Peri-implant Proximal Humerus Fracture Stabilized with Stacked Plating: A Case Report.

Introduction: A peri-implant proximal humerus fracture is a rare complication after open reduction and internal fixation (ORIF) and poses a surgical dilemma. Case Report: A 56-year-old male sustained a peri-implant proximal humerus fracture after undergoing ORIF. We present a stacked plating method for fixation of this injury. This construct allows for decreased operative time, less soft-tissue dissection, and the ability to leave previous intact hardware in place. Conclusion: We describe the rare case of a peri-implant proximal humerus treated with stacked plating.

Increased length of stay following total joint arthroplasty based on insurance type.

BACKGROUND: Increased length of stay after total joint arthroplasty has been shown to be a risk factor for peri-operative complications. The purpose of this study was to determine if Medicaid insurance would be a risk factor for increased length of stay after total joint arthroplasty. METHODS: We retrospectively reviewed a single surgeon's practice of 428 total hip and total knee arthroplasties who had insurance status of Medicaid, Medicare, Private or none. After exclusion criteria there were 400 patients. Patients with insurance status of Medicaid, Medicare or Private were then compared based on length of stay ≤ 2 days and length of stay > 2 days and then further analyzed using demographic, operative data, and total length of stay. RESULTS: Medicaid patients had an increased length of stay compared to patients with Medicare or Private insurance [1.98 days versus 1.73 days, p = .037, 95% confidence intervals (1.78-2.18) and (1.61-1.85), respectively]. The greatest predictor of a less than two-night stay post-operatively was private insurance status (p = 0.001). Medicaid patients had a higher incidence of prescribed narcotic use pre-operatively (p = 0.013). Although not significant, a trend was noted in the Medicaid population with higher incidence of smoking (p = 0.094) and illicit drug abuse (p = 0.099) pre-operatively in this sample subset. CONCLUSIONS: Patients with Medicaid insurance undergoing total joint arthroplasty have increased length of stay compared to patients with Medicare or Private insurance and have higher incidence of pre-operative narcotic use.

Contrast Enhanced Computed Tomography in the Diagnosis of Acute Pyogenic Flexor Tenosynovitis.

BACKGROUND: The diagnosis of infectious flexor tenosynovitis (FTS) has historically been made based on physical exam using Kanavel's signs. The specificity of these findings has come into question. We looked to evaluate the use of contrast-enhanced computed tomography (CT) in increasing the successful diagnosis of FTS. METHODS: Two adult cohorts were formed, one of patients with FTS confirmed in the operating room and the second of patients with ICD.10 identified finger cellulitis (FC), without concomitant FTS. Demographics, laboratory values, CT scans, and examination findings were evaluated. Axial CTs were evaluated in the coronal and sagittal planes and tendon sheath/tendon width were measured. The tendon sheath/tendon was recorded as a ratio in the coronal (CR) and sagittal (SR) planes. Continuous and dichotomous variables were analyzed and measures of sensitivity, specificity, and predictivity were calculated. Seventy patients were included, 35 in the FTS cohort and 35 with FC. RESULT: A higher number of Kanavel signs were present in the FTS group (2.9 vs. 0.5, P < .05), with CR and SR both being significantly larger in the FTS group (P < .05). CR and SR cutoffs ≥ 1.3 provided high sensitivity, specificity, and positive predictive value (PPV) for FTS. Likelihood of FTS increased 5.9% and 5.5% for every 0.1 increase in CR and SR, respectively, with a 14% increase for every additional Kanavel sign. CONCLUSION: In conclusion, CT ratios are useful in identifying FTS; and when used on their own or in combination with Kanavel's signs, CR and SR objectively improve the diagnosis of FTS.

The Corkscrew Technique for Removing a Fibular Strut Allograft From the Proximal Humerus.

A fibular strut allograft is a reliable option for augmentation in open reduction internal fixation (ORIF) of proximal humerus fractures, but techniques to remove a fibular strut during revision shoulder arthroplasty are limited. Currently published techniques on extracting fibular strut grafts from humeral shafts include using a Midas burr, flexible osteotomes, humeral shaft osteotomy, and reaming. To our knowledge there has not been a technique that uses a corkscrew to remove the fibular strut from the proximal humerus in preparation for revision shoulder arthroplasty. This is a case report and description of a simple and reproducible technique that can be implemented in the setting of conversion from a proximal humerus lateral locking plate with fibular strut allograft to shoulder arthroplasty.

Resolution of Deep Peroneal Nerve Palsy after Seroma Evacuation in a Primary Total Hip Arthroplasty: A Case Report.

Introduction: In this manuscript, we present a late presentation of deep peroneal nerve symptoms after total hip arthroplasty (THA) which subsequently completely resolved after seroma evacuation and sciatic nerve decompression. While hematoma formation causing deep peroneal nerve symptoms after THA has been reported in the literature, we are unaware of any reports of seroma formation causing similar symptoms. Case Presentation: A 38-year-old female underwent an uncomplicated primary THA and developed paresthesia's over the lateral leg and foot drop on post-operative day 7. Ultrasound diagnosed a fluid collection compressing the sciatic nerve. The patient underwent seroma evacuation and sciatic nerve decompression. Patient regained active dorsiflexion and minimal paresthesia's over the dorsal lateral foot at the 12-month post-operative clinic visit. Conclusion: Early operative intervention in patients with diagnosed fluid collection and worsening neurological deficits can result in good outcomes. This is a unique case as there are no other case reports of seroma formation causing deep peroneal nerve palsy.

Pelvic Shadowing as a Diagnostic Predictor of Orthopedic Pathology in Orthopedic Trauma Patients.

Introduction The Throckmorton sign, or John Thomas sign, is a well-established orthopedic eponym, anecdotally used in orthopedic surgery to correlate the direction of male genitalia, observed on a pelvic radiograph, with the laterality of an associated orthopedic pathology. In earlier studies, the direction of pelvic shadowing on X-ray has been neither a credible nor a reliable predictor of fracture laterality. Given this small body of evidence, we sought to further investigate the relationship between peri-trochanteric hip fracture laterality and male genitalia lie. Method A single-center retrospective chart review was conducted of 397 consecutive male patients who received pelvic radiographs performed upon entry to an urban level 1 trauma center. Exclusion criteria included age less than 18 years or a prior history of pelvic or urological surgery. Of this cohort, 360 patients met the inclusion criteria and underwent investigation. Results The study population had an average age of 42 years (range: 18-91 years). Statistical analysis yielded a 4.24 relative risk with pelvic shadowing laterality and respective peri-trochanteric hip fracture sidedness. Additionally, there was a 4.63 and 9.88 relative risk of tibial shaft fractures and distal radius fractures having a concomitant positive Throckmorton Sign, respectively. Conclusion Pelvic shadowing can be used as an additional diagnostic tool in predicting peri-trochanteric hip fracture sidedness in a trauma bay setting.

Treatment of Distal Femur Fractures with a Combined Nail-Plate Construct: Techniques and Outcomes.

A combination treatment using a retrograde intramedullary (IM) nail and a lateral locking plate has scarcely been described in distal femur fracture treatment. In this retrospective inquiry, we review 97 patients who were treated for distal femur fracture by one of five fellowship-trained orthopedic trauma surgeons at an urban level-1 trauma center. Of the 97 patients enrolled in this investigation, eight were treated with a combined nail-plate hybrid construct. The remaining 89 patients were treated with either traditional IM nailing (22 patients) or locking plate fixation (67 patients) alone. Patient demographics, fracture and injury characteristics, operative variables, radiographic information, and postoperative outcome measurements were recorded for each patient in the study. All eight patients who were treated with the combined nail-plate construct proceeded to fracture union (100% vs. 69% in the control group; p = 0.33). Both procedure duration (p = 0.006) and total fluoroscopy time (p = 0.004) were significantly higher in the nail-plate construct group. No statistically significant difference was found between the two groups regarding complication rate. A combined nail-plate construct is a successful treatment alternative for acute management of distal femur fractures. This technique may be most beneficial for patients at higher risk for nonunion (i.e., those with open, comminuted metaphysis fractures) or those with a need for an additional load-sharing construct (i.e, osteopenic or noncompliant patients).

Isolated Volar Dislocation of the Distal Radioulnar Joint Treated With Successful Closed Reduction.

We report the case of A 34-year-old right-hand-dominant male who presented with an isolated left volar dislocation of the distal radioulnar joint (DRUJ) without any associated fractures. The patient had sustained the injury in an altercation in the evening prior to the presentation and had woken up the next morning with left wrist pain and restricted wrist motion. Closed reduction was successful under conscious sedation and the patient was treated conservatively with splint immobilization without needing operative intervention. This report highlights a rare injury pattern - an isolated volar DRUJ dislocation - that was successfully closed reduced, despite reports that this injury pattern frequently requires open reduction.