Radiographic Edema Is a Predictor of de Quervain's Tenosynovitis.

Background de Quervain's tenosynovitis (DeQ) is a clinical diagnosis; however, due to the symptom overlap with other pathologies, it can occasionally be challenging to make an accurate diagnosis, especially for nonorthopaedic trained physicians. Questions/Purposes We hypothesized that the ratio of radial-sided to ulnar-sided soft tissue swelling could serve as a universally accessible diagnostic tool to assist in differentiating DeQ from other upper extremity conditions. Patients and Methods We retrospectively identified patients with isolated DeQ (M65.4), thumb carpometacarpal arthritis (M18.X), or carpal tunnel syndrome (G56.0x) between 2018 and 2019. Five blinded, independent reviewers evaluated anterior-posterior radiographs of the affected wrist. A digital caliper was used to measure the shortest distance from the lateral cortex of the distal radius and the medial cortex of the distal ulna to the outer edge of the radial and ulnar soft tissue shadows, respectively. Results The mean radial:ulnar ratio in the DeQ group was significantly larger than in the control groups. The interclass correlation coefficient showed strong agreement between all measurements. Patients with a radial:ulnar ratio of 1.7 or higher had a 61% chance of having DeQ with a 56.5% sensitivity, 66.3% specificity, 59.3% positive predictive value (PPV), and 63.8% negative predictive value. A ratio of more than 2.5 correlates to a 55% chance of having DeQ with a sensitivity of 12.9%, specificity of 96.9%, and PPV of 78.6%. Conclusion The ratio of radial- to ulnar-sided wrist edema can be used as a novel diagnostic aid in DeQ, especially for those not trained in orthopaedics or hand surgery. Level of Evidence Level IV, diagnostic study.

Screw Position Following Percutaneous Versus Mini-Open Intramedullary Retrograde Screw Fixation of Metacarpal Fractures.

BACKGROUND: Metacarpal fracture fixation using the retrograde intramedullary screw technique can be performed through two different approaches. The mini-open approach requires greater soft tissue dissection but allows for direct visualization of the metacarpal head compared with the percutaneous approach. Our aim was to determine which approach resulted in optimal screw position. METHODS: Eighty-one consecutive patients that underwent intramedullary screw fixation for metacarpal fractures from 2016 to 2021 were identified. Patients were treated by 4 fellowship-trained orthopedic hand surgeons who employed the mini-open or percutaneous approach. Postoperative radiographs were reviewed for screw position. RESULTS: A total of 81 patients (41 mini-open, 40 percutaneous) were included in this study. There were no significant differences between the two groups in age, sex, hand dominance, or affected digit. Postoperative screw position at first postoperative visit was not significantly different between the two groups on anteroposterior or lateral radiographs. CONCLUSION: Postoperative screw position is not significantly different between the mini-open and percutaneous approaches for intramedullary screw fixation of metacarpal fractures. LEVEL OF EVIDENCE: Level III, therapeutic.

Metacarpal Shortening with Intramedullary Screw Fixation: A Cadaveric Study.

Background Intramedullary screw fixation is a commonly used technique for the management of metacarpal fractures. However, compression across the fracture site can lead to unintentional shortening of the metacarpal. Questions/Purposes Our aim was to evaluate the risk of overshortening with differing intramedullary device designs for fixation of metacarpals. Methods The small finger metacarpal of nine fresh-frozen cadavers were included. A metacarpal neck fracture was simulated with a 5-mm osteotomy. Three different intramedullary screw designs were compared. Each screw was placed in a retrograde fashion into the intramedullary canal and the amount of shortening measured. Screws were reversed and the number of reverse turns with the screwdriver needed to release overshortening were measured. Results The average shortening at the osteotomy site was 2.5 mm. The mean shortening was 80%, 58%, and 12% for the partially threaded screw, fully threaded screw, and threaded nail, respectively. The mean differences of the distance shortened were statistically significant for the threaded nail compared with the partially and fully threaded screws. The partially threaded screw had the most shortening, while the threaded nail provided the least amount of shortening. When the screws were reversed, the screws did not disengage until the screw was fully removed from the osteotomy site. Conclusion The fully threaded nail demonstrates less shortening and possibly minimizes overshortening of fractures compared with partially threaded and fully threaded screw designs. Overshortening cannot be corrected by unscrewing the screw unless completely removed from the distal fragment. Clinical Relevance Orthopaedic surgeons may select intermedullary screws based on the design that is suited for the particular metacarpal fracture pattern.

Use of Telemedicine Among Hand Surgeons and Their Patients.

PURPOSE: Initially designed to address geographic obstacles to patient care, reliance on telemedicine rapidly increased during the coronavirus pandemic. The purpose of this study was to analyze the proficiency of computer and mobile device usage among a cohort of surgeons and their patients who either used telemedicine or had in-person visits. METHODS: We retrospectively identified patients who had an outpatient telemedicine visit (T group), or in-person visit (NT group) with a hand and wrist orthopedic surgeon, between March 2020 and July 2020. These patients and their surgeons were sent the Computer Proficiency Questionnaire (CPQ-12) and the Mobile Device Questionnaire (MDPQ-16) via email. A total of 602 survey responses were collected, 279 of which belonged to patients in the T group and 323 to patients in the NT group. RESULTS: The two groups were similar in demographics, including age and sex. Scores on the CPQ-12 and MDPQ-16 did not significantly differ between the two groups. In the patient sample, there was no correlation between CPQ-12 and MDPQ-16 scores and the proportion of telehealth visits. The orthopedic surgeon group also had no observed correlation between the CPQ-12 and MDPQ-16 scores and number or proportion of telemedicine visits. CONCLUSIONS: Overall proficiency with computer and mobile devices was not correlated with the likelihood of patients or orthopedic surgeons using telemedicine visits. Patient selection appears to be driven by other factors, which could include limitations in transportation, convenience, and time constraints. CLINICAL RELEVANCE: Orthopedic surgeons should continue to offer telehealth visits to their patients regardless of estimated capabilities with electronic devices of both the patient and the surgeon.

Risk of noise-induced hearing loss in the spine surgeon.

Background: Occupation-related noise-induced hearing loss (NIHL) has both negative economic and quality of life implications. The risk spine surgeons undertake in regards to NIHL during operative intervention is unknown. Governing bodies, including the National Institute for Occupational Safety and Health, have recommended exposure limits not to exceed 85 decibels (dB) over 8 hours. The purpose of this study is to characterize noise exposure to spine surgeons in the operating room (OR). Methods: Prospective collection of intraoperative recordings of spinal surgeries (cervical and thoracic/lumbar) was undertaken. Data gathered included procedure, operative duration, presence of background music, and noise information. Noise information included maximum decibel level (MDL), Peak level (LCPeak), Equivalent continuous sound pressure level, time weighted average (TWA), dose, and projected dose. Noise measurements were compared with baseline controls with and without music (empty ORs). Results: Two hundred seven noise recordings were analyzed. One hundred eighteen of those being spinal surgeries, 49 baseline recordings without music, and 40 with music. Maximum decibel level reached a maximum value of 111.5 dBA, with an average amongst surgical recordings of 103 dBA. Maximum decibel level exceeded 85 dBA in 100% of cases and was greater than 100 dBA in 78%. The maximum LCPeak recorded was 132.9 dBC with an average of 120 dBC. Furthermore, the average dose was 7.8% with an average projected dose of 26.5%. The highest dose occurred during a laminectomy at 72.9% of daily allowable noise. Maximum projected dose yielded 156% during a 3-level anterior cervical discectomy and fusion. Conclusions: Spine surgeons are routinely exposed to damaging noise levels (>85 dBA) during operative intervention. With spine surgeons often performing multiple surgeries a day, the cumulative risk of noise exposure cannot be ignored. The synergistic effects of continuous and impact noise places spine surgeons at risk for the development of occupation-related NIHL.

Routine Preoperative Dental Clearance for Total Joint Arthroplasty: Is There a Benefit?

Background Periprosthetic joint infections (PJIs) place significant psychological and financial burdens on patients and healthcare systems. One measure to reduce the risk of PJIs is preoperative dental screening, for which there is no current consensus recommendation. This study aims to determine whether there is a difference in the rate of PJI and microorganism profile in patients who did and did not obtain preoperative dental clearance. Methodology A retrospective review was conducted among patients undergoing primary total hip arthroplasty and total knee arthroplasty from 2017 to 2021. A cohort of 8,654 patients who underwent routine dental clearance was matched with a cohort of patients who did not. Surgeons who changed their dental clearance protocol were also identified, and the rates of PJIs were compared before and after. Results No statistically significant difference was seen in the rate of PJIs between patients who did and did not undergo routine preoperative dental clearance. No statistically significant difference was seen in the rate of PJIs before and after for surgeons who changed their dental clearance protocol. The microorganism profile between the groups was also found to be without differences. Conclusions Eliminating dental clearance from routine preoperative clearance does not appear to increase the rates of acute PJIs following elective total joint arthroplasty (TJA) or to change the organism profile of the infections that did occur. It may be reasonable to not require routine preoperative dental clearance or to practice selective dental clearance in patients undergoing elective TJA, especially given the increased financial cost and delay in care experienced by patients.

A Video Teaching Tool Is Effective for Training Residents in Hip Arthroplasty Templating.

Work hour restrictions imposed on orthopedic surgery residents since the early 2000s have reduced educational opportunities at the workplace and encouraged alternative strategies for teaching outside the clinical setting. Preoperative templating is essential for safe and effective total hip arthroplasty (THA) and is accurate in predicting final implants. We sought to determine the effectiveness of a video tool for teaching orthopedic residents basic THA templating skills. We developed a video-based teaching tool with instructions on proper THA templating techniques. Ten cases were selected for testing, after excluding patients with severe hip deformities and poor-quality radiographs and only retaining those with concordance between templating by the senior authors and implanted components. The study subjects included three postgraduate year 1 (PGY-1), three PGY-2, and three PGY-5 residents, and three adult reconstruction fellows (PGY-6). Templating skills were assessed before and after watching the instructional video. The evaluation included the size and positioning of femoral and acetabular components, as well as the restoration of leg length. Each templating session was repeated twice. Variance was measured to evaluate consistency in measurements. A linear mixed model and F-test were used for statistical analyses. The number of years in training significantly affected performance prior to exposure to the instructional video. Post-exposure, there was a significant improvement in the accuracy of sizing and positioning of acetabular and femoral components for PGY-1, PGY-2, and PGY-5 residents. The results achieved were comparable to PGY-6 examiners, who did not gain substantial performance benefits from the instructional video. Limb length restoration was less affected by experience or exposure to the video. Component positioning and sizing, as well as leg length discrepancy (LLD), showed a significant decrease in variance after the intervention in all study groups. Video learning is reliable in teaching invaluable skills to orthopedic surgery residents without encroaching on work hours. We conceived a concise video to train orthopedic residents to perform THA templating with proper technique and demonstrated its efficiency and reproducibility.

Swelling, Stiffness, and Dysfunction Following Proximal Interphalangeal Joint Sprains.

PURPOSE: Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain. METHODS: This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy. RESULTS: Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of 10. CONCLUSIONS: It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Systemic Manifestation of Periprosthetic Joint Infection Is Associated With Increased In-Hospital Mortality.

Introduction Periprosthetic joint infection (PJI) is one of the most devastating complications of total joint arthroplasty. Systemic symptoms of infection may indicate a patient who is at a higher risk of serious complications. The goal of this study was to determine if systemic symptoms of infection in the setting of PJI were associated with greater in-hospital mortality. Materials and methods We used our institutional database to identify all patients urgently treated for deep PJI from 2002-2012. Records were reviewed to collect demographics, surgical data, vital signs prior to surgical intervention, blood and intraoperative culture results, preoperative intensive care unit (ICU) admissions, and deaths that occurred during the hospital admission. Patients were classified as having systemic inflammatory response syndrome (SIRS) based on the criteria established by the American College of Chest Physicians and the Society of Critical Care Medicine. Results During the 10-year timeframe of our study, 484 patients were treated emergently for deep infection, with 130 (27%) meeting SIRS criteria preoperatively and 31 (6%) of the patients with SIRS having positive blood cultures. Patients with positive blood cultures and SIRS demonstrated a higher in-hospital mortality rate (p < 0.001). Neither SIRS nor SIRS with positive blood cultures were associated with ICU admission. Discussion Occasionally, PJI can spread beyond the affected joint, showing physical symptoms of systemic illness and bacteremia. This study demonstrates that patients with SIRS and positive blood cultures are at an increased risk of in-hospital mortality. These patients should be monitored closely before definitive treatment in order to minimize their mortality risk.

Perianal basosquamous carcinoma treated with radiation therapy, a case report.

Background: Perianal basal cell carcinoma (BCC) is very rare and estimated to account for 0.08% of all BCC and 0.02% of all anorectal neoplasms. Perianal lesions are more likely to be squamous cell carcinoma (SCC) as BCC usually develops on areas of skin exposed to ultraviolet (UV) light such as the face and arms. Proper diagnosis with the assistance of immunohistochemistry (IHC) stains to distinguish the two entities can help inform the suitable course of treatment. Case Description: Our case is an 82-year-old male with a history of cutaneous BCC on the arms and trunk presenting with a symptomatic perianal lesion. Initial biopsy demonstrated BCC with subsequent IHC studies differentiating from basaloid SCC. Standard treatment includes wide local excision (WLE) but given his poor performance status, radiation only was recommended. He was successfully treated and tolerated 30 Gy in 5 daily fractions. Conclusions: Radiation only is a unique and feasible non-surgical treatment for basosquamous carcinoma of the anus.

Outcomes After Surgically Managed Oblique Extra-Articular Proximal Phalanx Fractures: A Comparison of Closed-Reduction Percutaneous Pinning and Open-Reduction Internal Fixation With Lag Screws.

BACKGROUND: Long oblique extra-articular proximal phalanx fractures are common orthopedic injuries. When unstable and without substantial comminution, treatment options include closed-reduction percutaneous pinning (CRPP) and open-reduction internal fixation using lag screws (ORIF-screws). The aims of this study are primarily to compare the functional outcomes and complication rates between these techniques and secondarily to assess potential factors affecting outcomes after surgery. METHODS: All patients with long oblique extra-articular proximal phalanx fractures treated surgically within a single orthopedic institution from 2010 to 2017 were identified. Outcome measures and complications were assessed at the final follow-up. RESULTS: Sixty patients were included in the study with a mean time to the final follow-up of 41 weeks (range: 12-164 weeks). Thirty-four patients (57%) were treated with CRPP and 26 patients (43%) with ORIF-screws. The mean Disabilities of the Arm, Shoulder, and Hand score across both fixation types was 8 (range: 0-43) and did not differ significantly between the 2 groups. Mean proximal interphalangeal extension at the final follow-up was 9° short of full extension after CRPP and 13° short of full extension after ORIF-screws. The rates of flexion contracture and extensor lag were 15% and 41% in the CRPP group compared with 12% and 68% in the ORIF-screws group. Reoperation rates and complication rates did not differ significantly between fixation strategies. CONCLUSIONS: Acceptable outcomes can be achieved after surgical fixation of long oblique extra-articular proximal phalanx fractures using both CRPP and ORIF-screws. Extensor lag may be more common after ORIF-screws.

Efficacy of Waterproof Cast Protectors and Their Ability to Keep Casts Dry.

PURPOSE: The purpose of the study was to compare the efficacy of 6 different commercially available waterproof cast protectors in their ability to maintain a dry environment and evaluate whether cast protectors perform better than a plastic bag secured with tape in keeping casts dry. METHODS: We enrolled 23 adult participants to test 6 different commercially available cast protectors and a plastic bag. Participants trialed all cast protectors twice, with and without motion, by fully submerging each cast protector in water with a paper towel held between their index and middle fingers. Moisture accumulation within the cast protectors was estimated by the change in weight of paper towel. An analysis of variance test was performed to compare differences between cast protectors in their ability to maintain a dry internal environment. RESULTS: The plastic bag showed an average moisture accumulation of 5.50 g without motion compared with all other cast protectors, which had 0.0 g of moisture accumulation. One cast protector and the plastic bag had an average moisture accumulation of 0.46 g and 4.51 g with motion compared to all other cast protectors. The plastic bag was ranked the worst by 100% of participants. CONCLUSIONS: Cast protectors appear to offer superior protection from moisture compared with a plastic bag. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effect of Perioperative Corticosteroid Administration on Early Postoperative Range of Motion and Functional Outcomes Following Dupuytren's Fasciectomy.

BACKGROUND: The purpose of the study was to evaluate whether perioperative corticosteroid (CS) administration improves early postoperative range of motion (ROM) and function in patients undergoing Dupuytren's fasciectomy. METHODS: We retrospectively identified 58 patients who underwent Dupuytren's fasciectomy by a single fellowship-trained orthopedic hand surgeon from 2016 to 2020. During this time period, 51 digits in 34 patients received a single intraoperative dose of 10 mg of intravenous dexamethasone followed by a 6-day oral methylprednisolone taper course (CS group), and 37 digits in 24 patients did not (control group). Postoperatively, all patients started hand therapy within 1 week of surgery. At 2 and 6 weeks, patients had ROM data and Disabilities of the Arm, Shoulder, and Hand (DASH) scores collected by a blinded hand therapist. Paired t tests were used to compare the change in ROM and DASH scores at weeks 2 and 6. RESULTS: The 2 cohorts had similar preoperative ROM. At 2 weeks postoperatively, the CS group had greater metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) flexion. There was no difference in MP, PIP, or DIP extension. At 6 weeks postoperatively, the CS group had greater PIP flexion. There was no difference between the groups in MP extension, MP flexion, PIP extension, DIP extension, or DIP flexion. Mean DASH scores were significantly lower in the CS group at weeks 2 and 6. There were no postoperative deep infections or complications requiring surgery in either group. CONCLUSION: Perioperative CS administration appears to be safe and to improve early ROM and DASH scores following Dupuytren's fasciectomy.

Risk of Noise-Induced Hearing Loss for Orthopaedic Surgeons.

BACKGROUND: Noise-induced hearing loss (NIHL) affects the ability of an individual to communicate and can negatively impact quality of life. The risk to orthopaedic surgeons of developing NIHL as a result of occupational exposures in the operating room (OR) is currently unknown. Hearing protection is recommended for levels of >85 decibels (dB), irrespective of length of exposure. The primary goal of the present study was to determine whether orthopaedic surgeons are exposed to harmful noise levels in the OR that puts them at risk for developing NIHL. METHODS: A prospective review was conducted with use of intraoperative audio recordings across 6 orthopaedic subspecialties. Recordings were made in ORs prior to the surgical start time to serve as baseline controls. Decibel levels were reported as the maximum dB level (MDL), defined as the highest sound pressure level during the measurement period, and as the time-weighted average (TWA), defined as the average dB level projected over an 8-hour time period. Noise doses were reported as the percentage of maximum allowable daily noise (dose) and as the measured dose projected forward over 8 hours (projected dose). RESULTS: Three hundred audio recordings were made and analyzed. The average MDL ranged from 96.9 to 102.0 dB, with noise levels for all subspeciality procedures being significantly greater compared with the control recordings (p < 0.001). Overall, MDLs were >85 dB in 84% of cases and >100 dB in 35.0% of cases. The procedure with the highest noise dose was a microdiscectomy, which reached 11.3% of the maximum allowable daily noise and a projected dose of 104.1%. Among subspecialties, adult reconstruction had the highest dose and projected dose per case among subspecialties. CONCLUSIONS: The present results showed that orthopaedic surgeons are regularly exposed to damaging noise levels (i.e., >85 dB), putting them at risk for permanent hearing loss. Further investigation into measures to mitigate noise exposure in the OR and prevent hearing loss in orthopaedic surgeons should be undertaken. CLINICAL RELEVANCE: Orthopaedic surgeons are at risk for NIHL as a result of occupational exposures in the OR.

Household Transmission of Group A Streptococcus Necrotizing Fasciitis.

A healthy 40-year-old woman was diagnosed with necrotizing fasciitis 2 days after her husband's death from the same infectious process. Prompt identification and immediate surgical intervention prevented a similar result in this patient. Additional investigation into both patients' medical records found the inciting organism to be group A streptococcus. Although the exact mechanism of inoculation is unknown, the spread of this infection within a household prompts the question of whether antibiotic prophylaxis should be given among close contacts in future cases of necrotizing fasciitis.

Late Femoral Component Revision for Femoral Canal Perforation.

Femoral perforation during total hip arthroplasty is a rare complication. Most of the existing literature regarding the complication involves acutely recognized perforations. We report a case of femoral component revision for a symptomatic femoral perforation 12 years after a primary cementless total hip arthroplasty. The revision allowed for intramedullary component positioning, restoration of femoral length and offset, pain relief, and functional improvement. While management of this complication is debatable, we recommend revision in order to avoid future complications and optimize patient outcomes.

Blocking Screw Technique for Maintaining Reduction during Intramedullary Screw Fixation of Oblique Metacarpal Fractures.

Intramedullary screw fixation provides a less-invasive means of surgically managing metacarpal fractures. While there are advantages to using this technique compared to CRPP and ORIF, disadvantages of intramedullary screw fixation include loss of reduction intraoperatively due to sagittal and coronal plane translation. The blocking screw technique has been previously described as a solution for this problem in intramedullary fixation of long bone fractures. We describe the blocking screw technique as applied to aid intramedullary screw fixation of metacarpals.

An Unusual Foreign Object Attached to a Child's Finger: Emergency Department Management and Subsequent Intervention.

ABSTRACT: Strangulation injuries due to foreign objects are uncommon presentations of hand and finger injuries presenting to the emergency department (ED). Ring avulsion and hair tourniquet injuries are more commonly recognized mechanisms of strangulation, and algorithms for subsequent management and emergent treatment exist for these injuries. It is important to distinguish between hand injuries that can be managed in the setting of the ED and those that need emergent surgical management upon patient presentation. Nonemergent presentations of finger injuries include metallic bands or other objects trapped on digits without signs of neurovascular compromise. A 2-year-old girl presented to our ED with her right index finger trapped within a stainless steel salt shaker (2.55 in. H × 3.5 in. W × 4.9 in. D). The distal aspect of the digit was unable to be visualized, and communication with the patient was difficult secondary to distress and young age. Multiple attempts were made to remove the object in the ED by multiple health care providers, when concern for degloving injury prompted the patient to be taken to the operating room for removal with an electric saw by the hand surgeon and orthopedic team.

Morbidity After Metal Allergy to a Total Ankle Implant.

Metal allergy to total ankle arthroplasty is rare but can be both an unpredictable and devastating complication. Current literature describing metal allergy in orthopaedics is limited with there being no report to date on metal allergy after total ankle arthroplasty. Our patient underwent a total ankle arthroplasty and developed a diffuse rash 7 weeks postoperatively. The patient then tested positive for a metal allergy and ultimately was converted to an arthrodesis. In the setting of postoperative pain, swelling, erythema, or rash, it is important that metal allergy be on the differential diagnosis. Interestingly, when the patient here underwent allergy testing, only the articulating sides of the implant caused a positive reaction. Thus, allergy testing of both the articular and nonarticular sides of the component is of the utmost importance, as evidenced by the discrepancy found in this case.Levels of Evidence: Level IV: Case report.