Acrometastasis of Occult Renal Cell Carcinoma: A Case Report.

Renal cell carcinoma is a common malignancy with 30,000 new cases reported annually in the U.S. While bone is one of the most common sites of metastases of renal cell carcinoma, acrometastases are rare with an estimated incidence of 0.1 percent among patients with malignant disease. We present an 89-year-old white male who presented with a painful mass of the left thenar eminence. A preoperative medical evaluation revealed metastatic renal cell carcinoma with lytic infiltration of the diaphysis of the left thumb metacarpal with soft tissue involvement. The patient was treated with two intralesional currettage procedures and later radiation therapy. This approach allowed the patient to maintain functional use of the thumb for activities of daily living.

Cytochrome P450 2D6 Genotyping for Post-Operative Opioids.

Within most electronic medical records, automated decision support helps health care providers reduce the frequency of adverse drug reactions. Historically, this decision support has been used to prevent drug-drug interactions (DDIs). More recently, the clinical and scientific communities have been moving toward the use of this approach to predict and prevent drug-gene interactions (DGIs). Genetic variation in cytochrome P450 2D6 (CYP2D6) is known to impact clinical outcome for many drugs, including opioids. Randomized trials have been initiated to assess the utility of CYP2D6 gene-based dosing versus usual care. We review the use of this approach to guide opioid prescribing in the post-operative setting.

Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study.

BACKGROUND: The Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures. METHODS: Ten fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented. RESULTS: The average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens. CONCLUSION: Arthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.

Comparison of risk factors for postoperative complications across age groups in patients undergoing ORIF of the ankle.

INTRODUCTION: Risk factors associated with various adverse outcomes for patients undergoing open reduction and internal fixation (ORIF) of the ankle, and how these risks differ between younger and older patient populations, has not been clearly established. Objective quantitative data may aid physicians in surgical decision making, individualizing postoperative management, and targeting interventions for reducing postoperative comorbidity. The purpose of this study is to compare the incidence of and risk factors for adverse postoperative outcomes following ORIF of ankle fractures across patient age groups. MATERIALS AND METHODS: Charts of patients age 18 years and older who underwent open reduction and internal fixation (ORIF) for any closed, non-polytraumatic, non-pilon ankle fracture at a single institution between the years 2008 and 2018 were reviewed. Demographic information, comorbidities, and postoperative outcomes were collected. Relative risks for adverse outcomes were calculated and compared between patients younger than 50 and patients 50 years and older. RESULTS: A total of 886 patients were included, 375 (42.3%) of which were over age 50. In both age groups, risk of infection was significantly increased among patients with hypertension, although risk among older patients (RR = 3.52, p = 0.004) was greater than that among younger patients (RR = 2.46, p = 0.017). In patients younger than 50, significant risk of wound dehiscence was associated with tobacco use (RR = 3.39, p = 0.022), substance use (RR = 3.07, p = 0.020), and CHF (RR = 12.77, p < 0.001). Risk of implant failure was significantly increased among younger patients with HIV (RR = 4.33, p = 0.026), CHF (RR = 10.54, p < 0.001), and CKD (RR = 10.54, p < 0.001), and among older patients with HTN (RR = 4.51, p = 0.006), CHF (RR = 5.83, p < 0.001), and tobacco use (RR = 3.82, P = 0.001). CONCLUSION: Patients undergoing ORIF of the ankle should be well-informed of the potential risks of surgery as they pertain to specific comorbidities. Multidisciplinary approaches are warranted for appropriate management of patients with multiple comorbidities.

Discovering an Anatomic Variant of the Palmaris Profundus during Open Carpal Tunnel Release.

A 46-year-old female presented after 3 years of steadily increasing numbness in her hands bilaterally with worse symptoms in her right hand. She reported nighttime paresthesia and exacerbation of her symptoms while writing, typing, and driving. Tinel's and carpal tunnel compression test were positive bilaterally. During the right hand carpal tunnel release, a layer of synovium was present deep to the carpal ligament with a tendinous portion running midline longitudinally along the median nerve. This layer was an anomalous palmaris profundus (PP) tendon within the carpal tunnel, which inserted distally in the palmar fascia. The PP tendon was freed and released. The PP is a rare muscle variation of the forearm and wrist, and although it has no function, it has been reported as a cause of median nerve compression at the wrist. More commonly, it is an incidental finding during carpal tunnel surgery. Because of its close association with the median nerve, it can cause confusion when encountered during carpal tunnel surgery. Clinicians should be aware of this rare finding, which may be present during carpal tunnel surgery. We present a case, with intraoperative photographs, of a PP tendon that was encountered during a carpal tunnel release.

Wide-Awake Anesthesia in the In-Office Procedure Room: Lessons Learned.

BACKGROUND: Wide-awake local anesthesia and no tourniquet (WALANT) has become more popular in hand surgery. Without a tourniquet, there is no need for preoperative testing or sedation. The use of lidocaine with epinephrine has allowed a larger variety of cases to be done safely in an outpatient setting instead of the hospital. "Minor field sterility," which uses fewer drapes and tools to accomplish the same procedures, is a concept that is also gaining recognition. METHODS: Investigation of hand surgeons performing a majority of cases using WALANT and minor field sterility was the beginning of seeing its potential at our institution. Administration was concerned about patient safety, cost-effectiveness, and patient satisfaction of the proposed changes. Analysis of our institution to determine location of these procedures was also imperative to using WALANT. RESULTS: An in-office procedure room was built to allow for WALANT and minor field sterility. The requirements and logistics of developing an in-office procedure room for wide-awake surgery are reviewed in this article. CONCLUSIONS: The concurrent use of WALANT and minor field sterility has created a hand surgery practice that is cost-effective for the patient and the facility and resulted in excellent patient outcomes and satisfaction.

The role of corneal stroma: A potential nutritional source for the cornea.

Corneal stroma plays a pivotal role in normal visual function. Anatomically, it is located between the outer epithelium and the inner endothelium and is the thickest layer of the cornea. Keratocytes in the stroma produce a variety of cellular products, including growth factors/cytokines, extracellular matrix (ECM) components, and kinases. These products support normal corneal development and homeostasis.

Harvesting bone graft from the olecranon: a quantitative and biomechanical comparison of proximal and dorsal cortical windows.

We conducted a study to compare 2 techniques of harvesting ulna bone graft from the olecranon, one using a proximal cortical window (PCW), the other using a dorsal cortical window (DCW), in terms of cancellous bone graft quantity and ulna fracture strength after graft harvest. Cancellous bone was harvested from 8 pairs of embalmed cadaver proximal ulna. Each side of a matched pair was randomly assigned to graft harvest using either a PCW or a DCW approach. Packed bone volume (PBV) was determined by placing the harvested bone into a 3-mL syringe and compacting it with a quasi-static 25-N load. Biomechanical cantilever bending was performed on each elbow to determine load at failure (LF). Paired Student t tests were used to compare PBV and LF between the experimental and control groups. The graft PBV obtained from the matched-pair specimens was not statistically different between the PCW and DCW approaches. Ulnas subjected to proximal bone harvest exhibited higher LF than ulnas subjected to dorsal bone harvest, though the difference was not statistically significant. Compared with bone graft harvest using the traditional DCW approach, harvest using a PCW approach provides similar cancellous graft amounts and exhibits similar fracture resistance.

Empirically identified goals for the management of unexplained symptoms.

BACKGROUND AND OBJECTIVES: Effective management of patients with medically unexplained symptoms may be influenced by physicians' goals. This study's objective was to identify physicians' goals for managing primary care patients with unexplained symptoms. METHODS: This was a qualitative study of patients and clinicians from primary care clinics in Iowa and Illinois. Interviews were conducted with 47 patients who had unexplained symptoms and the 36 primary care clinicians who managed them. The interviews were transcribed and coded independently by two investigators. Categories for coding responses were derived from the data and the literature. RESULTS: Eleven goals were identified and grouped into four classes based on whether they were disease centered, patient centered, society centered, or clinician centered. The three goals most commonly held by patients were patient centered: clinician support (62%), functional improvement (45%), and patient coping (43%). The most common clinician goals were symptom alleviation (38%), patient coping (32%), and functional improvement (30%). Only one clinician (2%) cited making the patient feel supported as a goal. CONCLUSIONS: The goals of clinician support and patient coping appear to have value to patients beyond being means for achieving symptom alleviation. Although receiving physician support is an important goal for patients, it was not a commonly recognized goal by physicians. Clearly identified management goals may improve the care of patients with medically unexplained symptoms and help clinicians achieve greater satisfaction with the management of these patients.

Total wrist arthroplasty.

Total wrist arthroplasty preserves motion and improves hand function for daily tasks and lower-demand vocational and a vocational activities. It is often preferable to fusion when both wrists are arthritic. Newer prosthetic designs provide a functional range of motion, better wrist balance,reduced risk of loosening, and better implant stability than older designs. The success of total wrist arthroplasty depends on appropriate patient selection, careful preoperative planning, and sound surgical technique.

Excision of heterotopic ossification of the popliteal space following traumatic brain injury.

The occurrence of heterotopic ossification (HO) in traumatic brain injury (TBI) patients has been well described. A 20-year-old male with a fixed knee flexion contracture of 45 degree underwent side excision of heterotopic bone from the popliteal region 17 weeks following a TBI. This case is presented not only for being unique in the location of HO requiring excision but also to emphasize the importance of the awareness of the potential for HO formation in the TBI patient.