Open fixation of the posterior malleolus increases the morbidity of trimalleolar ankle fracture fixation.

PURPOSE: To assess the morbidity of open reduction internal fixation (ORIF) of posterior malleolus fractures (PMFs) in the setting of trimalleolar ankle fractures. METHODS: A retrospective review of 79 trimalleolar ankle fractures was performed to identify need for syndesmotic fixation, blood loss, operative/tourniquet time, complications, and reoperations. Patients with PMF ORIF (n = 38) were compared to those with no fixation (n = 41). A subanalysis of patients with small PMFs (< 25%) was performed. RESULTS: The PMF ORIF group required less syndesmosis fixation (proportional difference (PD) - 44.6%, 95% confidence interval (CI) - 61.8 to - 23.0%), had more blood loss (MD 20 ml, CI 0-40), longer operative times (MD 53.0 min, CI 35.9-70.1), longer tourniquet times (MD 26 min, CI 4-33), and had no difference in postoperative joint step-off or concentrically reduced joints. The PMF ORIF group had more postoperative complications (PD 26.9%, CI 6.3-44.8%) and a trend for more reoperations (PD 13.6%, CI -3.4 to 29.6%). Wound complications were more common in the PMF ORIF group (PD 26.5%, CI 6.9-43.6%), resulting in 5 (16.1%) irrigation and debridement procedures. On analysis of patients with small PMFs (n = 42), PMF ORIF (n = 15) resulted in longer operative/tourniquet times and had no observed difference in postoperative joint step-off, concentrically reduced joints, need for syndesmotic fixation, blood loss, or complications/reoperations. CONCLUSION: PMF ORIF in the setting of trimalleolar ankle fractures was associated with increased operative/tourniquet times, blood loss, wound complications, and did not eliminate the need for syndesmosis fixation.

Expectoration of anterior cervical discectomy and fusion cage: a case report.

Anterior cervical implant failure can lead to catastrophic sequalae and requires prompt evaluation and management to reduce significant morbidity. This case report describes a 51-year-old female who underwent a C2-3 and C3-4 anterior cervical discectomy and fusion (ACDF) with stand-alone, integrated plate-cage interbody devices for cervical spondylotic myelopathy (CSM). Initial procedure was performed at an outside institution. Unfortunately, no radiographic follow up was obtained by the primary surgeon during the initial post-operative period. Post-operatively she experienced persistent dysphagia and troubles swallowing. The patient was eventually seen by the ear, nose and throat (ENT) service at our institution. Eighteen months after the index procedure, a nasolaryngoscopy revealed exposure of her ACDF implant through the posterior aspect of her pharynx. The ENT service obtained radiographs and immediately contacted our Spine Surgery service. Repeat anterior approach with implant removal was planned; however, during the interim, the patient suffered a coughing fit and complete expectoration of the C2-3 implant with the locking screws in place had occurred. Patient experienced immediate relief of symptoms. Miraculously, the patient did not develop airway compromise, infection, or return of severe dysphagia symptoms. During continued follow up, no significant clinical sequelae of her anterior cervical soft tissue structures were identified. The patient chose to decline further surgical management of her cervical spine. This case report highlights a potentially catastrophic complication following ACDF. Several modifiable factors including implant design, C2-3 ACDF cage placement, use of post-operative radiographs, and patient education regarding need for consistent follow up may have prevented this complication. Implant extrusion is a rare, but potentially serious complication following ACDF. Presenting symptoms can be generalized and mild including pain, swelling, or worsening dysphagia. It is paramount to obtain orthogonal X-rays for routine follow-up of post-surgical ACDF patients, especially if dysphagia persists or worsens. Immediate surgical management in recommended if significant post-operative cage migration is encountered.

Intramedullary Nailing Versus Plate Fixation for the Treatment Displaced Midshaft Clavicular Fractures: A Systematic Review and Meta-Analysis.

The two commonly performed surgical techniques used to repair displaced midshaft clavicle fractures are plate fixation or intramedullary nailing; however, despite recent evidence, the optimal method to treat such fractures remains a continued topic of debate. A meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate long term function, complications, and operative duration in adult patients receiving intramedullary nailing in comparison to plating. Seven RCTs and three quasi-randomized trials were included. No significant difference was found in long-term function between the two groups (MD: -0.66, 95% CI: -2.03 to 0.71, I2 = 62%, p = 0.34). Patients who received plating had a 2.19 times increased risk of treatment failure, but this failed to reach significance (95% CI: 0.93 to 5.15, I2 = 0%, p = 0.07). The risk of non-operative complications was 2.11 times higher in patients who received plating and this reached statistical significance (95% CI: 1.38 to 3.23, I2 = 53%, p = 0.0006). Finally, plating significantly prolonged operative duration by 20.16 minutes (95% CI: 16.87 to 23.44, I2 = 56%, p < 0.00001). Our results suggest that intramedullary nailing and plating provide equivalent long-term functional outcomes; however, plating may lead to a higher risk of treatment failure and non-operative complications.

The PTIP-Associated Histone Methyltransferase Complex Prevents Stress-Induced Maladaptive Cardiac Remodeling.

Pressure overload induces stress-induced signaling pathways and a coordinated transcriptional response that begets concentric cardiac hypertrophy. Although concentric hypertrophy initially attenuates wall stress and maintains cardiac function, continued stress can result in maladaptive cardiac remodeling. Cardiac remodeling is orchestrated by transcription factors that act within the context of an epigenetic landscape. Since the epigenetic landscape serves as a molecular link between environmental factors (stress) and cellular phenotype (disease), defining the role of the epigenome in the development and progression of cardiac remodeling could lead to new therapeutic approaches. In this study, we hypothesized that the epigenetic landscape is important in the development of cardiac hypertrophy and the progression to maladaptive remodeling. To demonstrate the importance of the epigenome in HF, we targeted the PTIP-associated histone methyltransferase complex in adult cardiac myocytes. This complex imparts histone H3 lysine 4 (H3K4) methylation marks at actively expressed genes. We subjected PTIP null (PTIP-) mice to 2 weeks of transverse aortic constriction, a stress that induces concentric hypertrophy in control mice (PTIP+). PTIP- mice have a maladaptive response to 2wk of transverse aortic constriction (TAC)-induced pressure overload characterized by cardiac dilatation, decreased LV function, cardiac fibrosis, and increased cell death. PTIP deletion resulted in altered stress-induced gene expression profiles including blunted expression of ADRA1A, ADRA1B, JUN, ATP2A2, ATP1A2, SCN4B, and CACNA1G. These results suggest that H3K4 methylation patterns and the complexes that regulate them, specifically the PTIP-associated HMT, are necessary for the adaptive response to TAC.