Intercondylar T-Type Distal Humerus Fracture in a 10-Year-Old: A Case Report.

CASE: A 10-year-old, postmenarchal girl presented to the emergency department with a closed, displaced, intercondylar T-type distal humerus fracture. Open reduction and internal fixation was performed 3 days following initial presentation. The patient healed but experienced elbow stiffness in the 7 months following the procedure. Implant removal and capsular release were performed at that time. At the 31-month follow-up, the patient reported satisfactory elbow functionality. CONCLUSION: There is limited literature available discussing optimal management and associated outcomes of intercondylar T-type distal humerus fractures in the young-adolescent population. This report presents a possible method for management of the initial injury and the most common associated complication.

Evaluating the Quality, Readability, and Activity of Online Information on Brain Arteriovenous Malformations.

Introduction Brain arteriovenous malformations (AVMs) are vascular deformities created by improper connections between arteries and veins, most commonly in the brain and spinal cord. The management is complex and patient-dependent; further understanding of patient education activities is imperative. Internet access has become more ubiquitous, allowing patients to utilize a large database of medical information online. Using Google Trends (GT) (Google LLC, Mountain View, CA, USA), one can see the public interest in a particular topic over time. Further, when presented with numerous search results, patients may not be able to identify the highest-yielding resources, making objective measures of information quality and readability imperative. Methods A GT analysis was conducted for "hereditary hemorrhagic telangiectasia," "cerebral aneurysm," and "arteriovenous malformation". These relative search volumes (RSV) were compared with the 2017 to 2019 annual USA AVM diagnosis quantity for correlation. These RSVs were also compared with the 2017 to 2019 annual USA deaths due to cerebral hemorrhagic conditions. One search was conducted for "brain arteriovenous malformation". Since most users looking for health information online use only the first page of sources, the quality and readability analyses were limited to the first page of results on Google search. Five quality tools and six readability formulas were used. Results Pearson's correlation coefficients showed positive correlations between USA AVM RSVs and annual AVM deaths per capita from 2017 to 2019 (R2=0.932). The AVM annual diagnosis quantity and AVM RSVs showed a strong positive correlation as well (R2=0.998). Hereditary hemorrhagic telangiectasia and cerebral aneurysms had strong positive correlations between their RSVs and their corresponding annual diagnoses in the 2017 to 2019 time period (R2=0.982, R2=0.709). One-way ANOVA, for USA's 2004 to 2021 AVM RSVs and 2004 to 2019 deaths per capita, displayed no month-specific statistically significant repeating pattern (all p>0.483). The DISCERN tool had four websites that qualified as "poor" and five as "good." The average score for the tool was "good." The Journal of the American Medical Association (JAMA) benchmark scores were very low on average, as four websites achieved zero points. There was a wide variance in the currency, relevance, authority, accuracy, and purpose (CRAAP) scores, indicating an inconsistent level of webpage reliability across results. The patient education materials assessment tool (PEMAT) understandability (86.6%) showed much higher scores than the PEMAT actionability (54.6%). No readability score averaged at or below the American Medical Association (AMA)-recommended sixth-grade reading level. Conclusion These GT correlations may be due to patients and families with new diagnoses researching those same conditions online. The seasonality results reflect that no prior research has detected seasonality for AVM diagnosis or presentation. The quality study showed a wide variance in website ethics, treatment information quality, website/author qualifications, and actionable next steps regarding AVMs. Overall, this study showed that patients are routinely attempting to access information regarding these intracranial conditions, but the information available, specifically regarding AVMs, is not routinely reliable and the reading level required to understand them is too high.

Simplified soft tissue coverage of the distal lower extremity: The reverse sural flap.

Soft tissue defects involving the distal lower extremity present challenging problems for orthopaedic surgeons to manage. Historically, wounds not amenable to primary closure have necessitated assistance from multidisciplinary teams using plastic surgeons to obtain adequate soft tissue coverage through rotational flap or free tissue transfer procedures. Techniques related to soft tissue rearrangement and local rotational flap coverage have advanced over the years with a growing knowledge of local anatomy and vasculature. The reverse sural flap may be performed to cover soft tissue defects within 10 cm of the foot or ankle region, negating the need for microvascular intervention. The simplistic nature of the reverse sural flap is appealing to orthopaedic surgeons as a means to provide timely patient care without additional support because it does not require microvasculature work or the need for intraoperative microscopes and has been popularized among orthopaedic trauma surgeons as a necessary tool to possess. Here, we discuss the reverse sural flap to include history, relevant anatomy, clinical indications, and a description of the technique for application.

In-Vitro Assessment of the Effects of Transcatheter Aortic Valve Leaflet Design on Neo-Sinus Geometry and Flow.

Transcatheter aortic valve (TAV) leaflet thrombosis is a clinical risk with potentially fatal consequences. Studies have identified neo-sinus flow stasis as a cause of leaflet thrombosis. Flow stasis is influenced by the TAV leaflets, which affect the local fluid dynamics in the aortic sinus and neo-sinus. This study evaluated the effects of TAV leaflet features on the neo-sinus flow as a measure of leaflet thrombosis risk. Five TAVs of varied leaflet length and insertion height were tested in a simulator. Hydrodynamics and leaflet kinematics through en-phase imaging were quantified. Velocity fields were assessed using high-speed particle image velocimetry. Regions of flow stasis and particle residence times (PRTs) were quantified. TAVs with shorter leaflet length exhibited larger orifice areas and lower transvalvular pressure gradients. Shorter leaflet length and increased leaflet insertion TAVs additionally exhibited lower neo-sinus PRTs (0.44 ± 0.21 vs 2.83 ± 0.48 cycles, p < 0.05) and higher neo-sinus peak velocities (0.15 ± 0.009 vs 0.07 ± 0.005 m/s, p < 0.05) than TAVs with longer leaflet length and lower leaflet insertion. The average neo-sinus volume positively correlated with PRT(r = 0.810, p < 0.001), and extent of flow stasis (r = 0.682, p < 0.05). These results suggest that a small neo-sinus volume may reduce flow stagnation and particle residence, potentially reducing the risk of leaflet thrombosis. We propose that leaflet design features might be proactively controlled in the design of future transcatheter aortic valves.

Influence of Patient-Specific Characteristics on Transcatheter Heart Valve Neo-Sinus Flow: An In Silico Study.

Thrombosis in post-transcatheter aortic valve replacement (TAVR) patients has been correlated with flow stasis in the neo-sinus. This study investigated the effect of the post-TAVR geometry on flow stasis. Computed tomography angiography of 155 patients who underwent TAVR using a SAPIEN 3 were used to identify patients with and without thrombosis, and quantify thrombus volumes. Six patients with 23-mm SAPIEN 3 valves were then selected from the cohort and used to create patient-specific post-TAVR computational fluid dynamic models. Regions of flow stasis (%Volstasis, velocities below 0.05 m/s) were identified. The results showed that all post-TAVR anatomical measurements were significantly different in patients with and without thrombus, but only sinus diameter had a linear correlation with thrombus volume (r = 0.471, p = 0.008). A linear correlation was observed between %Volstasis and thrombus volume (r = 0.821, p = 0.007). The combination of anatomy and valve deployment created a unique geometry in each patient, which when combined with patient-specific cardiac output, resulted in distinct flow patterns. While parametric studies have shown individual anatomical or deployment metrics may relate to flow stasis, the combined effects of these metrics potentially contributes to the biomechanical environment promoting thrombosis, therefore hemodynamic studies of TAVR should account for these patient-specific factors.