Impact of Alignment and Alignment Correction on Outcomes Following Robotic Medial Unicompartmental Knee Arthroplasty.

BACKGROUND: The purpose of this study was to retrospectively examine the relationship between preoperative and postoperative alignment in robotic unicompartmental knee arthroplasty (UKA) and postoperative patient-reported outcome measures. METHODS: A retrospective review of 374 patients who underwent robotic-assisted UKA was conducted. Patient demographics, history, and preoperative and postoperative Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) scores were obtained via chart review. Average follow-up period was 2.4 years (range: 0.4 to 4.5 years) to chart review and 9.5 months (range: 6 to 48 months) to latest KOOS-JR. Preoperative and postoperative robotically-measured knee alignment was obtained from operative reports. Incidence of conversion to total knee arthroplasty (TKA) was determined by review of a health information exchange tool. RESULTS: Multivariate regressions showed no statistically significant relationship between preoperative alignment, postoperative alignment, or degrees of alignment correction and change in KOOS-JR score or achievement of KOOS-JR minimal clinically important difference (MCID) (P > .05). Patients who had >8 degrees of postoperative varus alignment had on average a 20% lower achievement of KOOS-JR MCID compared to patients who had <8 degrees of postoperative varus alignment; however, this difference was not statistically significant (P > .05). There were 3 patients who required conversion to TKA in the follow-up period, with no significant relationship to alignment variables (P > .05). CONCLUSION: There was no significant difference in KOOS-JR change for those patients who had a larger or smaller degree of deformity correction, and correction did not predict MCID achievement.

Complicated Open Wound Management in a Free Clinic Setting.

Wound healing is a complex and integrated process that involves several interdependent overlapping stages, including hemostasis, inflammation, proliferation, and vascularization. Cellulitis and skin abscesses are among the most common skin and soft tissue infections. Cellulitis typically involves the deeper dermis of subcutaneous fat and tends to have a more indolent course with the development of localized symptoms over a few days. Skin abscesses are described as a collection of pus within the dermis or subcutaneous space. Diabetes mellitus (DM) is the leading cause of impaired wound healing and consequently has higher rates of patients developing soft tissue infections. Diabetic patients experience decreased early inflammatory cell infiltration but increased numbers of neutrophils and macrophages. Complications include bacteremia, metastatic infection, sepsis, and toxic shock syndrome. In this case, we describe a 50-year-old Caucasian uninsured male who was referred to the Gary Burnstein Clinic (GBC) from a nearby hospital for wound management after an incision and drainage of a large back abscess and uncontrolled type 2 diabetes mellitus (T2DM). The patient presented with a large erythematous, indurated lesion with a cruciate incision that spanned from his mid-thoracic spine to the medial border of his left scapula. The wound management course required strict follow-up to the clinic every 48-72 hours for debridement and monitoring. This was complicated by the GBC's limited resources along with the volunteer nurses' and physicians' availability. To avoid the patient being lost to follow-up, shared decision-making was utilized to create a schedule that was advantageous for both the patient and the clinic. Ultimately, the patient made a full recovery without any adverse events. This case highlights the gaps in care for the medically uninsured. We also showcase the passion and dedication our medical volunteers exhibit to care for the community. The GBC provides high-quality healthcare to bridge gaps in access to care by offering broad specialist access while ensuring continuity of care.

Challenges in Management of Kidney Failure in a Free Clinic Setting: A Case Report.

Chronic kidney disease (CKD) is a condition that involves the deterioration of renal function over the course of months to years. Various clinical manifestations occur at the initial insult to the kidney, ranging from subtle changes in metabolic and volume control to asymptomatic hematuria, hypertension, and diabetes. The kidneys can adapt to damage or injury, but if left untreated, then there is a possibility of a gradual decline in renal function that progresses to kidney failure that requires dialysis. The rate of progression between stages of CKD is based upon the underlying disease, presence of comorbidity conditions, treatments, socioeconomic status, genetics, and ethnicity. If an individual's renal function progresses to kidney failure, then patients may experience a constellation of signs and symptoms that include hyperkalemia, volume overload, hypertension, anemia, and bone disorders. Classification or staging of CKD provides a guide to management and stratification of risk for progression to kidney failure. In this report, we describe a 47-year-old African American male who reported a 25-year history of intermittent homelessness, cocaine, and heroin use but remained free from drug use for 10 years before presenting to our clinic. The patient was diagnosed with hypertension and stage 3 kidney disease in his 30s but was unable to have regular follow-up appointments with a physician due to a lack of access to care. The patient presented asymptomatic with an estimated glomerular filtration rate of 14 mL/min and creatinine of 5.42 mg/dL. We stabilized his hypertension and consulted nephrology to assess the need and timing for dialysis. Once approved for Medicare, the patient was able to be seen within 72 hours and started on dialysis shortly after. He is currently awaiting a kidney transplant. In this case, we describe and highlight the gaps in care for the medically uninsured, specifically patients with CKD. Our patient was diagnosed with stage 3 kidney disease 17 years before presenting to the Gary Burnstein Clinic. The gaps in accessible healthcare prevented him from accessing treatments he desperately needed. We also highlight the achievements and barriers free health clinics face on a day-to-day basis when trying to manage complex medical needs. We were able to provide high-quality healthcare to bridge the gap in access to care and ultimately get the patient the proper treatment.

Eosinophilic Fasciitis: A Rare and Challenging Diagnosis in a Free Clinic Setting.

Eosinophilic fasciitis (EF) is a rare ailment that affects the immune system. Due to the rarity of this condition, there are few clear diagnostic criteria for clinicians to focus on. This may lead to significant delays in reaching a diagnosis and offering proper treatment, and patients may end up seeing multiple different specialists. This is especially true in a free clinic setting where continuity of care, follow-up, and specialist access are usually lacking. In this report, we describe a case of a 24-year-old white male who presented with sudden onset of redness, swelling, burning, and pain in the bilateral upper and lower extremities. Through arduous workup and testing, he was found to have increased eosinophils in peripheral blood, elevated levels of white blood cell count, increased C-reactive protein, and pathological changes in the tissue showing eosinophil and lymphocyte infiltration. We shed light on the relative rarity of this condition and its similar clinical characteristics to various dermatological/rheumatological disease processes. We also highlight how a free clinic can provide high-quality healthcare to bridge gaps in access to care by providing high-quality and broad specialist access while ensuring continuity of care.

Challenges of Treating an Acute Hepatitis C Virus Infection With Concurrent Seizure Treatment in a Free Clinic.

Currently, there is limited data evaluating the coadministration of first-generation anticonvulsants for epilepsy treatment and direct-acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) infection. There is a potential risk of suboptimal DAA serum concentrations that could potentially lead to HCV treatment failure. In this report, we describe the case of an uninsured, non-Hispanic Black male in his mid-40s with a history of generalized epilepsy that was managed with phenytoin 100mg twice a day and divalproex 500mg extended-release once daily. He was diagnosed with an acute hepatitis C viral infection with a genotype of 1a. Due to the viral genotype, treatment naivety, and lack of cirrhosis, the recommended treatment is to start glecaprevir/pibrentasvir, but the concomitant use of phenytoin and glecaprevir/pibrentasvir is not recommended due to a drug-drug interaction that could lead to subtherapeutic DAA levels and possible treatment failure. Through shared decision-making and close follow-up, we slowly weaned the patient off phenytoin, replaced it with levetiracetam, and started glecaprevir/pibrentasvir. We successfully eradicated the patient's HCV infection, and no breakthrough seizures were reported. Although an unprecedented case and with the limited data evaluating the coadministration of DAAs and treatment of acute HCV infection, we were able to successfully treat and achieve full remission of the HCV infection. By virtue of this case report, we hope to encourage others to report similar cases and spread awareness regarding the difficulties in management.