Splenic artery aneurysm in pregnancy: A systematic review.

OBJECTIVE: Splenic artery aneurysms (SAA) are associated with significant maternal and fetal mortality when ruptured in pregnancy. However, there is no consensus on the optimal obstetric management of both ruptured and asymptomatic SAA. We aimed to evaluate risk factors, presentation, investigation, and management of SAA in pregnancy and puerperium. METHODS: MEDLINE, EMBASE, and Scopus were screened from January 2000 to October 2020 using keywords related to pregnancy and SAA. Articles on ruptured and unruptured SAA in pregnancy until 6 weeks postpartum were considered. Data were extracted by two independent reviewers. Quantitative analysis and narrative synthesis were used. RESULTS: Seventy-five ruptured and nine unruptured SAA cases were included. Mean age was 31.1 ± 5.2 years, of which 47 (64.4%) were multiparous and 46 (54.8%) presented in their third trimester, largely with epigastric and left-sided abdominal pain. The double-rupture phenomenon of delayed blood loss and symptoms was noted in 11 (14.7%); 60 (70.7%) underwent preoperative imaging. Mean SAA size was 23.0 ± 13.6 mm. Ruptured SAA were primarily managed by laparotomy (61, 81.3%) typically with splenectomy,  and unruptured SAA by embolization or laparotomy. There was no mortality in unruptured SAA, but significant mortality on rupture (19, 25.7% maternal; 36, 50.0% fetal). CONCLUSION: Given their predisposition and high mortality in pregnancy, it is crucial that SAAs are promptly diagnosed and managed, requiring increased obstetrician awareness.

Repetitive trauma-induced extra-nuchal-type fibroma.

A nuchal-type fibroma is a rare, benign fibrous tumour that typically occurs in the posterior neck along the midline, but can occur in extra-nuchal locations, most commonly in the back, shoulder and face. We present a biopsy-proven case that arose as a result of heavy gym-related activities. In particular, a heavy barbell was rested on his vertebral prominence at the level of C7/T1 during leg squatting. Repetitive trauma as a cause for extra-nuchal-type fibromas has been sparsely reported, but we suggest that sustained high pressure is an additional required feature. Although this lesion was in the posterior neck, it was contained entirely within the subcutaneous tissues without involvement of the nuchal ligament. Hence, it was considered an extra-nuchal fibroma. A description of key ultrasound and MRI imaging characteristics are provided to assist in making the diagnosis, along with a review of the current literature and a discussion of differential diagnoses.

An uncommon lymphoma mimic: lipogranulomas.

A lipogranuloma is a complication of injecting exogenous oily composites, forming a nodule composed of foreign body histiocytes. These may be seen in the setting of use of anabolic steroids. We present a case of a 52-year-old male with rapidly growing intramuscular masses with accompanying lymphadenopathy and constitutional symptoms. A diagnosis of lymphoma was initially made in view of the multifocal nature of his disease. CT and PET/CT scans were used to profile the extent of disease. However, US-guided biopsy samples demonstrated acute-on-chronic fibro-inflammatory connective tissue, but no evidence of malignancy. A follow-up CT scan showed resolution of most of these masses. Subsequently, a history of self-injected anabolic steroids was obtained. Familiarity of imaging characteristics of lipogranuloma may be helpful in avoiding the pitfall of misdiagnosis in this clinical setting.

Evaluation of dynamic ultrasound scanning in the diagnosis of equivocal ventral hernias with surgical comparison.

OBJECTIVES: This study aims to compare ultrasonography for ventral hernias with surgical findings and establish its accuracy in equivocal cases. Comparison is also made against groin hernia ultrasound scanning, which has a positive predictive value ranging from 71-100%. METHODS: A retrospective review of all patients who underwent an ultrasound scan between June 2011 and June 2015 was performed. The word "hernia" in the referral information was the sole inclusioncriterion. Patients who were found to have a clinically evident ventral hernia, unrelated hernia in aseparate location or had a known hernia were excluded. Thus, only patients with a clinically suspected ventral hernia and equivocal clinical assessment were included. These patients were followed up for at least 12 months and subsequent operation notes, if any, were also analysed. RESULTS: 348 scans were included (F = 198, M = 150, F:M ratio = 1.32:1). The mean age was 53.4 years (range = 16-97 years). 101 scans were positive for hernias (29.0%), 190 were negative (54.3%), and 57 had other findings (e.g. seroma, lipoma; 16.3%). 54 patients were taken to surgery (15.5%), including 5 who were found to be negative on ultrasound. Of these, 45 were truepositives, 4 true-negatives, 4 false-negatives, and 1 false-positive, giving a sensitivity of 91.8% and positive predictive value of 97.8%. CONCLUSION: This study confirms that ultrasound scans are effective in the diagnosis of equivocal ventral hernias. Advances in knowledge: The accuracy of ultrasound scanning specifically for ventral hernias is quantified, and are comparable to that of groin hernias.

The virtual fracture clinic: Reducing unnecessary review of clavicle fractures.

INTRODUCTION: We re-designed the outpatient management of trauma at our institution to eliminate appointments if there would be no change in management or information provision. All cases referred by the Emergency Department (ED) were reviewed at a Virtual Fracture Clinic (VFC) by an orthopaedic consultant and telephoned afterwards by a senior nurse. If face-to-face review was required, it was arranged at a specialist shoulder clinic. AIMS: The primary aim of this study was to evaluate the proportion of clavicle fractures that could be discharged without physical review. The secondary aim was to assess the patient reported functional outcome and satisfaction among patients who were discharged without further review. PATIENTS AND METHODS: A retrospective review was performed of patients who attended the ED with a clavicle fracture between October 2011 and September 2012. 138 patients were included. The number of patients who were discharged without a physical review was analysed. All radiographs were classified according to the Robinson classification. We recorded the number of undisplaced/minimally-displaced fractures that were discharged virtually. The number of patients with a displaced midshaft fracture who were seen at a specialist clinic was also recorded. A questionnaire was sent to all patients at one year post-injury to evaluate their outcome (QuickDASH and EQ-5D) and satisfaction with the new service. RESULTS: 62/138 (45%) were directly discharged from the VFC. The majority of virtual discharges occurred in the undisplaced fracture types (84% versus 13%, RR 6.4, 95% CI 3.5-11.5). 78% patients responded to the questionnaires. 91% of patients were satisfied with their recovery from the injury. 86.4% patients were satisfied with the information provided regarding their treatment. In the virtually discharged group the mean EQ-5D VAS was 78.1 (EQ5D range 0.06-1, SD 0.248). The mean Quick DASH score was 16.1(SD 25.2). CONCLUSIONS: Virtual discharge of undisplaced clavicle fractures is appropriate and results in acceptable clinical outcomes and patient satisfaction. This redesigned process has significant benefits for patients as there were far fewer hospital visits by avoiding unnecessary appointments. The orthopaedic service also benefited by having more time available for the management of complex cases.

Prevalence and characteristics of noise in a series of 282 ceramic-on-ceramic total hip arthroplasties.

OBJECTIVE: The aim of this study was to determine the prevalence of noise with ceramic-on-ceramic (COC) bearings in total hip arthroplasty (THA). We evaluated if patients wished be counseled about this and its potential consequences preoperatively. METHODS: Two hundred eighty-two primary cementless THAs were performed in 260 patients (124 males and 136 females), with a mean age 68.5 years. All patients completed a questionnaire. Minimum follow-up was 3 years. Statistical analysis was used to evaluate if patient variables influenced whether the patient experienced a noisy hip. RESULTS: Thirty-one (11%) of hips had an audible noise; 50% of these were 'squeaks.' The noise was mainly present upon standing up (74%) and walking (45%). None of the patients noted 'noise' on their consent forms. Fifty-five percent of the entire cohort would have preferred to have known about the possibility of a noisy hip before consenting, though no patients would have refused consent had they known about the noise preoperatively. No patients have sought financial compensation to date. There was no significant influence of gender (p=0.92), age (p=0.66), height (p=0.17), weight (p=0.99), or body mass index (p=0.29) on whether the patient experienced a noisy hip. CONCLUSION: No patient factor associated with noise could be identified. It is suggested that this issue be discussed preoperatively with all patients. In our cohort, this would satisfy the majority of patients' wishes and may additionally serve as important evidence in a malpractice claim. Therefore, it is suggested that the British Orthopaedic Association include 'the possibility of noise' in their consent form for THA.