Spondyloarthropathies That Mimic Ankylosing Spondylitis: A Narrative Review.

Ankylosing spondylitis is the most common type of seronegative inflammatory spondyloarthropathy often presenting with low back or neck pain, stiffness, kyphosis and fractures that are initially missed on presentation; however, there are other spondyloarthropathies that may present similarly making it a challenge to establish the correct diagnosis. Here, we will highlight the similarities and unique features of the epidemiology, pathophysiology, presentation, radiographic findings, and management of seronegative inflammatory and metabolic spondyloarthropathies as they affect the axial skeleton and mimic ankylosing spondylitis. Seronegative inflammatory spondyloarthropathies such as psoriatic arthritis, reactive arthritis, noninflammatory spondyloarthropathies such as diffuse idiopathic skeletal hyperostosis, and ochronotic arthritis resulting from alkaptonuria can affect the axial skeleton and present with symptoms similar those of ankylosing spondylitis. These similarities can create a challenge for providers as they attempt to identify a patient's condition. However, there are characteristic radiographic findings and laboratory tests that may help in the differential diagnosis. Axial presentations of seronegative inflammatory, non-inflammatory, and metabolic spondyloarthropathies occur more often than previously thought. Identification of their associated symptoms and radiographic findings are imperative to effectively diagnose and properly manage patients with these diseases.

A systematic review of the surgical outcomes of interprosthetic femur fractures.

Background: Interprosthetic femur fractures (IFFs) are rare, but the treatment is challenging. Currently, there are many treatment methods used in practice, but an updated systematic review of comparison of common different surgical outcomes has not been thoroughly inspected. Methods: A systematic review of retrospective studies was conducted. The resource databases of PubMed, Cochrane, and Embase were searched using a combination of the keywords involving IFFs and surgical outcomes from inception through June 2021. Data collected included patient demographics, intraoperative data, and postoperative outcomes. Outcomes were measured based on healing time, revision rate, complication rate, and functional scores. Results: Forty studies were included for review with a total of 508 patients. Average reported age of patients was 78.7 years old and 403 (79.3%) were females. Overall union rate was 74.0% with 376 of 508 patients achieving fracture union after primary treatment of IFF. Only 271 patients had reported healing times of fractures with a mean of 5.15 months. The plate, prosthetic revision, nail/rod, and external fixator groups had mean healing times of 4.69, 8.73, 6.5, and 5.1 months, respectively. Revision rates were highest in the femur replacement treatment group with 9 (32.1%) patients needing at least one reoperation surgery for any reason. Overall, hardware failure and non-unions were the most reported complications in treatment of IFFs. Postoperative functional outcome scores were available for 242 patients. Harris Hip Scores for the plate, revision, replacement, nail/rod, and plate + revision groups were 76.84, 77.14, 69.9, 77, and 78.4, respectively. Conclusion: Each treatment method should be carefully considered by the surgeon depending on the patient. Locking plate was the most common method for the treatment of the patients with IFFs. Half of them combined with cerclage wires/cables. Around two thirds' patients could achieve union with the fastest mean healing time around 4.69 months. Other less common methods included prosthetic revision, femur replacement, nail/rod, external fixator, etc. A small number of patients treated with Ilizarov external fixator, and it has proven to be a viable option with few complications and high union rates.

Diabetes and Impaired Fracture Healing: A Narrative Review of Recent Literature.

PURPOSE OF THE REVIEW: Diabetes mellitus is a chronic metabolic disorder commonly encountered in orthopedic patients. Both type 1 and type 2 diabetes mellitus increase fracture risk and impair fracture healing. This review examines complex etiology of impaired fracture healing in diabetes. RECENT FINDINGS: Recent findings point to several mechanisms leading to orthopedic complications in diabetes. Hyperglycemia and chronic inflammation lead to increased formation of advanced glycation end products and generation of reactive oxygen species, which in turn contribute to the disruption in osteoblast and osteoclast balance leading to decreased bone formation and heightening the risk of nonunion or delayed union as well as impaired fracture healing. The mechanisms attributing to this imbalance is secondary to an increase in pro-inflammatory mediators leading to premature resorption of callus cartilage and impaired bone formation due to compromised osteoblast differentiation and their apoptosis. Other mechanisms include disruption in the bone's microenvironment supporting different stages of healing process including hematoma and callus formation, and their resolution during bone remodeling phase. Complications of diabetes including peripheral neuropathy and peripheral vascular disease also contribute to the impairment of fracture healing. Certain diabetic drugs may have adverse effects on fracture healing. The pathophysiology of impaired fracture healing in diabetic patients is complex. This review provides an update of the most recent findings on how key mediators of bone healing are affected in diabetes.

Clinical presentation and surgical anatomy of sympathetic nerve injury during lumbar spine surgery: a narrative review.

Background and Objective: To highlight the surgical anatomy, procedural variations, presentation, and management of sympathetic nerve injury after surgery of the lumbar spine. Methods: PubMed and Google Scholar were searched for publications that were completed between 1951 and 2021. Relevant full-text articles published in the English language were selected and critically reviewed. Key Content and Findings: Sympathetic injury is a highly variable postsurgical complication with a greater incidence after an anterior or oblique approach to the lumbar spine compared to posterior and lateral approaches. The direct and extreme lateral approaches reduce the need to disturb sympathetic nerves thus reducing the risk of complications. It can present in multiple manners, including complex regional pain syndrome (CRPS) and retrograde ejaculation. These complications can be transient and resolve spontaneously or be treated with medications, physical therapy, and spinal blocks. The severity of the conditions and extent of recovery can vary drastically, with some patients never fully recovering. Conclusions: To access the lumbar spine, there are operational approaches and techniques that should be used to decrease the risk of intraoperative injury. It is crucial to understand the advantages and risks to different approaches and take the necessary steps to minimize complications. Early identification of dysfunction and adequate management of symptoms are imperative to effectively manage patients with lumbar sympathetic trunk and sympathetic nerve fiber injuries.

Spondylodiscitis secondary to Mycobacterium chelonae: a case report.

Background: Spondylodiscitis secondary to Mycobacterium chelonae (M. chelonae) is a rare primary infection of the spine, with a few case reports highlighted. Treatment of this infection is not well established but here we discuss a case where a patient recovered well following early aggressive surgical intervention and antibiotic treatment. Case Description: A 32-year-old male presented with a 3-month history of worsening low back pain, Horner's syndrome, dysphagia, lower extremity weakness, and a 5-day history of bowel and bladder incontinence. The patient had an extensive orthopedic history but no recent trauma or history of spinal surgery. He had no known prior medical conditions that would suggest immunocompromise. Magnetic resonance imaging (MRI) scan showed lumbar spondylodiscitis, and blood cultures did not show any growth. The patient underwent L4-S1 decompression and fusion with iliac crest bone grafting, and intraoperative biopsy. Intraoperative tissue cultures grew M. chelonae. Repeat computerized tomography (CT)-guided biopsy confirmed the pathogen. The patient was initially treated with vancomycin and piperacillin-tazobactam. Numerous alterations in antibiotic regimen occurred secondary to medication adverse effects and noncompliance, and he was ultimately treated with azithromycin and tigecycline. Interval follow-up demonstrated gradual improvement of bilateral lower extremity strength and return of bowel and bladder function. Follow-up at 16 months post-operatively demonstrated significant improvement in pain and neurological symptoms, with no signs of infection recurrence. Conclusions: This case demonstrates the importance of aggressive surgical management of M. chelonae spondylodiscitis. Early aggressive surgical management in combination with antibiotics may improve clinical outcomes for these patients.

Electronic Cigarette Burns: A Case Report and Review of Current Literature.

Due to the development of electronic cigarettes and their use in our patient population, this article seeks to evaluate the safety and associated morbidity that may result from their use. This article also presents a patient case regarding an explosion of an electronic cigarette battery and the resultant injury and deformity that occurred.

Management of Subtrochanteric Proximal Femur Fractures: A Review of Recent Literature.

Subtrochanteric femur fractures are an uncommon injury in orthopedics, but when they are encountered they may present difficulties in management. The purpose of this paper is to examine the recent literature on the epidemiology, classification, initial evaluation, and definitely treatment for these injuries. These will assist the physician to determine the optimal treatment strategy and avoid potential surgical complication.

A Case Report of an Isolated Dislocation of the Scaphoid in a Lesser Arc Injury and a Review of the Literature.

Isolated dislocations of the scaphoid are extremely uncommon injuries and are often associated with significant ligamentous failures. Since scaphoid dislocations typically present with associated carpal fractures, few cases of isolated dislocations of the scaphoid exist in the literature. The proposed treatment options in the literature range from closed reduction and casting to open reduction and internal fixation. We present the case of a 41-year-old male with an isolated scaphoid dislocation in whom open reduction and internal fixation was performed with K-wires. At five months follow-up, the patient had returned to work and all desired activities.

Comparison of intramedullary nail, plate, and external fixation in the treatment of distal tibia nonunions.

PURPOSE: The purpose of this study was to examine time to union of extra-articular distal tibia nonunions based on fracture type and fixation methods: intramedullary nail (IMN), plate osteosynthesis (PO), and external fixation (EF). METHODS: This retrospective chart review included all patients who presented at a Level I trauma center with AO/OTA 43A & distal third 42A-C fracture nonunions between 2008 and 2014. Fixation methods were recorded and patient course was followed until nonunion had healed clinically. RESULTS: Thirty-three distal tibia nonunions were included, and 29 reached eventual union (88%). Five AO/OTA fracture types were present. Mean times to union from nonunion diagnosis between original fracture types were compared (p = 0.203). Comminuted fracture types had longer times to union from nonunion diagnosis compared to simple fracture types (78 vs. 46 weeks, p = 0.051) and more revision fixations (1.5 vs. 0.5, p = 0.037). Mean time to union from nonunion diagnosis was shorter when no revision fixation was done compared to revisions (15 vs. 42 weeks, p = 0.102). Times to union from nonunion diagnosis without revision fixation were: IMN (12 weeks), PO (27 weeks), and EF (13 weeks) (p = 0.202). Times to union from definitive revision fixation were: IMN (17 weeks), PO (21 weeks), and EF (66 weeks) (p = 0.009), with EF taking significantly longer than both other methods. 21 patients (64%) underwent revision fixation. Revision fail rates were: IMN (0/6, 0%), PO (2/8, 25%), and EF (15/21, 71%). Time to union was longer in revisions that changed fixation method compared to revisions that used the same method (51 vs. 18 weeks, p = 0.030). Deep infections were also associated with longer union times (81 vs. 47 weeks, p = 0.040). CONCLUSIONS: In this nonunion population, comminuted fracture types needed more time and revisions to reach union. Time to union was only clinically shorter when revision fixation was not performed, but IMN and PO were both successful fixation options with significantly shorter times to union than EF. Mean time to union increased even more when revision of fixation method was performed vs. exchange revision, as did nonunions with deep infections.

Nonconsecutive Pars Interarticularis Defects.

Lumbar spondylolysis is a well-recognized condition occurring in adolescents because of repetitive overuse in sports. Nonconsecutive spondylolysis involving the lumbar spine is rare. In contrast to single-level pars defects that respond well to conservative treatment, there is no consensus about the management of multiple-level pars fractures; a few reports indicated that conservative management is successful, and the majority acknowledged that surgery is often required. The current study presents a rare case of pars fracture involving nonconsecutive segments and discusses the management options. In this case report, we review the patient's history, clinical examination, radiologic findings, and management, as well as the relevant literature. An 18-year-old man presented to the clinic with worsening lower back pain related to nonconsecutive pars fractures at L2 and L5. After 6 months of conservative management, diagnostic computed tomography-guided pars block was used to localize the symptomatic level at L2, which was treated surgically; the L5 asymptomatic pars fracture did not require surgery. At the last follow-up 2 years after surgery, the patient was playing baseball and basketball, and denied any back pain. This article reports a case of rare nonconsecutive pars fractures. Conservative management for at least 6 months is recommended. Successful management depends on the choice of appropriate treatment for each level. Single-photon emission computed tomography scan, and computed tomography-guided pars block are valuable preoperative tools to identify the symptomatic level in such a case.

Pre-hospital hypothermia is not associated with increased survival after traumatic brain injury.

BACKGROUND: Conclusions from in vivo and in vitro studies suggest hypothermia may be protective in traumatic brain injury (TBI). Few studies evaluated the effect of admission temperature on outcomes. The purpose of this study is to examine the relationship between admission hypothermia and mortality in patients with isolated, blunt, moderate to severe TBI. METHODS: The Los Angeles Trauma Database was queried for all patients ≥ 14 y of age with isolated, blunt, moderate to severe TBI (head abbreviated injury score (AIS) ≥ 3, all other <3), admitted between 2005 and 2009. The study population was then stratified into two groups by admission temperature: hypothermic (≤ 35°C) and normothermic (>35°C). Demographic characteristics and outcomes were compared between groups. Logistic regression analysis was used to determine the relationship between admission hypothermia and mortality. RESULTS: A total of 1834 patients were analyzed and then stratified into two groups: hypothermic (n = 44) and normothermic (n = 1790). There was a significant difference noted in overall mortality (25% versus 7%), with the hypothermic group being four times more likely to succumb to their injuries. After adjusting for confounding factors, admission hypothermia was independently associated with increased mortality (AOR 2.5; 95% CI 1.1-6.3; P = 0.04). CONCLUSIONS: Although in-vivo and in-vitro studies demonstrate induced hypothermia may be protective in TBI, our study demonstrates that admission hypothermia was associated with increased mortality in isolated, blunt, moderate to severe TBI. Further prospective research is needed to elucidate the role of thermoregulation in patients sustaining TBI.

Pre-hospital intubation is associated with increased mortality after traumatic brain injury.

BACKGROUND: Early endotracheal intubation in patients sustaining moderate to severe traumatic brain injury (TBI) is considered the standard of care. Yet the benefit of pre-hospital intubation (PHI) in patients with TBI is questionable. The purpose of this study was to investigate the relationship between pre-hospital endotracheal intubation and mortality in patients with isolated moderate to severe TBI. METHODS: The Los Angeles County Trauma System Database was queried for all patients > 14 y of age with isolated moderate to severe TBI admitted between 2005 and 2009. The study population was then stratified into two groups: those patients requiring intubation in the field (PHI group) and those patients with delayed airway management (No-PHI group). Demographic characteristics and outcomes were compared between groups. Multivariate analysis was used to determine the relationship between pre-hospital endotracheal intubation and mortality. RESULTS: A total of 2549 patients were analyzed and then stratified into the two groups: PHI and No-PHI. There was a significant difference noted in overall mortality (90.2% versus 12.4%), with the PHI group being more likely to succumb to their injuries. After adjusting for possible confounding factors, multivariable logistic regression analysis demonstrated that PHI was independently associated with increased mortality (AOR 5, 95% CI: 1.7-13.7, P = 0.004). CONCLUSIONS: Pre-hospital endotracheal intubation in isolated, moderate to severe TBI patients is associated with a nearly 5-fold increase in mortality. Further prospective studies are required to establish guidelines for optimal pre-hospital management of this critically injured patient population.