Tranexamic Acid Treatment Reduces Blood Loss After Elective and Semi-Urgent Reverse Total Shoulder Arthroplasty.

Introduction: Post operative blood loss after reverse shoulder arthroplasty (RSA) is associated with the need for blood transfusion and prolonged hospital stay, among other complications. Tranexamic acid (TXA) reduces perioperative blood loss and is effective when delivered systemically or locally. We compared the effects of TXA on perioperative blood loss between elective and semi-urgent RSA. Methods: We retrospectively reviewed patients who underwent either elective or semi-urgent RSA for fracture repair, with and without TXA treatment. Demographics, clinical records, and laboratory results were collected and analyzed to compare peripheral blood hemoglobin concentrations before and after surgery, the need for blood transfusion, and length of hospital stay between the 2 groups. Results: In a cohort of 158 patients, 91 (58%) underwent elective RSA. TXA was administered in 91 (58%) patients from the entire group. TXA administration was associated with a significant decrease in post operative hemoglobin concentration reduction in both the elective and fracture groups (P = .026 and P = .018, respectively), a significant decrease in post operative blood transfusion rates (P = .004 and P = .003, respectively), and a decrease in the need for prolonged hospitalization (P = .038 and P = .009, respectively). Discussion: The local application of TXA during RSA yielded a significant reduction in perioperative blood loss. We showed a significant positive effect of local TXA administration during RSA that is comparable for both elective and semi-urgent patients. Due to the baseline characteristics of fracture patients, their clinical benefits may be more notable. Conclusions: The positive outcomes for surgical patients with the use of TXA during RSA can possibly cause future consideration in clinical practice.

The effect of steroid injection into the shoulder on glycemia in patients with type 2 diabetes.

Background: Injections of corticosteroids into or around joints have been reported to increase blood glucose in patients with diabetes due to corticosteroid absorption into the bloodstream. However, the magnitude, duration, and clinical implications of local corticosteroid injections on glycemic control are not clear. The purpose of this study was to evaluate the effects of corticosteroid injection to the shoulder on glycemia in patients with type 2 diabetes mellitus using a continuous glucose monitoring device. Methods: Twenty-five patients with symptomatic shoulder problems and type 2 diabetes mellitus, not treated with insulin, prescribed a corticosteroid injection into the shoulder, were investigated. The patients were connected to a flash glucose monitoring system, which continuously monitored interstitial glucose levels. Data were collected 3 days before injection and for additional 11 days after corticosteroid injection. We analyzed glucose levels in the first 3 days (early postinjection) and on days 4-11 (late postinjection) after the injection and compared them to the preinjection period. The outcome measures included change in the average glucose levels, per patient, between the preinjection and postinjection periods and the differences in the time spent at glucose >180 mg/dL, >250 mg/dL, and >350 mg/dL, per patient, between the preinjection and postinjection periods. Results: The increase in the mean glucose level per patient was statistically significant from 136 mg/dL in the preinjection period to 159 mg/dL in the first 3 days after the injection and returned to normal thereafter. Time at blood glucose >250 mg/dL increased from 4.3% in the preinjection period to 9.5% on the first day after the injection. It then decreased to 7% on day 2, 3.8% on day 3, and 1.4% in the late postinjection period. New onset of glucose levels >350 mg/dL was found in 4 of 25 patients during the early postinjection period. In all 4 patients, the exposure to severe hyperglycemia (>350 mg/dL) was short. None of the patients required intensification of the antidiabetic treatment or insulin injections. Conclusion: Local corticosteroid injection to the shoulder can create a significant, short-term increase in systemic glucose levels in patients with D2DM not treated with insulin. Some of these patients may have periods with glucose above 350 mg %. However, these glycemic changes are short lived and are mostly limited to the 2-3 days after the injection. In addition, none of the patients in our study needed any change in antidiabetic treatment or any medical care after the injection.

Meniscal Entrapment After Tibial Plateau Fracture and Fixation: A Case Report.

CASE: A 40-year-old man presented with limited in range of motion, pain, and tenderness over the medial joint line after an open reduction and internal fixation (ORIF) because of a bicondylar tibial plateau fracture (TPF). The cause of his pain was inconclusive on Magnetic Resonance Image (MRI), so arthroscopy was performed and identified an incarcerated medial meniscus at the fracture site. An osteotomy with medial joint elevation was performed followed by a meniscus release, with excellent results at the 1-year follow-up. CONCLUSION: To our knowledge, this is the first case reporting a trapped/incarcerated meniscus in a healed TPF after ORIF.

Mielinolisis central y periférica de la protuberancia: presentación de un caso y revisión de la literatura / Central and peripheral pontine Myelinolysis: case report and review of literature

Resumen La mielinolisis central de la protuberancia o síndrome de desmielinización osmolar, es un padecimiento que se asocia a pacientes con hiponatremia grave, a los cuales se les realiza una corrección brusca del sodio4. Se manifiesta como parálisis pseudobulbar que se presenta con: tetraparesia, encefalopatía que en ocasiones se puede presentar con rigidez, ataxia y movimientos anormales. Se trata de una desmielinización no inflamatoria secundaria al edema neuronal intenso tanto a nivel del puente como en otras zonas extrapontinas10. Es una patología infrecuente, sin embargo tiene mal pronóstico y la terapia con rehabilitación es el único tratamiento. El objetivo de la presente comunicación es informar el caso de un hombre de 63 años con cuadro de déficit neurológico progresivo posterior a un evento quirúrgico y corrección rápida de hiponatremia que presentó en días posteriores, mielinolisis pontina y extrapontina con diagnóstico por imagen y resonancia magnética. El paciente ameritó un largo periodo de hospitalización y rehabilitación, sin embargo las secuelas neurológicas actuales no son incapacitantes. Es imprescindible reconocer la hiponatremia y corregirla de manera correcta para evitar este tipo de complicaciones.

Abstract Central pontine myelinolysis or osmolar demielinization syndrome is a very wellknown disorder in patients with severe hyponatremia that undergo to a rapid sodium replacement. It is clinically described as a pseudobulbar palsy, with tetraparesis, and encephalopathy, that can also show generalized rigidity, ataxia and the presence of abnormal movements. It consists of a non-inflammatory demielinization secondary to neuronal swelling or edema, at the pontine level and in other extrapontine locations. It is an infrequent pathology that carries a bad prognosis and where the only available treatment is prolonged rehabilitation. Herein we inform the case of a 63 year old male, with a progressive neurological deficit following a surgical intervention and rapid replacement of a severe hyponatremia. The patient required a prolonged in hospital stay and further rehabilitation, although the neurological sequels actually are not disabling. It is essential to recognize hyponatremia and to perform an adequate correction of sodium levels to avoid this complication.