variables. Results: At an average followup of 17.6 years (13.1 - 26.0 years), 32 patients with 33 isolated meniscus repairs (29 M: 3F) with an average age of 16.1 (9.9 - 18.7) were included in this study. At early follow-up, complex tears (80%) had a higher overall failure rate compared to simple tears (18.2%). However, no further failures occurred since mid-term follow-up with any tear type. At final follow-up, the average IKDC score was 92.3, which was significantly increased when compared to both preoperative 65.3 (p< 0.0001) and mid-term scores, 90.2 (p= 0.01). However, the average Tegner score (6.5) was significantly lower than both pre-operative 8.3 (p< 0.0001) and mid-term 8.4 (p< 0.0001) scores. There was no correlation for Tegner or IKDC values with any risk factors. Conclusion: In conclusion, this study demonstrates overall good to excellent long-term clinical outcomes following isolated meniscus repair in a pediatric population. Early failure and reoperation rates were variable depending on tear type, with complex multiplanar tears having more failures at short-term follow-up. However, at long-term follow-up, IKDC and Tegner scores were not significantly different for those with complex tears compared to other tear types.

Double wedge osteotomy and subtalar arthrodesis for rockbottom malunion after calcaneal fracture

Category: Hindfoot Introduction/Purpose: The pathoanatomy characteristics of the rockbottom malunion after calcaneal fracture include severe loss of calcaneal height, which result in the horizontal of the talus in the ankle mortise and anterior ankle impingement. This study was carreid out to evaluate the clinical results of double wedge osteotomy and subtalar arthrodesis for rockbottom malunion after calcaneal fracture. Methods: From February 2014 to February 2015, 9 cases of calcaneal rockbottom malunion after calcaneal fracture were treated with wedged osteomy and subtalar arthrodesis. And 8 patients get final followup. Weight bearing X ray were taken before the surgery and at final followup. Talar declination, lateral talocalcaneal angle, lateral talo-first metatarsal angle and Bohler’s angle were used to evaluate the correction of the malunion. The American Orthopaecid Foot and Ankle Society (AOFAS) ankle-hindfoot scale and visual analog scale (VSA) for pain were collected. SPSS 22.0 software was used for Statistical analysis. Results: The average time for bone union was 17.1 weeks (12weeks~22weeks). The talar declination was improved from 2.5 ° (- 6°~13°) preoperatively to 13.25° (5°~19°) postoperatively (P<0.001); the lateral talocalcaneal angle was improved from -0.25° (-15°~10°) preoperatively to 0.25° (7°~25°) postoperatively (P<0.001); the talo-first metatarsal angle was improved from 21.13° (10°~30°) preoperatively to 9.88° (5°~14°) postoperatively (P<0.001); and the calcaneal Bohler’s angle was improved from -25.6 ° preoperatively to 22.4 °postoperatively(P<0.001). The AOFAS scale was 26.63 (12~53) preoperatively, and 79.75 (72~89) at final followup (P<0.001); the VAS scale for pain was 7.5 (6~9) preoperatively, and 2.6 (2~3) at final followup (P<0.001). Conclusion: Wedge osteomy and sutalar arthrodesis can effectively correct the malunion, restore the calcaneal height and hindfoor alignment. Pain was relieved after correction, and the function of the ankle and hindfoot was restored.

P.022 Hemifacial Spasm due to dolichoectatic vertebrobasilar artery compression

Background: Hemifacial Spasm (HFS) is rarely caused by a dolichoectatic vertebrobasilar artery (eVB) compression of the Facial Nerve. This can pose a surgical challenge when performing microvascular decompression as vessel mobilization is often difficult due to atherosclerosis, tethering from brainstem perforators, and large size. These patients are often not considered for surgery. Methods: A retrospective chart review of patients who were surgically treated by the senior author between 2003 and 2017 with an admitting diagnosis of HFS was performed. Patients with preoperative neuroimaging demonstrating eVB compression of their facial nerve/root were included. Results: During the 15-year review, 315 patients underwent microvascular decompression for HFS and 21 (6.7%) had dolichoectactic vertebrobasilar compressions. At final followup (>3 months) 19 patients (90.4%) experienced reduction in symptoms with 15 (71.4%) having complete resolution. One patient required re-operation and benefitted from subsequent symptom relief. The majority of culprit compression was found proximally on the pontine surface. Mobilization of the culprit vessel was achieved successfully in the majority of cases with Teflon pledgets. There were no perioperative strokes or death. Complications are presented Conclusions: Microvascular Decompression for Hemifacial Spasm caused by dolichoectatic vertebrobasilar artery compression can be performed with a high rate of safety and success in the setting of a high case volume centre.

Surgical Outcomes of Severe Turf Toe Injuries in High-Level Football Players

Category: Sports Introduction/Purpose: Turf toe is a term used to describe a hyperextension injury to the first metatarsophalangeal joint. Although the vast majority of turf toe injuries can be treated successfully without surgical intervention, there are instances where surgery is required to allow the athlete to return to play. Surgical turf toe repair restores the continuity of the plantar plate structures, re-establishes stability, and simultaneously addresses any sesamoid pathology or cartilage lesions. Although there is extensive literature on turf toe injuries and its nonoperative management, there are currently no reports on surgical outcomes in athletes larger than three to four patients. Methods: After obtaining Institutional Review Board approval, we attained all cases of turf toe repair according to the ICD-10 procedural code. The inclusion criteria included: age greater than 16, turf toe injury requiring operative management and at least a varsity level high school football player. Our patient population consisted of thirteen patients. Their charts were reviewed for age, BMI, level of competition, injury mechanism (if known), football position, setting of injury (practice or game) and playing surface. In addition, we recorded the specifics of the surgical procedure, a listing of all injured structures, the surgical implants used and the great toe range of motion at final followup visit. In addition, a followup survey was administered to all patients. Results: The average patient was 19.5 years old with an average followup time of 21.4 months. Our group consisted of six linemen and seven skill position players. There was one semiprofessional player, ten collegiate players and two high school players. Eight of the 13 patients had complete rupture of both fibular and tibial phalangeal sesamoid ligaments while five patients had a partial injury. Seven of the patients had a suture only primary repair while in six patients suture anchors were utilized. The average playing time missed was 16.4 weeks. No patient had to stop playing football or change positions due to the injury or surgery. At final followup, the average patient had a VAS pain score of 0.21. Conclusion: Severe turf toe injuries are often debilitating and may require operative management to restore a pain-free, stable, and functional forefoot. The injuries sustained and procedures performed were variable in our patient population but every player was able to return to play at a high level with the use of a custom orthotic placed inside their cleat. This study represents the largest cohort of operatively treated severe turf toe injuries in the literature and demonstrates that good clinical outcomes can be expected with surgical repair.