Iatrogenic atlantoaxial rotatory subluxation after thyroidectomy in a pediatric patient:A case report

BACKGROUND Atlantoaxial rotatory subluxation(AARS)is an uncommon disease with a greater prevalence among children than adults,and it is mostly associated with trauma.Iatrogenic spinal injury accounts for a low percentage of injuries.However,in AARS,20%-40%of cases are associated with surgery,and 48%are caused by infection.Here,we describe our experience with a case of iatrogenic AARS after general anesthesia.CASE SUMMARY A 12-year-old girl presented with right-sided torticollis and cervical motion limit.The patient had undergone thyroidectomy 2 mo ago.Computed tomography revealed AARS with bilateral locked facets.Following the failure of repeated external reduction under general anesthesia,the patient underwent an open surgical reduction.The patient gained atlantoaxial alignment without any complications.Follow-up radiographs showed a normal appearance without instability.The cervical spine of children is more predisposed to injury due to anatomical and biomechanical differences.AARS secondary to infection and surgery is known as Grisel’s syndrome,which involves non-traumatic AARS.Several cases of AARS after surgery and other procedures with no evidence of inflammation have been reported.Our experience shows that surgery requiring hyperextension of the neck after general anesthesia should also be included as a risk factor.CONCLUSION Surgeons and anesthesiologists should be careful not to excessively extend the neck during pediatric surgery.Moreover,clinicians caring for pediatric patients with recent head and neck procedures must be aware of common AARS presentations.

Technique of using Cionni-modified capsular tension ring in the management of severely traumatic lens subluxation

AIM:To investigate the effect of Cionni-modified capsular tension ring(CTR)implantation in patients with severely traumatic subluxated cataracts.METHODS:All patients who totally had traumatic cataracts and lost zonule support and underwent cataract surgery were retrospectively analyzed.Corrected distance visual acuity(CDVA),extent of zonulysis,intraocular lens(IOL)position,intraoperative presentation,and complications were assessed.The primary outcomes included IOL centration stability and other postoperative complications.RESULTS:Twenty patients(20 eyes)were included in this study.The mean age in this study was 58.0±11.3y,and the average follow-up time was 17.3±12.8mo.Capsule bags were saved by Cionni-modified CTR.Nine eyes(45%)underwent simultaneously anterior vitrectomy due to the presence of vitreous in the anterior chamber.The preoperative mean CDVA was 0.83±0.24 log MAR,and the postoperative average CDVA was 0.23±0.30 log MAR(P<0.05).The horizontal and vertical IOL decentration after surgery was 0.27±0.12 mm and 0.41±0.19 mm,respectively;the vertical and horizontal IOL tilt after surgery was 5.5°±2.5°and 6.1°±2.2°,respectively.None of the eyes had obvious IOL decentration during the follow-up time.Eight eyes(40%)had posterior capsule opacification(PCO)that was severe enough to cause poor vision.Neodymium:YAG laser capsulotomy were performed on these eyes when the CTR was stabilized.CONCLUSION:With the help of Cionni-modified CTR,capsular bag preservation and better IOL concentration can be achieved without major complications in patients with severely traumatic subluxated cataracts.

Multiple methods of surgical treatment combined with primary IOL implantation on traumatic lens subluxation/dislocation in patients with secondary glaucoma

AIM:To describe clinical findings and complications from cases of traumatic lens subluxation/dislocation in patients with secondary glaucoma,and discuss the multiple treating methods of operation combined with primary intraocular lens(IOL)implantation.METHODS:Non-comparativeretrospectiveobservational case series.Participants:30 cases(30 eyes)of lens subluxation/dislocation in patients with secondary glaucoma were investigated which accepted the surgical treatment by author in the Ophthalmology of Xi’an No.4Hospital from 2007 to 2011.According to the different situations of lens subluxation/dislocation,various surgical procedures were performed such as crystalline lens phacoemulsification,crystalline lens phacoemulsification combined anterior vitrectomy,intracapsular cataract extraction combined anterior vitrectomy,lensectomy combined anterior vitrectomy though peripheral transparent cornea incision,pars plana lensectomy combined pars plana vitrectomy,and intravitreal cavity crystalline lens phacofragmentation combined pars plana vitrectomy.And whether to implement trabeculectomy depended on the different situations of secondary glaucoma.The posterior chamber intraocular lenses(PC-IOLs)were implanted in the capsular-bag or trassclerally sutured in the sulus decided by whether the capsular were present.Main outcome measures:visual acuity,intraocular pressure,the situation of intraocular lens and complications after the operations.RESULTS:The follow-up time was 11-36mo(21.4±7.13).Postoperative visual acuity of all eyes were improved;28 cases maintained IOP below 21 mm Hg;2cases had slightly IOL subluxation,4 cases had slightlytilted lens optical area;1 case had postoperative choroidal detachment;4 cases had postoperative corneal edema more than 1wk,but eventually recovered transparent;2 cases had mild postoperative vitreous hemorrhage,and absorbed 4wk later.There was no postoperative retinal detachment,IOL dislocation,and endophthalmitis.CONCLUSION:To take early treatment of traumatic lens subluxation/dislocation in patients with secondary glaucoma by individual surgical plan based on the different eye conditions would be safe and effective,which can effectively control the intraocular pressure and restore some vision.

Effective treatment for secondary angle-closure glaucoma caused by traumatic lens subluxation:phacoemulsification with capsular-tension-ring implantation combined with ophthalmic endoscope-controlled goniosynechialysis

AIM:To investigate the safety and efficacy of phacoemulsification with capsular-tension-ring implantation and posterior chamber intraocular lens implantation combined with ophthalmic endoscope-controlled goniosynechialysis(Phaco-CTR-IOL-OE-GSL)for treating secondary angle-closure glaucoma induced by traumatic lens subluxation.METHODS:A retrospective and descriptive study was performed on patients with lens subluxation,angle closure,goniosynechia,and evaluated intraocular pressure(IOP)that cannot be controlled with medication,who underwent Phaco-CTR-IOL-OE-GSL.The postoperative best-corrected visual acuity(BCVA),IOP,range of goniosynechia and complications were retrospectively observed.RESULTS:Nine patients with secondary angle-closure glaucoma induced by traumatic lens subluxation were included.The follow-up period was 51.1±8.6 mo.The preoperative range of zonule rupture was 158.2°±33.0°,and the range of goniosynechia was 220.0°±92.5°.The baseline BCVA was 0.9±1.0 logMAR,IOP was 30.7±17.3 mm Hg and number of anti-glaucoma medication was 3.2±1.1.Mild intraoperative hyphaemia with 8 eyes(88.8%)in the anterior chamber,and was absorbed two days postoperatively.One eye(11.1%)had postoperative ciliary body detachment and was recovered after five days of topical drug treatment.BCVA was 0.2±0.2 logMAR at 3 mo postoperatively.The average IOP at the last follow-up was 16.7±2.0 mm Hg,and no anti-glaucoma medications were used.The average range of recurrent goniosynechia was 54.9°±33°at the final postoperative gonioscopic examination.CONCLUSION:Phaco-CTR-IOL-OE-GSL is safe and effective in the treatment of secondary angle-closure glaucoma induced by traumatic lens subluxation.The use of an endoscope provides a more direct and clear examination for GSL,and 360°dissection is easily achieved.

Arthroscopic surgery for synovial chondroma of the subacromial bursa with non-traumatic shoulder subluxation complications:Two case reports

BACKGROUND Synovial chondromatosis is a disease originating from the synovium and characterized by the presence of metaplastic cartilaginous nodules in synovial cavities.The exact prevalence of synovial chondromatosis remains unknown,and the involvement of the shoulder joint is very rare.Synovial chondromatosis accompanied by subluxation of the humeral head without a history of trauma is rarely encountered,and to our knowledge,no published reports describe this condition.CASE SUMMARY We present two cases of synovial chondromatosis in the shoulder joint,accompanied by subluxation of the humeral head,in two arthroscopically managed adult patients.We performed arthroscopic labrum fixation and removal of the loose body from the shoulder joint.To identify primary and secondary categories,pathological analysis was arranged.Clinical and radiographic evaluations at the 1-mo follow-up were satisfactory.CONCLUSION The biomechanical function of the shoulder joint requires attention,especially following the detection of loose bodies,as observed with synovial chondroma occurring in rare sites.Arthroscopic management is successful in patients with synovial chondromatosis combined with shoulder subluxation.

Medial Patella Subluxation after Minor Trauma

Most cases of medial patella subluxation occur under iatrogenic conditions that are often associated with a prior excessive lateral retinacular release procedure. We report a case of medial subluxation following minor trauma with no history of previous lateral release. The abnormality was identified on magnetic resonance imaging and was successfully treated by direct repair of the lateral retinaculum. The recognition and treatment of medial subluxation of the patella without retinacular release can be difficult. Therefore, consideration of multiple causes through careful medical history taking, physical examination, and radiologic examination is needed for accurate diagnosis.

Treatment of rotatory subluxation of the scaphoid by scapho-trapezoid limited arthrodesis

Objective To introduce a new procedure for treatment of rotatory subluxation of the scaphoid. Methods Eighteen patients with rotatory subluxation of the scaphoid were divided into five types according to clinical manifestation and cause: type Ⅰ (predynamic) 1 case,type Ⅱ (dynamic) 2 cases, type Ⅲ (static) 7 cases, type Ⅳ (degenerative) 3 cases, type Ⅴ( secondary) 5 cases. All cases underwent scapho-trapezio-trapezoid limited wrist arthrodesis. Results The follow-up ranged from 6 months to 3 years. The results showed that the all rotatory subluxatiopn of scaphoid in the study had been corrected with satisfactory fusion and painless wrist. The average grip strength was 90% of the normal wrist, and the average range of motion was 62% of the opposite side. Conclusion Scapho-trapezio-trapezoid limited arthrodesis is a reliable and useful procedure for treatment of chronic andChina Medical Abstracts(Surgery) static rotatory subluxation of the scaphoid. 15 refs,2 figs.

Sutured scleral fixation of existing subluxated/dislocated acrylic one-piece intraocular lenses

AIM:To evaluate the visual and refractive outcomes in cases after sutured scleral fixation of existing subluxated or dislocated acrylic one-piece intraocular lenses(IOLs).METHODS:This study retrospectively enrolled a consecutive series of patients who underwent a surgery of sutured existing subluxated or dislocated IOLs from October 2018 to June 2020.All patients underwent comprehensive preoperative and postoperative ophthalmologic examination,and data were collected including age,sex,surgical indications,best-corrected visual acuity,refractive error,intraocular pressure.Presence of intraoperative and postoperative surgical complications was documented.RESULTS:A total of 20 consecutive cases were enrolled for analysis with mean final follow-up period 9.8±5.3mo.Visual acuity improved from a mean of 0.35(0.46±0.32 logMAR)preoperatively to 0.61(0.21±0.18 logMAR)at the 3-month follow-up(P=0.002).The mean amount of preoperative keratometric astigmatism and total postoperative refractive astigmatism was-1.24±0.80 diopters(D)and-1.42±0.97 D,respectively.There was no statistically significant difference between preoperative and postoperative astigmatism(P=0.156).The mean IOL-induced astigmatism was-0.23±0.53 D.The mean spherical equivalent at the 3-month follow-up was-0.1±0.94 D.No major complications were noted during the follow-up period.CONCLUSION:Surgical techniques using sutured scleral fixation of existing subluxated or dislocated acrylic one-piece IOLs result in favorable visual and refractive outcomes without major complications.

Discussing tuina for atlantoaxial subluxation in adults based on the theory of‘tendon-bone balance’

According to Chinese medicine,the atlantoaxial joint is a composite joint composed of tendons and bones,and the stability of the joint depends on the‘tendon-bone balance’involving tendons,ligaments,atlas and axis.Multiple causes of‘tendon off-position,joint subluxation’will lead to joint‘tendon-bone imbalance’,which will evolve into atlantoaxial subluxation(AAS),endangering human health.Chinese therapeutic massage(tuina)is a very effective treatment for AAS in adults,but conventional manipulations are prone to ineffectiveness or accidents due to neglect of the causal relationship of the‘tendon-bone imbalance’and inappropriate manipulations.Compared with conventional manipulations,the rational choice of modified manipulations under the guidance of‘tendon-bone balance’theory is more effective and less risky,and more worthy of clinical promotion.From the‘tendon-bone balance’theory,we considered the shortcomings of conventional manipulations,and introduced several modified manipulations that have their own strengths in‘tendon smoothing’and‘bone setting’,in order to provide new ideas for treatment of AAS in adults.

Tuina for Leg Length Discrepancy and Lumbosacral Pain Due to Sacroiliac Joint Subluxation

Objective： To observe theclinical effect of tuina reduction manipulation on leg length discrepancy and lumbosacral pain due to sacroiliac joint subluxation. Methods： A total of 60eligible cases were randomly allocated into an observation group and a control group, 30 in each group. Cases in the observation group were treated with conventional tuina plus reduction manipulation of sacroiliac joint subluxation; whereas cases in the control group were treated with conventional tuina plus acupuncture. The clinical effects were observed after 10 times of treatment. In addition, the relapse rates were observed 2 months after treatment. Results： The total effective rate in the observation group was 80.0%, versus 50.0% in the control group, showing a statistically significant difference （P＆lt;0.05）. The relapse rate of lumbosacral pain in the observation group was 12.5%, versus 66.7% in the control group, showing a statistically significant difference （P＆lt;0.01）. The relapse rate of leg length discrepancy in the observation group was 16.7%, versus 80.0% in the control group, showing a statistically significant difference （P＆lt;0.01）. Conclusion： Tuina reduction manipulation can obtain substantial therapeutic effect for leg length discrepancy and lumbosacral pain due to sacroiliac joint subluxation, coupled with a low relapse rate.

Intraocular lens exchange or explantation post cataract surgery

AIM:To report incidence,indications,and visual outcomes of intraocular lens(IOL)exchange/explantation surgery.METHODS:Retrospective analysis of 60 eyes requiring IOL exchange/explantation surgery between 1^(st) January 2017 and 31^(st) December 2022.The overall outcomes as well as comparison between the trainee versus experienced surgeons were analyzed.RESULTS:Out of 39778 cataract surgeries(with no preexisting ocular co-morbidities)during a six-year period(2017-2022),60(0.15%)needed IOL exchange/explantation.Surgeons-under-training performed 36/60 cases(60%)while 24/60(40%)were by experienced surgeons.The commonest indication was subluxated IOL in 26(43.3%),followed by dislocated IOL in 20(33.3%),postoperative refractive surprise in 7(11.6%),IOL induced uveitis in five and broken haptic in two eyes.Twenty-four(40%)eyes had intraoperative complications during primary surgery.Posterior chamber IOL(PCIOL)was the commonest secondary IOL in 21(35%)eyes,scleral fixated in 20(31.6%),anterior chamber IOL(ACIOL)in 13(21.6%),iris fixated IOL in three(5%)and three eyes(5%)were left aphakic.The mean time between primary and secondary surgery was 168d(168±338.8).Best corrected visual acuity(BCVA)of>20/60 was obtained in 43 eyes(71.66%),20/80-20/200 in 14(23.33%),20/250 in two and hand movements in one.No statistically significant difference in visual outcome was noted at post-op one month between trainees versus experienced surgeons(UCVA 0.45±0.29 vs 0.53±0.32,P=0.20,BCVA 0.34±0.25 vs 0.37±0.26,P=0.69).CONCLUSION:IOL subluxation as the commonest indication and posterior capsular rupture is the commonest intraoperative risk factor.This complication can be effectively addressed with selection of the appropriate secondary IOL achieving good visual outcomes in over 70% of patients.

Radial head subluxation in pediatric clinics and emergency departments in China

Purpose:To investigate the characteristics of the onset and treatment of radial head subluxation(RHS)in pediatric clinics and emergency departments.Methods:A retrospective study was performed on 11,404 RHS cases in 9827 children who visited pediatric clinics and emergency departments from January 2015 to December 2018.The patients who with history of trauma and fracture of the affected limb were excluded.The following factors were examined:the mechanisms of RHS,the type of manual reduction,the attending physician's clinical background(emergency surgeon,junior pediatric orthopedic surgeon or senior pediatric orthopedic surgeon),and the epidemiological features(gender,age,climate and location)of the injury.Results:The mean age of the patients was 27.93±17.94 months(range 0.93-214.53 months),with a peak incidence of 10.73-44.53 months.Approximately two-thirds of RHS cases occurred in cold weather from January to March and from September to December.Females accounted for 53.81%(n=6137)of the cases,and left injuries were predominant(56.87%,n=6485)in all cases.Mechanisms of injury were classified as"pull"(90.57%,n=10,339),"fall"(1.56%,n=178),"hit"(0.75%,n=86)and"unknown"(7.02%,n=801).The overall success rate of manual reduction was 99.47%,and the success rate of reduction was higher for senior pediatric orthopedic surgeons than for emergency surgeons and junior pediatric orthopedic surgeons(p<0.05).However,there was still a recurrence rate of 12.16%in the 9827 patients.Conclusion:Younger children are predisposed to RHS,and there is a possibility of recurrence.Trained emergency doctors can handle it well,but it is essential to refer patients to specialists when manual reduction failed.

Pain management of hemiplegic shoulder pain post stroke in patients from Nanjing,China

We selected 106 hemiplegic patients with shoulder pain hospitalized after stroke from three hospi- tals in Nanjing, China between February 2007 and January 2012. All patients had complete clinical data sets and accounted for 45.5% of the inpatients because of stroke. Results showed that the number of patients with hemiplegic shoulder pain post stroke increased yearly, attacking mainly males 50-69 years of age. Of 106 patients, there were 60 cases （56.6%） of adhesive capsulitis, 19 （17.9%） of shoulder subluxation, 14 （13.2%） of complex regional pain syndrome, and 13 （12.6%） of central pain. The main symptoms were shoulder pain （100%）, limit of shoulder mobility （98.1%）, and adhesion of the scapula （56.6%）. MRI of the shoulder showed tendon and ligament lesions （57.1%） and rotator cuff tear （38.1%）. 53.8% of central pain was related to the thalamus, in addition to the basal ganglia, brain stem, and cerebellopontine angle. Shoulder pain, upper limb motor function, and function independence were significantly improved after comprehensive rehabilitation. In par- ticular, electroacupuncture based on basic physical therapy exhibited efficacy on shoulder subluxa- tion and complex regional pain syndrome. Multiple linear regression results showed a negative re- lationship of efficacy of pain management with the attack period of shoulder pain, involvement of the posterior limb of the internal capsule, and duration between onset and rehabilitation treatment, but a positive correlation with pain-related education, pain regression period, and pain diagnosis.

Advances in the treatment of cervical rheumatoid: Less surgery and less morbidity

Rheumatoid arthritis is a chronic systemic inflammatory disease that often affects the cervical spine.While it was initially thought that cervical involvement was innocuous,natural history studies have substantiated the progressive nature of untreated disease.Over the past 50 years,there has been further elucidation in the pathophysiology of the disease,as well as significant advancements in medical and surgical therapy.The introduction of disease modifying drugs and biologic agents has reduced the amount of patients with advanced stages of the disease needing surgery.Advancement in instrumentation techniques has improved patient outcomes and fusion rates.The introduction of endoscopic approaches for ventral decompression may further lower surgical morbidity.In this review,we give a brief overview of the pertinent positives of the disease.A discussion of historical techniques and the evolution of surgical therapy into the modern era is provided.With improved medical therapies and lessinvasive approaches,we will likely continue to see less advanced cases of disease and less surgical morbidity.Nonetheless,a thorough understanding of the disease is crucial,as its systemic involvement and need for continued medical therapy have tremendous impact on overall complications and outcomes even in patients being seen for standard degenerative disease with comorbid rheumatoid.

Atlantoaxial rotatory displacement in children

AIM To correlate the Pang and Lee class with the clinical course in a consecutive series of patients presenting with painful torticollis.METHODS Forty-seven dynamic rotational computed tomography(CT) scans in 35 patients were classified into one of the five types defined by Pang and Li, including types Ⅰ(atlantoaxial rotatopry fixation), Ⅱ("pathologic stickiness" without crossover of C1 on C2), Ⅲ("pathologic stickiness" with crossover of C1 on C2), Ⅳ(normal or muscular torticollis), and Ⅴ(diagnostic grey zone). The Pang and Li class was then compared with the radiologist's report, which was graded abnormal, diagnosis of rotatory subluxation or fixation, or non-diagnostic. Medical records were reviewed and the clinical course was compared among the five subtypes.RESULTS We reviewed 47 CT scans in 35 patients, and the majority were performed without sedation. The average age was 7.7 years(4-14 years old) and associated conditions included minor trauma(20%), surgical procedures around the head and neck(29%), and Grisels syndrome(20%). Twenty-six percent of our studies fell within the pathologic spectrum(5% type 1 or rotatory fixation, 21% types 2 and 3 or rotatory subluxation), while 45% were classified as muscular torticollis(45%) and 28% fell within the diagnostic grey zone. Seven radiologists interpreted these studies, and their interpretation was discordant in 45% of cases. Clinical resolution occurred in 27 of 29 cases for which follow-up was available. One of two patients with fixed rotatory subluxation required a C1-C2 arthrodesis.CONCLUSION The Pang and Li classification characterizes a spectrum of abnormalities in rotation to facilitate communication, although the indications for dynamic CT scan should be further defined.

Developmental Dysplasia of the Hip (DDH) in Saudi Arabia: Time to Wake up. A Systematic Review (1980-2018)

The objective of this systematic literature review was to assess the incidence of DDH among the Saudi Arabian population. Methods: A systematic review was performed for all the published articles in the English language literature on DDH in Saudi Arabia. Data sources were PubMed Medline (1980-2018) (http://www.ncbi.nlm.nih.gov/pubmed/), Ovid Medline (1980-2018), EMBASE MEDLINE (1980 to May 2018), EMBASE (1991 to May 2018), the Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews, the Science Citation Index (1966 to May 2018), published data from the Saudi Medical Journal (1985-2018) and Annals of Saudi Medicine (1985-2018). The author independently reviewed articles and abstracted the data. The key words used were Saudi Arabia developmental dysplasia of the hip ORDDH, congenital hip dislocation or congenital subluxation of the hip, and congenital dysplasia of the hip. Results: The authors identified 18 potentially relevant articles published in the last 38 years, and 10 met the inclusion criteria. The 10 studies analyzed included 2037 studies of infants diagnosed with DDH;and they gave an average incidence of 10.46/1000. Two studies (303 subjects) did not report the affected gender;in the remaining 338 were boys and 1396 were girls and one study did not report the side of affection. The majority presented after 12 months of age. The right side was affected in 532 (27.2%) affected, 734 (37.6%) were left side and 687 (35.2%) infants were affected bilaterally. Consanguinity, breech presentation, and family history were found to be the risk factors in 32.9%, 17.3%, and 23.6% of the patients, respectively. Conclusions: There is paucity of available literature on DDH in Saudi Arabia. New strategies have to be developed that include mandatory screening programs in all hospitals (private and public) so that more children can be treated by nonsurgical methods.

Perioperative Outcomes Following Surgical Treatment of the Neuromuscular Hip: An Analysis of the National Surgical Quality Improvement Program—Pediatrics

Background: Surgical treatment for neuromuscular (NM) hip subluxation or dislocation is undertaken to maintain functionality and decrease pain. Longterm complications are well described;however, the acute complication profile is poorly understood. Questions/Purpose: The aim of this study was to identify the rate of and risk factors for complications following surgical treatment of hip subluxation/dislocation, especially as it relate to NM children. Methods: Hip reconstruction cases in patients with a NM diagnosis and non-NM patients were obtained from the 2015 American College of Surgeons NSQIP-Pediatric database by CPT code. 30-day postoperative complications were classified according to the Clavien-Dindo system as minor (grade 1 or 2) or major (grade 3+). Patient and surgical factors were assessed in univariate and multivariate logistic regression analyses for association with post-operative complications. Results: 1081 cases were identified (median age 7.7, 55% female), of whom 420 (39%) had a NM diagnosis. Overall complication rate was significantly higher in NM patients (33% vs. 19%, p < 0.001). Numerous factors were associated with postoperative complication on univariate analysis. Multivariate analysis identified NM diagnosis (OR 1.5), age > 6 years (OR 1.5), or pelvic osteotomy (OR 1.9) as independent risk factors for complication. Conclusion: In pediatric reconstructive hip surgery requiring pelvic osteotomy, a NM diagnosis is associated with an increased risk of 30-day postoperative complications. Older age and increasing surgical complexity were also independently associated with complications. These findings support special attention for the older patients undergoing concomitant pelvic osteotomies to minimize complication rate.

Acute lens-induced glaucomas: A review

Lens-induced factors are important and common mechanisms causing acute elevation of intraocular pressure. While in most cases, the diagnosis and management are straight-forward, in others it is difficult and can lead to improper procedures, complications and poor visual outcomes. This review was done with the aim of studying the various types of lens-induced glaucomas, classifying them in an easy way to understand manner, their clinical features, current management and future possibilities.

Conservative Treatment in Grisel’s Syndrome Following Tonsillectomy

Grisel’s syndrome is a rare complication that is characterized by non-traumatic atlantoaxial subluxation. It is most commonly seen in children after an upper respiratory tract infection or neck surgery, such as an adenoidectomy, tonsillectomy and mastoidectomy. Grisel’s Syndrome is characterized by torticollis and a limited range of motion of the neck with pain. Here the authors report a case of a Malian 5-year-old girl with Grisel’s syndrome following tonsillectomy. The patient’s complaints were fully resolved after 2 weeks of conservative treatment.

Prosthetic Impingement in Total Hip Arthroplasty—The Trigger for Adverse Wear

Development of total hip arthroplasty (THA) now spans more than 5 decades encompassing combinations of metal-on-metal (MOM), ceramic-on-metal (COM), metal-on-plastic (MOP), ceramic-on-plastic (COM), and ceramic-on-ceramic (COC). In every arena of extensive technical development, there exists a data set that when viewed in isolation seemed of little import, but when assembled in-toto may produce a generational shift in perception. Our review focused on two such THA events. Firstly, COC retrieval studies (1999-2001) noted habitual wear patterns on heads and peripheral wear stripes, along with femoral-neck impingement, and ceramic surfaces stained gray by metal debris. These COC data indicated THA risks included, 1) cup edge-loading (E/L) on heads producing “stripe wear”, 2) component impingement releasing metal particles resulting in 3) tissues contaminated by metal debris. A corresponding MOM impingement-debris mechanism was only perceived by Howie (2005) in a McKee-Farrar retrieval study. Our anticipation at LLUMC was that MOM retrievals would provide superior wear details to those seen on COC retrievals. We noted stripe wear in the polar zone of CoCr heads and basal stripes in the non-wear areas. The basal-polar stripe combinations were found in all MOM retrievals. Basal-polar stripe combinations followed cup-rim profiles in our LLUMC simulations of prosthetic impingement. LPUH videos demonstrated the formation of stripe wear in functional-standing and functional-sitting postures for both impingement and subluxation episodes using THA and RA designs. The stripes on CoCr heads revealed the large scratches we now term “microgrooves”. Microgroove width varied from 40 - 400 um with 100 um being typical. The longitudinal striations in microgrooves, the raised jagged lips, scratches with shallow entry and exit termini, were all indicative of a classic 3rd-body wear mechanism. The THA impingement simulations denoted four sites of edge-loading, i.e. neck-E/L, inferior cup-E/L, superior cup-E/l and head-E/L, and ingress of Ti64 particles as a contaminating-roughness effect. Individual MOM cases referred to LLUMC demonstrated dramatic evidence of neck notching. At one end of the debris spectrum, a Ti64-notch model predicting a 6 mm3 annual wear-rate represented the release of 5700 particles of 126 um-size (approximating daily release of 16 particles). At the other end of the spectrum, if metal particles were crushed between MOM surfaces to the equivalent nanometer size found in tissues, our notch model represented approximately 22-trillion Ti64 particles annually deposited in tissues. The anatomical THA models represented in LPUH videos demonstrated that even 1-degree of head subluxation from a rigid cup created a cup “lift-off” scenario (CLO) that would open a gap of 250 - 400 microns between femoral head and cup. This would void all lubrication potential and focus the total hip-joint force along the beveled cup rim, i.e. stripe wear. It is therefore interesting that MOM impingement/debris predictions by Howie et al. have not been confirmed until now or discussed in contemporary literature. Therefore, this review of 50 years of THA data demonstrated that hip impingement was always the trigger for adverse wear and that metal-backed cups represent the potential for release of metal debris at extremes of functional standing and sitting postures.