Retroperitoneal ganglioneuroma with nodal involvement in an adult patient with human immunodeficiency virus: a case report and review of the literature.

BACKGROUND: Ganglioneuromas are a benign tumor originating from neural crest cells. As one of the neuroblastic tumors, ganglioneuromas are most common in children, with a mean age at presentation of 7 years. Ganglioneuromas are typically singular in nature, but rarely can present with lymph node involvement and distant metastasis. We present a rare case of a retroperitoneal ganglioneuroma found in a human immunodeficiency virus positive adult, which was complicated by lymph node involvement. This case is notable not only in regard to the age of the patient, but also because of his human immunodeficiency virus positive status and the extension of tumor to lymph nodes. CASE PRESENTATION: A 27-year-old Latino male with history of human immunodeficiency virus presented with a 6-month history of left upper quadrant and epigastric abdominal pain with associated nausea and vomiting. The patient had a computed tomography scan showing a retroperitoneal mass encasing the aorta, celiac axis, and superior mesenteric artery. Core needle biopsy revealed ganglioneuroma. Owing to obstructive symptoms, resection of the mass along with partial gastric resection, partial pancreatic resection, and splenectomy was performed by a multidisciplinary group of surgeons. Pathology results revealed metastatic spread of ganglioneuroma to surrounding lymph nodes. CONCLUSIONS: Ganglioneuromas are most common in children and very rarely occur in adults. However, it is still important to consider this entity in the differential for patients presenting with suspicious symptoms. While rare, it is essential to consider metastasis in this generally benign disease.

A graphic guide to the percutaneous tripod acetabular reconstruction for metastatic cancer.

Symptomatic peri-acetabular metastatic lesions are often treated with open surgery such as modified Harrington procedures. In an effort to avoid surgical complications inherently associated with open surgical approaches, we developed and recently reported a novel Tripod percutaneous screw technique. The tripod technique is minimally invasive and was found to yield excellent outcomes regarding both pain control and functionality. The procedure is performed in a standard operative theater using fluoroscopic guided percutaneous screws. Despite the simplicity of intraoperative set-up and instrumentation, it is technically demanding. Obtaining the correct fluoroscopic views and troubleshooting intraoperative hurdles can be challenging for even an experienced orthopedic surgeon. The technique and bony conduits were previously described in the trauma literature, however, there are key points of difference in the setting of metastatic disease. Here we provide a compilation of a stepwise graphic guide for the tripod model in the setting of metastatic peri-acetabular lesions, as well as the tips and tricks based on our own experience. These encompass preoperative preparation, operating room settings, intraoperative fluoroscopic guidance, postoperative care, and subsequent conversion to a cemented total hip arthroplasty, if needed.

Midgut malrotation complicated by small bowel obstruction in an 80-year-old woman: A case report.

INTRODUCTION: Midgut malrotation results from abnormalities in the 270-degree counterclockwise rotation of the midgut around the axis of the superior mesenteric artery during embryological development, and classically presents early in life with symptoms of intestinal obstruction. Nevertheless, adult cases have occasionally been reported. PRESENTATION OF CASE: An 80-year-old female with no surgical history was brought to our emergency department for acutely altered mental status. On exam, her abdomen was distended and diffusely tender to palpation. Computed tomography (CT) scan of the abdomen and pelvis showed a dilated loop of jejunum with evidence of mesenteric twist concerning for closed-loop small bowel obstruction. The patient was taken for exploratory laparotomy and was found to have Ladd bands and other findings suggestive of intestinal malrotation. A Ladd procedure was performed and the patient remained under observation. She experienced intermittent abdominal distension and bilious nasogastric tube output, but subsequent CT scans revealed no evidence of obstruction. She was discharged following clinical improvement and ability to tolerate a diet. DISCUSSION: Malrotation of the small bowel exists on a spectrum depending on the embryologic stage during which anomalous rotation occurs. Classic findings on CT imaging (including abnormal mesenteric vasculature, right-sided duodenojejunal junction, whirlpool signs, and left-sided ascending colon) can provide clues to the existence of malrotation. CONCLUSION: Although malrotation is rare in adults, clinical and radiologic findings play an important role in the correct diagnosis of adult malrotation for appropriate and timely intervention.

Musculoskeletal Health Literacy, Pain Catastrophization, and Sleep Quality: Effect on Functional Disability Scores.

Limited musculoskeletal health literacy, catastrophic pain thinking, and poor sleep quality may be associated with adverse long-term health outcomes, but are sparsely studied concomitantly in orthopedics. The purpose of this study was to assess how these factors influence baseline functional disability. Hand and wrist and foot and ankle patients presenting with a previously untreated complaint were enrolled and completed the Literacy in Musculoskeletal Problems questionnaire, Pain Catastrophization Scale (PCS), and Pittsburgh Sleep Quality Index (PSQI). Upper extremity patients completed the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and lower extremity patients completed the Foot and Ankle Outcome Score (FAOS) survey. DASH and FAOS scores were normalized to the same scale and termed "functional survey" (FS). Two hundred thirty-one patients (mean age 45.8 ± 16.8) were included in the analysis. PCS and PSQI were significantly correlated with FS score. The only other variables significantly correlated with FS score were insurance and diagnosis type. The variables PCS, PSQI, insurance, and diagnosis were entered into a multivariate analysis with FS score. All four variables significantly added to FS score in the model (R2 = .194, p < .001). Interventions that target both catastrophizing tendencies and sleep quality may independently improve functional outcomes. Further in-depth multifactorial research in this topic is critical to craft effective treatments with sustainable outcomes. (Journal of Surgical Orthopaedic Advances 28(2):144-149, 2019).

Prevalence and Risk Factors of Limited Musculoskeletal Health Literacy in the Outpatient Setting: A Logistic Regression Model.

INTRODUCTION: The purpose of this study was to determine the risk factors of limited musculoskeletal health literacy (MHL) in a general population of orthopaedic patients. METHODS: Patients presenting to either a foot or ankle surgeon or hand or wrist surgeon were given the Literacy in Musculoskeletal Problems (LiMP) questionnaire, a nine-item survey for assessing "limited" MHL (LiMP score < 6). After confirming group homogeneity, the two populations were analyzed together to determine factors significantly correlated with and predictive of limited MHL. RESULTS: Overall, 231 patients were included in the analysis. Average LiMP score was 5.4 ± 1.8, and 49% of participants had "limited" MHL. Chi-square analysis revealed that being non-Caucasian, using cigarettes, and having a less than college-level education were associated with a higher prevalence of "limited" MHL (P < 0.05). Logistic regression revealed that being of non-Caucasian race (P = 0.04) or having less than college-level education (P = 0.03) were significant independent predictors of "limited" MHL, with adjusted relative risks of 1.37 and 1.40, respectively. DISCUSSION: In this study, the patients at the greatest risk of limited MHL are often at the risk of many other complications. These results should be used as a groundwork to craft directives aimed at improving MHL and outcomes in these patients.

Anatomy of the ankle capsule: A cadaveric study.

Although bony and ligamentous injuries of the ankle are well understood, little is known about the degree to which injury of the ankle capsule can be a component of such injuries. The purpose of this study was to determine the dimensions of the ankle capsule and its relationship to adjacent structures. Thirteen fresh-frozen ankle specimens were systematically dissected. Methylene blue solution was injected to identify the dimensions of the ankle capsule. External dimensions were measured as the distance from the capsular reflection to the bony margin of the ankle. Internal dimensions were measured as the distance from the capsular attachment of the distal tibia, fibula, and talus to the cartilage margin. The anterior aspect of the capsule demonstrated the most proximal capsular reflection in all specimens. The most proximal reflections of the anteromedial, anterior middle and anterolateral capsule were 10.3, 13.5, and 9.8 mm, respectively. The most proximal reflections of the posteromedial, posterior middle and posterolateral region were 8.7, 6.2, and 3.5 mm, respectively. There was no capsular reflection over the medial malleolus and less than 1 mm over the posterior lateral malleolus. There was a confluence of the capsule and ligamentous complex on the medial side, and also with the transverse tibiofibular ligament about the posterolateral ankle. The most proximal attachment of the ankle capsule was located at the anterior aspect of the distal tibia. The medial and posterolateral capsules were confluent with the ligamentous complexes of the ankle in those regions. Clin. Anat. 31:1018-1023, 2018. © 2018 Wiley Periodicals, Inc.

Arthroscopic Wrist Debridement and Radial Styloidectomy for Advanced Scapholunate Advanced Collapse Wrist: Long-term Follow-up.

BACKGROUND: Symptomatic stage 2 or 3 scapholunate advanced collapse (SLAC) wrist is aggressively treated with salvage procedures, such as proximal row carpectomy or partial wrist fusion with resultant pain relief but limited motion. We hypothesize that arthroscopic synovectomy, radial styloidectomy, and neurectomy will preserve wrist motion, relieve pain, and delay or avoid salvage procedures. METHODS: We evaluated outcomes in 13 wrists through questionnaires and 11 of these through additional physical examination at a mean follow-up of 5.0 years. Eight wrists were stage 2 and 5 were stage 3. Data at final follow-up included mobility/strength measurements, subjective outcome scores (Disabilities of the Arm, Shoulder, and Hand [DASH] and visual analog scale [VAS] pain), patient satisfaction, and return to work statistics. RESULTS: Patients had an average flexion-extension arc of 88.0° in the treated wrist and an average grip strength that was 95.0% of the contralateral side. No patients required revision surgery at follow-up. The 13 wrists reported an average DASH score of 16.4 and mean VAS pain score at rest and with activity of 17.9 and 31.6, respectively. All patients working prior to the procedure (n = 8) were able to immediately return to work. In all, 84.6% of patients were satisfied. CONCLUSIONS: The procedure studied may have advantages in relieving pain, while preserving wrist motion for SLAC stage 2 or 3 disease. This procedure does not preclude future salvage procedures in those patients with severe disease who prefer to maintain wrist motion for the short term. Patients experience good functional outcomes with the majority experiencing a reduction in pain with the ability to return to work.

Risk factors for achilles tendon rupture: A matched case control study.

PURPOSE: The purpose of this study was to elucidate whether body mass index (BMI), activity level, and other risk factors predispose patients to Achilles tendon ruptures. MATERIALS AND METHODS: A retrospective review of 279 subjects was performed (93 with Achilles tendon rupture, matched 1:2 with 186 age/sex matched controls with ankle sprains). Demographic variables and risk factors for rupture were tabulated and compared. RESULTS: The rupture group mean BMI was 27.77 (95% CI, 26.94-28.49), and the control group mean BMI was 26.66 (95% CI, 26.06-27.27). These populations were found to be statistically equivalent (p=0.047 and p<0.001 by two one-sided t-test). A significantly higher proportion of those suffering ruptures reported regular athletic activity at baseline (74%) versus controls (59%, p=0.013). CONCLUSION: There was no clinically significant difference found in BMI between patients with ruptures and controls. Furthermore, it was found that patients who sustained ruptures were also more likely to be active at baseline than their ankle sprain counterparts.

Development and Validation of a Disease-Specific Questionnaire for Basal Joint Arthritis.

Background The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is the most commonly used instrument to assess outcomes of basal joint arthritis (BJA). However, the DASH is subject to influence by the entire upper extremity. Purpose This study aims to develop and validate a disease-specific questionnaire for BJA that would be more sensitive to changes in thumb function and pain, and correlate better with objective and subjective metrics. Patients and Methods The thumb disability examination (TDX) was developed and 80 patients presenting with BJA at one of the two hospital-based hand clinics were enrolled in the validation study. At enrollment, subjects were given the TDX, DASH, and visual analog pain scale with activity (A-VAS) surveys. The strength was assessed. Patients receiving corticosteroid injection were seen for follow-up at 6 weeks and those who underwent surgery were seen between 3 and 6 months postoperatively. Both the groups were given the TDX, DASH, and A-VAS scales at follow-up. Results In total, 65 subjects were included in the analysis. Average TDX completion time was 134.3 seconds. The TDX correlated more strongly with A-VAS scores at baseline than the DASH, but less strongly with tip-pinch measures. The TDX was more responsive to injection and surgical treatments for BJA than the DASH, yielding a larger effect size and standardized response mean, and was the only instrument to significantly correlate with changes in A-VAS. Conclusion The TDX is a reliable instrument for assessing BJA treatment outcomes. It bears less of a burden on patients, is more responsive to symptomatic changes, and correlates better with most objective and subjective measures than the DASH. Level of Evidence II, diagnostic.

Timing of Antibiotic Prophylaxis for Preventing Surgical Site Infections in Foot and Ankle Surgery.

BACKGROUND: Surgical site infections (SSIs) are one of the most troublesome complications after foot and ankle surgery. Previous literature has emphasized the significance of appropriate timing of antibiotic prophylaxis. However, the optimal timing of antibiotic prophylaxis for SSI prevention is still inconclusive. Our study aimed to investigate the optimal timing of antibiotic administration and to elucidate the risk factors for SSIs in foot and ankle surgery. METHODS: A retrospective review of 1933 foot and ankle procedures in 1632 patients from January 1, 2011, through August 31, 2015, was performed. Demographic data; type, amount, and timing of antibiotic administration; incision; and closure time were recorded. Subsequent wound infection and incision and drainage procedure (I&D) within 30 days and 90 days were documented. Outcomes and demographic variables were compared between procedures in which antibiotics were administered less than 15 minutes and between 15 to 60 minutes prior to incision. A total of 1569 procedures met inclusion criteria. RESULTS: There were 17 cases (1.1%) of subsequent wound infection, of which 6 required a subsequent I&D within 30 days. There were 63 additional cases (4%) of wound complications, which did not meet SSI criteria. When comparing SSI and non-SSI groups, the only significant independent predictors were longer surgeries and nonambulatory surgeries (both P < .05). Stepwise multivariate logistic regression analysis demonstrated that 91.8% of the risk of an SSI could be predicted by ASA score and length of surgery alone. CONCLUSION: In foot and ankle surgeries, the timing of intravenous antibiotic prophylaxis did not appear to play a significant role in the risk of SSI. Host factors and duration of surgery appear to have played a much larger role in SSI than the timing of antibiotic prophylaxis. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Extensor Pollicis Longus Rupture after Mini TightRope Suspensionplasty.

Background Arthritis of the first carpometacarpal (CMC) joint has been surgically treated in multiple ways with varying levels of success as measured by subjective and objective measures. Trapeziectomy with numerous variations in suspensionplasty comprises one of the more commonly used surgical procedures. Recently, the Mini TightRope apparatus has been utilized as a new method for achieving suspensionplasty, and as such lacks significant review of use and safety in the literature. Case Description An extensor pollicis longus (EPL) rupture following a trapeziectomy and Mini TightRope suspensionplasty for CMC arthritis of the thumb is presented. The patient successfully underwent an extensor indicis proprius (EIP) to EPL transfer to treat this complication. Literature Review There is well-established documentation of injury to the extensor tendons from orthopedic hardware such as volar locking plates. Regarding use of the Mini TightRope apparatus, guidelines for placement of the suture button include caution to place the button away from the EPL tendon to minimize the chance of tendon irritation. Additionally, FiberWire sutures, a component of the apparatus, have been shown to demonstrate soft tissue reactions with adjacent inflammatory response. Published reports on adverse events utilizing this device have been limited to case reports including an index metacarpal fracture. Clinical Relevance The aim of this case report was to cite an occurrence of EPL rupture following its use and discuss the possibilities of its direct contribution.