Two Cases of Anterior Shoulder Dislocation and Fracture Secondary to Generalized Tonic-Clonic Seizure.

Dislocation of the glenohumeral joint secondary to generalized tonic-clonic seizures is well documented in the medical literature, with posterior dislocation being most commonly described. Still, these occurrences tend to be rare and affect a minority of patients, and fractures associated with dislocations after seizures are even less common. As such, the management of these injuries tends to be quite varied, and there is a paucity of documented cases in the literature. Here, we would like to present two rare cases of anterior shoulder dislocation secondary to seizures, with one patient also sustaining a fracture of the proximal humerus. We would also like to discuss the management and outcomes that have been achieved, since these cases tend to occur in a small number of epileptic patients.

Hydroxychloroquine in the treatment of outpatients with mildly symptomatic COVID-19: a multi-center observational study.

BACKGROUND: Hydroxychloroquine has not been associated with improved survival among hospitalized COVID-19 patients in the majority of observational studies and similarly was not identified as an effective prophylaxis following exposure in a prospective randomized trial. We aimed to explore the role of hydroxychloroquine therapy in mildly symptomatic patients diagnosed in the outpatient setting. METHODS: We examined the association between outpatient hydroxychloroquine exposure and the subsequent progression of disease among mildly symptomatic non-hospitalized patients with documented SARS-CoV-2 infection. The primary outcome assessed was requirement of hospitalization. Data was obtained from a retrospective review of electronic health records within a New Jersey USA multi-hospital network. We compared outcomes in patients who received hydroxychloroquine with those who did not applying a multivariable logistic model with propensity matching. RESULTS: Among 1274 outpatients with documented SARS-CoV-2 infection 7.6% were prescribed hydroxychloroquine. In a 1067 patient propensity matched cohort, 21.6% with outpatient exposure to hydroxychloroquine were hospitalized, and 31.4% without exposure were hospitalized. In the primary multivariable logistic regression analysis with propensity matching there was an association between exposure to hydroxychloroquine and a decreased rate of hospitalization from COVID-19 (OR 0.53; 95% CI, 0.29, 0.95). Sensitivity analyses revealed similar associations. QTc prolongation events occurred in 2% of patients prescribed hydroxychloroquine with no reported arrhythmia events among those with data available. CONCLUSIONS: In this retrospective observational study of SARS-CoV-2 infected non-hospitalized patients hydroxychloroquine exposure was associated with a decreased rate of subsequent hospitalization. Additional exploration of hydroxychloroquine in this mildly symptomatic outpatient population is warranted.

Internal anterior fixators for pelvic ring injuries: Do monaxial pedicle screws provide more stiffness than polyaxial pedicle screws?

OBJECTIVES: Little is known about the mechanical properties of internal anterior fixators (known as INFIX), which have been proposed as subcutaneous alternatives to traditional anterior external fixators for pelvic ring disruptions. We hypothesised that INFIX has superior biomechanical performance compared with traditional external fixators because the distance from the bar to the bone is reduced. METHODS: Using a commercially available synthetic bone model, 15 unstable pelvic ring injuries were simulated by excising the pubic bone through the bilateral superior and inferior rami anteriorly and the sacrum through the bilateral sacral foramen posteriorly. Three test groups were established: (1) traditional supra-acetabular external fixation, (2) INFIX with polyaxial screws, (3) INFIX with monaxial screws. Load was applied, simulating lateral compression force. Outcome measure was construct stiffness. RESULTS: The traditional external fixator constructs had an average stiffness of 6.21 N/mm ± 0.40 standard deviation (SD). INFIX with monaxial screws was 23% stiffer than the traditional external fixator (mean stiffness, 7.66 N/mm ± 0.86 SD; p = .01). INFIX with polyaxial screws was 26% less stiff than INFIX with monaxial screws (mean stiffness, 5.69 N/mm ± 1.24 SD; p = .05). No significant difference was noted between polyaxial INFIX and external fixators (mean stiffness, 6.21 N/mm ± 0.40 SD; p=.65). CONCLUSIONS: The performance of INFIX depends on the type of screw used, with monaxial screws providing significantly more stiffness than polyaxial screws. Despite the mechanical advantage of being closer to the bone, polyaxial INFIX was not stiffer than traditional external fixation.

A comparison of two approaches for the closed treatment of low-energy tibial fractures in children.

BACKGROUND: Many orthopaedic surgeons treat tibial shaft fractures in children with a period of non-weight-bearing after application of a long leg cast, presumably to prevent fracture angulation and shortening. We hypothesized that allowing children to immediately bear weight as tolerated in a cast with the knee in 10° of flexion would lessen disability, without increasing the risk of unacceptable shortening or angulation. METHODS: We divided eighty-one children, between the ages of four and fourteen years, with a low-energy, closed tibial shaft fracture into two groups. One group (forty children) received a long leg cast with the knee flexed 60° and were asked not to bear weight. The second group (forty-one children) received a long leg cast with the knee flexed 10° and were encouraged to bear weight as tolerated. All patients were switched to short leg walking casts at four weeks. We compared time to healing, overall alignment, shortening, and physical disability as determined by the Activities Scale for Kids-Performance (ASK-P) questionnaire. RESULTS: The mean time to fracture union was 10.8 weeks in both groups (p = 0.47). At the time of healing, mean coronal alignment was within 1.3° in both groups, mean sagittal alignment was within 1°, and mean shortening was <0.5 mm, with no significant differences. The ASK-P scores showed that both groups had overall improvement in physical functioning over time. However, at six weeks, the children who were allowed to bear weight as tolerated had better overall scores (p = 0.03) and better standing skills (p = 0.01) than those who were initially instructed to be non-weight-bearing. CONCLUSIONS: Children with low-energy tibial shaft fractures can be successfully managed by immobilizing the knee in 10° of flexion and encouraging early weight-bearing, without affecting the time to union or increasing the risk of angulation and shortening at the fracture site.

The suitability of human adipose-derived stem cells for the engineering of ligament tissue.

Rupture of the anterior cruciate ligament (ACL) is the one of the most common sports-related injuries. With its poor healing capacity, surgical reconstruction using either autografts or allografts is currently required to restore function. However, serious complications are associated with graft reconstructions and the number of such reconstructions has steadily risen over the years, necessitating the search for an alternative approach to ACL repair. Such an approach may likely be tissue engineering. Recent engineering approaches using ligament-derived fibroblasts have been promising, but the slow growth rate of such fibroblasts in vitro may limit their practical application. More promising results are being achieved using bone marrow mesenchymal stem cells (MSCs). The adipose-derived stem cell (ASC) is often proposed as an alternative choice to the MSC and, as such, may be a suitable stem cell for ligament engineering. However, the use of ASCs in ligament engineering still remains relatively unexplored. Therefore, in this study, the potential use of human ASCs in ligament tissue engineering was initially explored by examining their ability to express several ligament markers under growth factor treatment. ASC populations treated for up to 4 weeks with TGFß1 or IGF1 did not show any significant and consistent upregulation in the expression of collagen types 1 and 3, tenascin C and scleraxis. While treatment with EGF or bFGF resulted in increased tenascin C expression, increased expression of collagens 1 and 3 were never observed. Therefore, simple in vitro treatment of human ASC populations with growth factors may not stimulate their ligament differentiative potential.

Incidence and factors predicting pulmonary embolism and deep venous thrombosis following surgical treatment of ankle fractures.

BACKGROUND: The purpose of this study was to identify the incidence and risk factors associated with pulmonary embolism and deep venous thrombosis following open reduction and internal fixation of ankle fractures. METHODS: This was a retrospective study of patients in California undergoing operative treatment of an ankle fracture from 1995 to 2005. The main outcome measure was readmission for pulmonary embolism or deep venous thrombosis within 90 days of surgery. RESULTS: A total of 57,183 patients from the California discharge database were identified. The readmission rate for pulmonary embolism was low at 0.34%. The risk was increased in patients aged 50-75, those with open fractures, and those with higher Charlson comorbidity score. The overall rate of readmission for deep venous thrombosis was also low at 0.05%. CONCLUSIONS: The overall rate of thromboembolic disease was low in this large patient sample. Increased age and comorbidity were associated with an increased risk.

Stress fractures of the lateral rays in the cavovarus foot: indication for surgical intervention.

Lateral ray stress fractures are a known complication of the cavovarus foot deformity. Malpositioning of the forefoot and hindfoot leads to increased pressure on the heel and lateral rays, resulting in significant morbidity. Patients with nonprogressive deformities can be managed surgically or nonsurgically in an attempt to decrease adverse events. It is often difficult to predict which patients will benefit most from a surgical intervention. This article describes 2 model cases of stress fractures in patients with nonprogressive cavovarus foot deformities. Patient 1 was an active patient with a minor, flexible cavovarus deformity, and patient 2 was a relatively inactive patient with a severe, fixed deformity. These cases serve to illustrate a spectrum of the 2 major risk factors for the development of a stress fracture of the lateral rays: severity of deformity and activity level of the patient. We believe the relationship between these 2 risk factors constitutes a threshold that allows the development of a stress fracture to serve as an adequate marker for surgical intervention. Within this patient population, a stress fracture indicates that given a patient's lifestyle, his or her deformity is sufficient enough to cause significant and repeated morbidity. Surgical restoration of the foot to plantigrade will eliminate the increased forces to the lateral metatarsals and decrease the incidence of further injury. Thus, stress fractures of the lateral rays in patients with nonprogressive cavovarus deformities should be considered an indication for surgical intervention.

Variations in the quality of care delivered to patients undergoing total knee replacement at 3 affiliated hospitals.

While excellent clinical results have been seen with total knee replacement (TKR), extensive documentation exists in variations in outcomes due to factors such as hospital and surgeon volume. The hypothesis of this study was that statistically significant variation exists in the processes of care delivered to patients undergoing TKR at 3 affiliated hospitals.Retrospective chart review was used to compare the quality of care delivered to a sample of patients from an academic medical center, public county hospital, and private community hospital. Two hundred twenty-four patients undergoing primary TKR were included. Quality of care was measured by determining adherence to a set of 31 evidence-based quality indicators created using the RAND/UCLA modified Delphi expert panel methodology. The overall rate of adherence to the quality indicators was 53% (95% confidence interval [CI], 52%-55%) for the 224 patients. There was a statistically significant difference between sites, with patients treated at the high-volume academic center demonstrating a 58% rate of adherence (95% CI, 56%-61%) compared with 50% (95% CI, 48-51%; P =.008) at the lower-volume public hospital and 52% (95% CI, 51%-54%; P =.03) at the lower-volume private hospital.Further study is warranted to determine the extent of variation in the delivery of care and its relationship to variation in outcomes of care for patients undergoing TKR.

Efficacy of intraoperative cell salvage systems in pediatric idiopathic scoliosis patients undergoing posterior spinal fusion with segmental spinal instrumentation.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: Determine whether intraoperative cell salvage system use during pediatric posterior spinal fusion (PSF) with segmental spinal instrumentation for idiopathic scoliosis decreases intraoperative and perioperative (intraoperative plus postoperative) allogeneic blood transfusion. SUMMARY OF BACKGROUND DATA: Intraoperative cell salvage and reinfusion can reduce or obviate perioperative allogeneic blood transfusion. Despite these benefits, their efficacy in pediatric PSF is unclear. Reported complications include transient hematuria, altered hemostasis, and electrolyte imbalance. METHODS: A total of 54 consecutive idiopathic scoliosis patients were studied: 21 non-cell saver and 33 cell saver patients. Data included age, body mass index, Cobb angle, perioperative hemoglobin levels, mean arterial pressure, surgical time, levels fused, perioperative estimated blood loss, and perioperative transfusions. A chi2 and t tests were performed for intraoperative and perioperative allogeneic transfusion between groups. A regression analysis was performed between selected covariates and allogeneic transfusion. Relative risk analysis examined significant covariates regarding allogeneic transfusion rate. RESULTS: Allogeneic transfusion rates were lower in the cell saver group (6% vs. 55% intraoperative and 18% vs. 55% perioperative, P < 0.05). Mean allogeneic transfusion volumes (mL/kg) were also lower (0.4 vs. 9.1 intraoperative and 1.9 vs. 11.1 perioperative, P < 0.05). Multivariate analysis confirmed these differences were independent of perioperative blood loss, and also demonstrated that surgical time and blood loss were significantly related to allogeneic transfusion volume. The allogeneic transfusion relative risk was 2.04 in patients with surgery >6 hours and 5.87 in patients not receiving cell saver blood. All patients with surgeries >6 hours and estimated blood loss >30% of total blood volume received cell saver system blood. CONCLUSION: Cell saver use decreased allogeneic transfusion, particularly in surgeries >6 hours with estimated blood loss >30% of total blood volume. This study confirms the utility of routine cell saver use during PSF with segmental spinal instrumentation for idiopathic scoliosis.

Complication rates following open reduction and internal fixation of ankle fractures.

BACKGROUND: Ankle fractures are among the most common injuries treated by orthopaedic surgeons. The purpose of the present investigation was to examine the risks of complications after open reduction and internal fixation of ankle fractures in a large population-based study. METHODS: With use of California's discharge database, we identified 57,183 patients who had undergone open reduction and internal fixation of a lateral malleolar, bimalleolar, or trimalleolar ankle fracture as inpatients in the years 1995 through 2005. Short-term complications were examined on the basis of the rates of readmission within ninety days after discharge. The intermediate-term rate of reoperation for ankle fusion or arthroplasty was also analyzed. Logistic regression and proportional hazard regression models were used to determine the strength of the relationships between the rates of complications and fracture type, patient demographics and comorbidities, and hospital characteristics. RESULTS: The overall rate of short-term complications was low, including the rates of pulmonary embolism (0.34%), mortality (1.07%), wound infection (1.44%), amputation (0.16%), and revision open reduction and internal fixation (0.82%). The intermediate-term rates of reoperation were also low, with ankle fusion or ankle replacement being performed in 0.96% of the patients who were observed for five years. Open fractures, age, and medical comorbidities were significant predictors of short-term complications. The presence of complicated diabetes was a particularly strong predictor (odds ratio, 2.30; p < 0.001), as was peripheral vascular disease (odds ratio, 1.65; p < 0.001). The intermediate-term rate of reoperation for ankle fusion or replacement was higher in patients with trimalleolar fractures (hazard ratio, 2.07; p < 0.001) and open fractures (hazard ratio, 5.29; p < 0.001). Treatment at a low-volume hospital was not significantly associated with either the aggregate risk of short-term complications or the risk of intermediate-term reoperation. CONCLUSIONS: By analyzing a large, diverse patient population, the present study clarifies the risks associated with open reduction and internal fixation of ankle fractures. Open injury, diabetes, and peripheral vascular disease were strong risk factors predicting a complicated short-term postoperative course. Fracture type was a strong predictor of reoperation for ankle fusion or replacement. Hospital volume did not play a significant role in the rates of short-term or intermediate-term complications.

Biology of allograft incorporation.

The use of implantation of allograft tissue in sports medicine has risen steadily over the last decade. Allograft tissues offer several advantages over autografts, including reduced donor-site morbidity and decreased operative time, and in some instances, no autograft option exists. However, with allografts, there is a small risk of disease transmission, immunologic rejection, and decreased biologic incorporation. Several techniques to limit these pitfalls and maximize graft incorporation are available, however. This chapter takes an in-depth look at the biology of allograft incorporation and how these techniques affect graft incorporation.

A cotton batting compression dressing and fiberglass cast used safely in the immediate postoperative period after hindfoot or ankle surgery.

BACKGROUND: Patients undergoing surgery on the foot and ankle who require immobilization are typically placed in splints or soft compression dressings after surgery to avoid complications associated with swelling. As swelling subsides, this temporary immobilization is removed and replaced with a short-leg cast, making an additional office visit necessary, which adds to the cost as well as patient discomfort. METHODS: We apply a cast in the operating room using a special padding technique to accommodate postoperative swelling. It is supportive enough that it does not need to be replaced shortly after surgery. This cast was applied to 38 patients having surgery on the hindfoot or ankle between March, 2003, and February, 2004. RESULTS: All patients tolerated the cast during the initial 2 weeks after surgery, and there were no complications. CONCLUSION: The purpose of this study was to describe the casting technique and document its safety for use immediately after surgery on the hindfoot and ankle.