Treatment of the stress positive ligamentous SE4 ankle fracture: incidence of syndesmotic injury and clinical decision making.

OBJECTIVES: The objective of the study was to review our experience with the treatment of stress positive (+) supination and external pattern injuries using shared decision making with the patients. DESIGN: Retrospective case review. SETTING: Level 1 trauma center. PATIENTS: Over a 9-year period, we treated 114 patients (aged 19-76 years, average 43 years) with stress (+) supination and external rotation type fibula fractures, who were included in the present study. INTERVENTION: X-rays were reviewed, and the medial clear space (MCS) measured on the presentation, stress, and final united radiographs. The decision for surgical or nonsurgical management was made by the patient and surgeon after a discussion of risks/benefits of both. Syndesmotic instability for the operative cases was diagnosed by medial widening and talar subluxation on abduction/external rotation stress after fibular fixation. MAIN OUTCOME MEASURE: MCS measurement at union. RESULTS: Of the 114 cases, 54 were definitively treated in a cast, and 60 were treated operatively. Twenty-seven (45%) of the operative cases demonstrated syndesmotic instability on radiographic examination. The MCS on stress examination was statistically different, with greater widening seen for operatively treated patients (4.8 ± 0.5 vs. 6.9 ± 0.86) (P < 0.001). No patient healed with any subluxation on weight bearing x-rays. CONCLUSIONS: Stress (+) SE pattern fibular fractures with minimal MCS widening on stress examination may be treated in a cast to union with predictable healing. In those patients treated operatively, the treating surgeon should be aware of the high rate of syndesmotic injury. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Combined intravitreal bevacizumab with phacoemulsification in visually significant cataract and visually significant exudative maculopathy.

PURPOSE: We investigated the visual outcome of combined phacoemulsification with intravitreal bevacizumab, in eyes with dense cataract and visually significant exudative maculopathy. MATERIALS AND METHODS: Prospective longitudinal pilot study of consecutive patients treated by two surgeons in 2006, using intravitreal bevacizumab at the end of phacoemulsification. The historical control group consisted of consecutive subjects with exudative maculopathy and dense cataract treated by the same surgeons with the help of phacoemulsification without intravitreal bevacizumab prior to 2006. RESULTS: Thirty-one treated patients had the mean (SD) logMar best corrected visual acuity improving from - 1.48 (0.50) preoperatively to - 0.67 (0.38) in the first postoperative week (P < 0.001), to - 0.64 (0.40) in the first postoperative month (P < 0.001), and to - 0.62 (0.42) (P < 0.001) on the last follow-up (mean 4.2 months, range 1 - 9 months). Fourteen control patients had the mean (SD) logMar best corrected visual acuity improving from - 1.78 (0.79) preoperatively, to - 0.91 (0.53) in the first postoperative week (P < 0.001), to - 0.86 (0.45) in the first postoperative month (P < 0.001), and to - 0.90 (0.47) (P < 0.001) on the last follow- up (mean 19.6 months, range 1 - 49 months). Initial visual acuities, final visual acuities, and percentage of visual improvement at one month were all not significantly better in the intervention compared to the control group at one month. In the study group, the fovea was flattened at the one-month follow-up, by 90-diopter slit lamp examination and / or Optical coherence tomography. CONCLUSION: The combination of intravitreal bevacizumab and phacoemulsification is beneficial for maximal visual rehabilitation in the first postoperative month.

Seasonal variation of retinal detachment in Lebanon.

BACKGROUND: The literature remains controversial regarding seasonal variation of rhegmatogenous retinal detachment (RRD). METHODS: In this retrospective chart review, seasonal variation of RRD was examined based on the records of 211 consecutive patients operated for idiopathic RRD in one referral medical center over a 13-year period. RESULTS: The number of eyes with RRD recorded per season was 46 in autumn, 46 in winter, 62 in spring and 57 in summer. There was a significant seasonal variation (p < 0.05) with an increase in RRD in the warm seasons (spring and summer) compared to the cold seasons (winter and autumn; 56 vs. 44%). Right eyes were more likely to be affected than left eyes (54 vs. 46%), and cases presented with a significantly younger age at onset in the warm than in the cold seasons (47 vs. 54 years, p = 0.007). A literature review of 8,533 cases including the present case series established further the seasonal variation of RRD (p < 0.001). CONCLUSION: There is convincing evidence for a seasonal variation of RRD in Lebanon and in the literature. This is likely to be related to sun exposure and outdoor activities in the warm seasons.

Infectious Collet-Sicard syndrome in the differential diagnosis of cerebrovascular accident: a case of head-to-neck dissociation with skull-based osteomyelitis.

BACKGROUND CONTEXT: Collet-Sicard syndrome (CSS) is a rare condition that includes palsies of cranial nerves IX, X, XI, and XII. There are multiple reported causes in the literature, although infection is particularly unusual. PURPOSE: To report an unusual case of CSS as a result of infection causing head-to-neck dissociation with involvement of the upper cervical spine. STUDY DESIGN: Case report. METHODS: A 56-year-old male with medical comorbidities developed a cranial-based infection secondary to initial incomplete treatment of otitis media. The mass effect of the infection resulted in multiple cranial nerve palsies and extremity symptoms initially confused with a cerebrovascular accident. Clinical course of the patient and a review of CSS are presented. RESULTS: With progression of the disease, further evaluation revealed a disseminated upper cervical and skull-based infection causing destructive head-to-neck infectious instability. This was treated with posterior occipitocervical debridement, fixation, and fusion and appropriate long-term antibiotics. Over the course of several months, the infection resolved and there was a significant improvement in his dysphagia, dysarthria, and hearing. CONCLUSIONS: Delay in diagnosis of CSS is common, and this syndrome should be considered in patients who present with a constellation of lower cranial nerve palsies. Early recognition and treatment should result in successful recovery, but even in cases of delayed detection, suitable intervention can result in substantial clinical improvement.

Comparison of domestic and war ocular injuries during the Lebanese Civil War.

OBJECTIVE: To examine the differences between war and domestic ocular injuries during the Lebanese Civil War in terms of baseline characteristics, treatment provided and prognosis. METHODS: We retrospectively reviewed the charts of subjects with traumatic ocular injuries referred to a major medical center from 1980 to 1996. The variables were tabulated according to the international classification of ocular trauma. RESULTS: Compared to domestic ocular injuries, war injuries were significantly more likely to include males (84.7 vs. 75.1%) and adults (72.7 vs. 39.1%), concomitant systemic injury (43.7 vs. 10.1%), and bilateral ocular affection (19.3 vs. 4.4%). Also, patients with war injuries had significantly worse initial and final visual acuities, less visual improvement (28.6 vs. 44.8%), and more intraocular foreign bodies (42.9 vs. 11%), the majority being metallic removed via an electric magnet. Moreover, war injuries had significantly more posterior scleral involvement 5 mm behind the limbus (25.2 vs. 11.6%) with more secondary retinal detachment (10.3 vs. 4.8%) and vitreous hemorrhage (36.6 vs. 17.1%). Primary evisceration was performed significantly more frequently in war injuries (24.0%) than in domestic injuries (7.7%). CONCLUSIONS: During the Lebanese Civil War, war injuries compared to domestic ones were severer resulting in more enucleation/evisceration and more retinal detachment, tended to be bilateral, and were accompanied by concurrent systemic injuries and less visual recovery. Wearing special glasses and imposing an international arms embargo are recommended to decrease ocular injuries and blinding consequences in potential future wars.

Internal decapitation: survival after head to neck dissociation injuries.

STUDY DESIGN: Case series. OBJECTIVE: To describe survival and outcomes after occipitocervical dissociation injuries. SUMMARY OF BACKGROUND DATA: Historically, occipitocervical dissociation injuries have a high rate of associated neurologic deficit with a relatively high incidence of mortality. METHODS: Six patients with occipitocervical dissociation injuries are reported and their management and imaging findings reviewed. Possible contributory factors for survival are discussed. RESULTS: All patients had upper neck and head dissociation injuries. The pattern of injury in all of these cases included a distraction type mechanism. All cases demonstrated soft tissue disruption in the zone of injury, which was consistent and apparent on all imaging studies. In these patients, the extent and severity of injury was more apparent on magnetic resonance imaging (MRI) than on radiograph or computed tomography scan. Management of these injuries included immobilization followed by surgery with particular care taken to avoid application of distraction forces to the neck. CONCLUSION: Patients with occipitocervical dissociation injuries may survive their injury and even retain neurologic integrity. Initial in-line head stabilization is emphasized to prevent catastrophic neurologic injury. The resting osseous relationships and vertebral alignment at the time of imaging evaluation may be deceivingly normal, and the damage often primarily or exclusively involves disruption of the perivertebral soft tissue structures. Prevertebral soft tissue swelling was apparent in all cases. For these injuries that involve primarily damage to the ligamentous structures, MRI seems to be the optimal test for revealing the magnitude of the injury.

A positive or a negative confounding variable? A simple teaching aid for clinicians and students.

Anticipating the direction of a confounding variable can be problematic especially to introductory students. Using elementary rules of mathematics, we describe below a simple instructional tool for deriving the direction of confounding bias. The tool is illustrated with examples and a heuristic mathematical justification is also described.