Influence of health insurance on withdrawal of life sustaining treatment for patients with isolated traumatic brain injury: a retrospective multi-center observational cohort study.

BACKGROUND: Healthcare inequities for patients with traumatic brain injury (TBI) represent a major priority area for trauma quality improvement. We hypothesized a relationship between health insurance status and timing of withdrawal of life sustaining treatment (WLST) for adults with severe TBI. METHODS: This multicenter retrospective observational cohort study utilized data collected between 2017 and 2020. We identified adult (age ≥ 16) patients with isolated severe TBI admitted participating Trauma Quality Improvement Program centers. We determined the relationship between insurance status (public, private, and uninsured) and the timing of WLST using a competing risk survival analysis framework adjusting for baseline, clinical, injury and trauma center characteristics. Multivariable cause-specific Cox regressions were used to compute adjusted hazard ratios (HR) reflecting timing of WLST, accounting for mortality events. We also quantified the between-center residual variability in WLST using the median odds ratio (MOR) and measured insurance status association with access to rehabilitation at discharge. RESULTS: We identified 42,111 adults with isolated severe TBI treated across 509 trauma centers across North America. There were 10,771 (25.6%) WLST events in the cohort and a higher unadjusted incidence of WLST events was evident in public insurance patients compared to private or uninsured groups. After adjustment, WLST occurred earlier for publicly insured (HR 1.07, 95% CI 1.02-1.12) and uninsured patients (HR 1.29, 95% CI 1.18-1.41) compared to privately insured patients. Access to rehabilitation was lower for both publicly insured and uninsured patients compared to patients with private insurance. Accounting for case-mix, the MOR was 1.49 (95% CI 1.43-1.55), reflecting significant residual between-center variation in WLST decision-making. CONCLUSIONS: Our findings highlight the presence of disparate WLST practices independently associated with health insurance status. Additionally, these results emphasize between-center variability in WLST, persisting despite adjustments for measurable patient and trauma center characteristics.

Scoliosis in osteogenesis imperfecta: results of posterior spinal fusion in 39 patients.

PURPOSE: To evaluate the outcomes of scoliosis corrective surgery in Osteogenesis Imperfecta (OI) patients with primarily pedicles screw fixation in terms of correcting and maintaining the correction of the spinal deformity, and to assess for several peri-operative parameters and complications associated with this surgical treatment. METHODS: Retrospective case series of 39 consecutive patients with OI treated surgically for scoliosis. The surgeries were performed between 2002 and 2020 by three different surgeons. All patients' medical peri-operative and post-operative charts were evaluated. Radiological assessment was performed by evaluation of the pre-operative, immediate post-operative and last follow-up plain radiographs. RESULTS: There were 20 females and 19 males included in this review with a mean age of 14 years (range, 6-20 years) at the time of surgery. The median follow-up time was 7.9 years. The mean pre-operative cobb angle (CA) of the major curve was 76.5 degrees (SD ± 18.9), decreasing to 42.6 (SD ± 17.4) in the long-term post-operative follow-up (P < 0.001). A total of 21 adverse events in 16 patients were noted. Only 4 patients required subsequent invasive surgical treatment or prolonged hospital stay. All other patients were treated conservatively with no lasting complication. CONCLUSION: Scoliosis surgical correction in OI patients seems to yield acceptable results, with maintained coronal plane surgical correction in the long-term follow-up. Even though a high peri-operative complications rate is observed in this series, there were no long-term sequelae or lasting complications. LEVEL OF EVIDENCE: Level IV, Case series.

Is Tension Band Wire Fixation Superior to Plate Fixation for Simple Displaced Olecranon Fractures? A Randomized Trial With Median Follow-up of 7.5 Years.

BACKGROUND: Surgeons disagree about the best surgical treatment for simple, displaced olecranon fractures. Although the tension band wiring technique and plate fixation are the most common surgical options for fixation, studies comparing both are limited. To date, there have been no randomized trials comparing patient-reported outcomes and complications at more than 5 years of follow-up. QUESTIONS/PURPOSES: (1) Does tension band wiring or plate fixation result in better ROM and patient-reported outcome scores for simple displaced olecranon fractures? (2) What is the risk of complications associated with each technique? METHODS: Between November 2012 and October 2017, 68 patients were treated for acute, displaced olecranon fracture in a hand and upper extremity surgery unit at a tertiary-care center. Patients 18 years or older with traumatic, nonpathologic, simple olecranon fractures who presented within 2 weeks of injury were considered potentially eligible. Based on that, 74% (50) of patients met the inclusion criteria; 16% (11) of patients declined to participate in the study, and another 10% (seven) were excluded because they did not meet the prespecified inclusion criteria. Patients were randomized on a 1:1 basis to either tension band wiring or plate fixation and were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after surgery. At the final follow-up interval, 16% (eight) were lost to follow-up: 4% (two) in the tension band wiring group and 12% (six) in the plate fixation group. The median follow-up time was 8 years (IQR 7 to 9 years). We evaluated complications at a minimum of 6 years after surgery. The primary outcome measure was the 1-year postoperative DASH score. Additional outcome measures included the patient-reported Oxford Elbow Score, ROM, and the proportion of patients in each group who reported hardware-related symptoms and had subsequent implant removal or postoperative infection. RESULTS: No differences were observed in the DASH score (tension band wiring 18 [range 3 to 65] versus plate fixation 24 [range 3 to 52], median difference -6 [95% CI -12.7 to 14.9]; p = 0.73), Oxford Elbow Score (tension band wiring 36 [range 10 to 48] versus plate fixation 39 [range 17 to 47], median difference -3; p = 0.53), or all ROM measurements (p > 0.05) between the groups at 1 year of follow-up. The odds of having surgery for symptomatic implant removal were lower for plate fixation than for tension band wiring (one of 19 versus eight of 23, OR 9.6 [95% CI 1.08 to 85.7]; p =0.02); the odds of infection, however, were higher in the plate group (three of 19 versus 0 of 23; p = 0.048). CONCLUSION: No differences were observed between the two techniques in terms of ROM or patient-reported outcomes. Surgeons should consider that although the risk of implant removal is higher in tension band wiring, patients older than 85 years undergoing plate fixation for simple olecranon fractures are at a greater risk of postoperative infection. LEVEL OF EVIDENCE: Level I, therapeutic study.

Lisfranc Injury Diagnosis: What Is the Diagnostic Reliability of New Radiographic Signs Using Three-dimensional CT?

BACKGROUND: Up to one-third of Lisfranc injuries (an injury affecting the normal stability, alignment, and congruency of the tarsometatarsal joints) are misdiagnosed. Delayed diagnosis and improper treatment may lead to long-term, irreversible sequela and functional disability. Recently, the employment of three-dimensional (3D) CT demonstrated higher diagnostic reliability, but there is limited evidence on this, and radiologic features of Lisfranc injuries when using this diagnostic modality are not well described. QUESTION/PURPOSE: What is the diagnostic performance of several novel radiographic signs on 3D CT when evaluating for Lisfranc injury, namely the Mercedes sign, the peeking metatarsal sign, and the peeking cuneiform sign, and what is the interobserver and intraobserver reliability of those diagnostic signs? METHODS: In this retrospective, diagnostic study, video clips of 3D CT reconstructions of 52 feet with intraoperatively confirmed Lisfranc injuries and 50 asymptomatic feet with a normal appearance of the tarsometatarsal joints, as ascertained by a subspecialty-trained foot and ankle surgeon and a musculoskeletal radiologist, were analyzed by two foot and ankle specialists and three orthopaedic residents twice each, with a washout period of 2 weeks. Among the 52 patients with intraoperative evidence of Lisfranc injury, there were 27 male patients and 25 female patients, with a median (IQR) age of 40 years (23 to 58); among the 50 controls, there were 36 male and 14 female patients, with a median age of 38 years (IQR 33 to 49). For each video clip, the presence of all three radiographic signs was documented (each sign was rated in a binary yes/no fashion). Before the evaluations, all observers underwent a short training session by the head of the foot and ankle department. Later, these reading were used to assess for the sensitivity, specificity, and area under the receiver operating characteristic curve in terms of Lisfranc diagnosis against the gold standard of intraoperative testing of tarsometatarsal joint stability. Intraoperatively, the congruency and stability of the second tarsometatarsal joint had been evaluated by direct visualization and by the insertion of a probe into the joint between the base of the second metatarsus and the medial cuneiform and twisting the probe to assess for stability. The individuals evaluating the video clips were unaware of the surgically obtained diagnosis at the time they performed their evaluations. RESULTS: All 3D radiographic signs that were examined had excellent diagnostic reliability in terms of sensitivity and specificity, ranging from 92% to 97% and from 92% to 93%, respectively. When assessing the association between the suggested 3D radiographic signs and Lisfranc injury diagnosis as a function of the area under the receiver operating characteristic curve, the Mercedes sign demonstrated a higher area under the curve than the other signs did (0.91 versus 0.87 versus 0.8; p < 0.001). The mean intraobserver and interobserver reliability (kappa) values were excellent for all 3D radiographic signs that were evaluated. CONCLUSION: The proposed radiographic findings demonstrated excellent diagnostic performance and were repeatable within and among observers. Three-dimensional CT radiographic signs could function as a valuable diagnostic tool for the evaluation and initial screening for Lisfranc injury in the acute injury phase because obtaining AP bilateral standing radiographs of the foot is often impractical in the acute setting. Further research and comparison with AP weightbearing radiographs of the bilateral feet may be warranted. LEVEL OF EVIDENCE: Level III, diagnostic study.

Individualized tibial tubercle-trochlear groove distance-to-patellar length ratio (TT-TG/PL) is a more reliable measurement than TT-TG alone for evaluating patellar instability.

PURPOSE: To evaluate the intra/inter-rater and diagnostic reliability of the sagittal plane adjusted patellar instability ratios (PIRs) compared to tibial tubercle-trochlear groove (TT-TG) distance alone while employing a matched case-control analysis for age and sex to minimize a potential confounding effect. METHODS: A retrospective case-control study was performed of all knee MRI studies of patients diagnosed with patellar instability, between 2005 and 2020 at a regional tertiary medical centre. Using a 1:1 case-control matching of sex and age at the time of the diagnosis, one control subject was assigned to each case of patellar instability. Measurements of TT-TG distance, sagittal patellar length (PL), sagittal patellar tendon length (PTL), TT-TG/PL ratio, and TT-TG/PTL ratio were conducted. Two orthopaedic surgery residents and a senior musculoskeletal radiologist were assigned to assess the intra- and inter-rater reliability. Inter-class coefficients were calculated (ICC). The receiver operating characteristic (ROC) curve and area under curve (AUC) for each parameter were compared to evaluate for diagnostic reliability. Odds ratios (OR) and their 95% confidence intervals (CI) were calculated and a multivariable logistic regression model was performed to control for possible confounders. RESULTS: The study included 324 individuals (162 case-control matched pairs). In terms of intra- and inter-rater reliability, TT-TG/PL and TT-TG/PTL ratios showed an excellent correlation within and between readers (TT-TG/PL; intra-rater ICC 0.94 and inter-rater ICC 0.92, TT-TG/PTL; intra-rater ICC 0.91 and inter-rater ICC 0.88). The ROC curve showed a slightly greater AUC of the TT-TG/PL ratio compared to TT-TG distance alone (0.75 vs 0.73, p < 0.001). When applying the pathologic cutoff of TT-TG ≥ 20 mm and TT-TG/PL ≥ 0.5; the calculated odds ratios for the above cutoff were as follows; TT-TG distance alone had an OR of 14 (95% CI 1.8-106.5, p = 0.011) and OR for TT-TG/PL ratio was 23 (95% CI 3.1-170.3, p = 0.002). In the multivariable analysis, while controlling for height and weight, only the association between TT-TG/PL ratio and patellar dislocation remained statistically significant with an adjusted OR of 2.7 (CI 1.3-5.4, p = 0.006), compared to TTTG distance alone (OR = 1.9, n.s.). CONCLUSIONS: Patellar instability ratios are significantly more reliable compared to TT-TG distance alone for the evaluation of patellar instability. Patellar instability ratios present superior diagnostic reliability, sensitivity and specificity, and intra\inter rater reliability. Thus, patellar instability ratios could function as a valuable diagnostic tool for the evaluation of patellar instability. LEVEL OF EVIDENCE: III.

Lower Extremity Amputee Outcomes with Reference to Co-morbidities.

BACKGROUND: Lower extremity amputation related to diabetes is a serious outcome, which can have devastating effects on the patient and family. The epidemiology of amputations has recently been used as a possible measure of the adequacy of medical prevention and treatment of diabetes and diabetic foot complications. OBJECTIVES: To report on patients undergoing amputations at one medical center in Israel, their co-morbidities, and the outcomes. METHODS: A retrospective chart study was conducted of amputees operated between 1 September 2017 and 30 September 2018. RESULTS: The study population comprised 72 patients who had major amputations for diabetes and/or ischemia, mean age 72 ± 10 years, 74% males, 93% with type 2 diabetes. Mean age corrected Charlson Comorbidity Index was 8.2 ± 2.1 with 90% (65 patients) presenting with a score of 6 or higher. Before the recent deterioration, fewer than 20% of the patients exited their home routinely and 24% had an official diagnosis of dementia. There were 31 below knee amputations (BKA) and 41 above knee amputations (AKA). The 30-day, 3-month, 1-year, and 2-year mortality rates were 15.3%, 27.8%, 43.1%, and 54.2% respectively. Median survival period was 20 months. Survival after AKA was 13.4 ± 20, which was significantly less than after BKA (25.4 ± 2.7, P = 0.097). CONCLUSIONS: Factors other than the quality of management of patients with diabetes and complications may contribute to amputation rates; thus, making speculations from international comparisons of raw amputation rates problematic. This population was less healthy than reported in most studies.

Neck of femur fractures treated with the femoral neck system: outcomes of one hundred and two patients and literature review.

INTRODUCTION: The recently developed femoral neck system (FNS) for treatment of femoral neck fractures (FNF), comprises theoretical biomechanical advantages compared to other implants. The aim of this study was to validate the safety and to report outcomes of patients treated with the FNS. METHOD: A retrospective multicentric analysis of patients treated by FNS with a minimum of three months of follow-up. Details analysed from three medical centres were operative duration, estimated blood loss, initial hospitalisation duration, fixation quality as well as complications and reoperation rate. Patients who had revision surgery were compared to all other patients to identify risk factors for failure. In addition, a literature review was performed to analyse data on FNS clinical implementation and patient's outcomes. The two data sets were combined and analysed. RESULTS: One-hundred and two patients were included in this study cohort with an average follow-up of seven months (range 3-27). Ten papers were included in the literature review, reporting data on 278 patients. Overall, 380 patients were analysed. Average age was 62.6 years, 52% of the fractures were classified as Gardens 1-2. Overall, the revision rate was 9.2% (14 patients diagnosed with cut-out of implant, 10 with AVN, 8 with non-union and 8 with hardware removal). For the 102 patients in the cohort risk factors for reoperation included patients age, surgeon seniority and inadequate placement of the implant. CONCLUSION: This study shows that FNS is a safe treatment option for FNF. Intra-operative parameters and failure rates are comparable to previously reported rates for this implant and other frequently used implants.

Delivery mode and future infectious morbidity of the offspring: a sibling analysis.

PURPOSE: Cesarean delivery (CD) has been recently suggested to be associated with offspring's long-term health implications. We aimed to investigate the association between delivery mode and long-term infectious morbidity of the offspring while employing sibling matched analysis to maximize confounder control. METHODS: A retrospective population-based cohort study was performed, which included all sibling deliveries occurring between 1991 and 2014 at a regional tertiary medical center. Offsprings were followed up until the age of 18 years. The study included 13,516 individuals (6758 sibling pairs): the first born was via vaginal delivery and the second via CD. Each siblings pair was considered a matched set, with the aim to perform a within-family analysis. A Kaplan-Meier survival curve was used to compare the cumulative infectious morbidity incidence and a multivariable Cox survival hazards regression model to control for confounders. RESULTS: Crude rates of total infectious hospitalizations were found to be significantly higher in the CD group (OR 1.25; 95% CI 1.12-1.40). Specifically, bronchiolitis (OR 2.02, 95% CI 1.56-2.63), otitis (OR 1.52, 95% CI 1.21-1.9), and gastroenteritis (OR 1.41, 95% CI 1.05-1.9) were all found to be significantly more common in the CD group. The survival curve demonstrated significantly higher cumulative infection-related hospitalization rates in the CD group (log-rank p < 0.001). The Cox model, adjusted for several confounders, confirmed the significant association between CD and offspring's infection-related morbidity (adjusted HR 1.25; 95% CI 1.02-1.53). CONCLUSION: CD appears to be independently associated with later offspring infection-related morbidity, even while rigorously adjusting for confounders.

Unusual Presentation of Hip Pain in a Pregnant Woman Due to Bilateral Cervical Neck Stress Fractures: A Case Report.

CASE: We present an unusual case of bilateral femoral neck fatigue fractures in a 28-year-old pregnant woman at the 18th week of gestation successfully treated through operative intervention involving consecutive total hip arthroplasty and internal fixation within the same procedure, resulting in favorable clinical outcomes. CONCLUSION: Current clinical practices suggest that a restricted use of plain radiographs, even those involving the pelvis in pregnant women carries a minimal risk to the fetus and is not contraindicated. Magnetic resonance imaging proved valuable for differential diagnosis, contrasting with sonography.

Quantifying the Association Between Surgical Spine Approach and Tracheostomy Timing After Traumatic Cervical Spinal Cord Injury.

BACKGROUND AND OBJECTIVES: Recent evidence suggests earlier tracheostomy is associated with fewer complications in patients with complete cervical spinal cord injury (SCI). This study aims to evaluate the influence of spine surgical approach on the association between tracheostomy timing and in-hospital adverse events treating patients with complete cervical SCI. METHODS: This retrospective cohort study was performed using Trauma Quality Improvement Program data from 2017 to 2020. All patients with acute complete (American Spinal Injury Association-A) cervical SCI who underwent tracheostomy and spine surgery were included. Tracheostomy timing was dichotomized to early (within 1 week after surgery) and delayed (more than 1 week after surgery). Primary outcome was the occurrence of major in-hospital complications. Secondary outcomes included occurrences of immobility-related complications, surgical-site infection, hospital and intensive care unit length of stay, and time on mechanical ventilation. RESULTS: The study included 1592 patients across 358 trauma centers. Mean time to tracheostomy from surgery was 8.6 days. A total of 495 patients underwent anterior approach, 670 underwent posterior approach, and 427 underwent combined anterior and posterior approach. Patients who underwent anterior approach were significantly more likely to have delayed tracheostomy compared with posterior approach (53% vs 40%, P < .001). Early tracheotomy significantly reduced major in-hospital complications (odds ratio 0.67, 95% CI 0.53-0.84) and immobility complications (odds ratio = 0.78, 95% CI 0.6-1.0). Those undergoing early tracheostomy spent 6.0 (95% CI -8.47 to -3.43) fewer days in hospital, 5.7 (95% CI -7.8 to -3.7) fewer days in the intensive care unit, and 5.9 (95% CI -8.2 to -3.7) fewer days ventilated. Surgical approach had no significant negative effect on the association between tracheostomy timing and the outcomes of interest. CONCLUSION: Earlier tracheostomy for patients with cervical SCI is associated with reduced complications, length of stay, and ventilation time. This relationship appears independent of the surgical approach. These findings emphasize that tracheostomy need not be delayed because of the SCI treatment approach.

Contemporary trends in the incidence and timing of spinal metastases: A population-based study.

Background: Spinal metastases are a significant complication of advanced cancer. In this study, we assess temporal trends in the incidence and timing of spinal metastases and examine underlying patient demographics and primary cancer associations. Methods: In this population-based retrospective cohort study, health data from 2007 to 2019 in Ontario, Canada were analyzed (n = 37, 375 patients identified with spine metastases). Primary outcomes were annual incidence of spinal metastasis, and time to metastasis after primary diagnosis. Results: The age-standardized incidence of spinal metastases increased from 229 to 302 cases per million over the 13-year study period. The average annual percent change (AAPC) in incidence was 2.2% (95% CI: 1.4% to 3.0%) with patients aged ≥85 years demonstrating the largest increase (AAPC 5.2%; 95% CI: 2.3% to 8.3%). Lung cancer had the greatest annual incidence, while prostate cancer had the greatest increase in annual incidence (AAPC 6.5; 95% CI: 4.1% to 9.0%). Lung cancer patients were found to have the highest risk of spine metastasis with 10.3% (95% CI: 10.1% to 10.5%) of patients being diagnosed at 10 years. Gastrointestinal cancer patients were found to have the lowest risk of spine metastasis with 1.0% (95% CI: 0.9% to 1.0%) of patients being diagnosed at 10 years. Conclusions: The incidence of spinal metastases has increased in recent years, particularly among older patients. The incidence and timing vary substantially among different primary cancer types. These findings contribute to the understanding of disease trends and emphasize a growing population of patients who require subspecialty care.

Validation of Becton Dickinson Barricor™ tubes for use with Abbott Alinity™ and Siemens Atellica® highly sensitive cardiac troponin I measuring systems.

BACKGROUND: BD Barricor™ tubes have been proposed to decrease laboratory turnaround time (TAT). We analytically validated and then clinically verified these tubes for use with Abbott Alinity™ and Siemens Atellica® highly sensitive cardiac troponin I (hs-cTnI) assays. METHODS: hs-cTnI measurements were undertaken in paired Barricor™ and in-use PSTII™ tubes on both systems. 359 matched samples with hs-cTnI levels between 3 and 15,000 ng/L (Atellica® values) were used to assess the hemolysis rate and make method comparisons. 599 paired patient samples were collected on emergency department (ED) admission to compare the performance of the rapid acute myocardial infarction (AMI) rule-out strategy based on hs-cTnI concentrations lower than recommended thresholds (<4 ng/L Alinity™; <5 ng/L Atellica®) when different tubes and systems were employed. RESULTS: No between-tube differences in hemolysis rate were seen when free hemoglobin concentrations in plasma samples were ≥0.25 g/L, even if PSTII™ showed a significant increase of hemolysis rate vs. Barricor™ (31% vs. 22%, p=0.007) when a lower cut-off for hemolysis (≥0.11 g/L) was employed on the Atellica® detection system. The alternate use of these tubes did not influence the hs-cTnI results obtained from either of the two assays, which remained markedly biased (~40%) irrespective of the tube used. The expected optimal ability of very low hs-cTnI values on ED admission for ruling out AMI was confirmed by using both systems regardless of the tube type. CONCLUSIONS: Barricor™ and PSTII™ tubes can provide analytically equivalent hs-cTnI results when used on either Alinity™ or Atellica® hs-cTnI assays.

Fusion's Location and Quality within the Fixated Segment Following Transforaminal Interbody Fusion (TLIF).

Transforaminal interbody fusion (TLIF) has gained increased popularity over recent decades and is being employed as an established surgical treatment for several lumbar spine pathologies, including degenerative spondylosis, spondylolisthesis, infection, tumor and some cases of recurrent disc herniation. Despite the seemingly acceptable fusion rates after TLIF (up to 94%), the literature is still limited regarding the specific location and quality of fusion inside the fixated segment. In this single-institution, retrospective population-based study, we evaluated all post-operative computed tomography (CT) of patients who underwent TLIF surgery at a medium-sized medical center between 2010 and 2020. All CT studies were performed at a minimum of 1 year following the surgery, with a median of 2 years. Each CT study was evaluated for post-operative fusion, specifically in the posterolateral and intervertebral body areas. The fusion's quality was determined and classified in each area according to Lee's criteria, as follows: (1) definitive fusion: definitive bony trabecular bridging across the graft host interface; (2) probable fusion: no definitive bony trabecular crossing but with no gap at the graft host interface; (3) possible arthrosis: no bony trabecular crossing with identifiable gap at the graft host interface; (4) definite pseudarthrosis: no traversing trabecular bone with definitive gap. A total of 48 patients were included in this study. The median age was 55.6 years (SD ± 15.4). The median time from surgery to post-operative CT was 2 years (range: 1-10). Full definitive fusion in both posterolateral and intervertebral areas was observed in 48% of patients, and 92% showed definitive fusion in at least one area (either posterolateral or intervertebral body area). When comparing the posterolateral and the intervertebral area fusion rates, a significantly higher definitive fusion rate was observed in the posterolateral area as compared to the intervertebral body area in the long term follow-up (92% vs. 52%, p < 0.001). In the multivariable analysis, accounting for several confounding factors, including the number of fixated segments and cage size, the results remained statistically significant (p = 0.048). In conclusion, a significantly higher definitive fusion rate at the posterolateral area compared to the intervertebral body area following TLIF surgery was found. Surgeons are encouraged to employ bone augmentation material in the posterolateral area (as the primary site of fusion) when performing TLIF surgery.

Traumatic Posterior Atlantoaxial Dislocation With an Associated Fracture: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To investigate the clinical presentation, mechanism of injury, patients' characteristics, diagnosis, treatment, and prognosis of traumatic posterior atlantoaxial dislocation with fracture (TPAD). BACKGROUND: TPAD is an extremely rare entity, with a limited number of cases reported in the literature. Although rare, a thorough understanding of the pathogenesis and management of such cases is required due to the high risk of spinal cord compression and the severity of neurological deficits. We conducted a systematic review of all cases of TPAD with fractures reported in the literature. METHODS: This systematic review was conducted following the Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. Relevant literature was retrieved from the Pubmed database. All published English-written studies involving human subjects with relevant data regarding TPAD were included. RESULTS: Two case series and 20 case reports published between 1924 and 2021 describing 28 patients with TPAD were included. The median age at presentation was 51.5 years, with male predominance (83%). The most common fracture pattern was Anderson and D'alonzo type II odontoid fracture (78%). Neurological exam at presentation was intact in 52% of patients. The primary diagnostic imaging was computed tomography employed in 96% of cases. The management consisted of 2 stages protocol, initially, a temporary axial traction was employed (54%), and later definitive surgical treatment was employed (93%). The posterior surgical approach was favored in 82% of cases. CONCLUSION: TPAD with fracture occurred in the majority of cases with Anderson and D'alonzo type II odontoid fracture, predominantly in males. Diagnosis is usually established based on computed tomography imaging; further imaging may not be indicated as it does not seem to alternate the patient's management course. Surgical intervention was employed in almost all cases, with favored results through posterior C1-C2 fusion. LEVEL OF EVIDENCE: Level-IV.

Preliminary results: continuous double luminal catheter drainage for the management of septic hip arthritis in children.

Septic arthritis in children is considered an orthopedic surgical emergency, which requires prompt intervention to prevent later sequela. In the last decades, several minimal invasive techniques were suggested as an alternative to the standard treatment of septic arthritis in the pediatric hip via open arthrotomy. We aimed to investigate the efficacy and safety of a new minimal invasive technique-double luminal catheter drainage (DLDC)-in treating septic hip arthritis in children. Retrospective case series analysis was performed on all patients 1-18 years of age diagnosed with septic hip arthritis and treated by the new suggested minimal invasive technique between the years 2009-2019 at medium-sized medical center. Five patients were treated by DLDC with a follow-up period of 12 months posttreatment. The diagnosis was based on joint aspirated fluid analysis criteria. During the follow-up period, no later sequel, including avascular necrosis, or infection recurrence were observed. The new minimal invasive treatment technique suggested in this study seems to be efficient and safe in treating septic hip arthritis in children without later sequela or the need for open arthrotomy, especially if performed early on. However, due to the small study sample, no generalization of the findings can be made as future studies with larger study samples are needed to validate the DLDC technique.

Frostbite of The Extremities - Recognition, Evaluation and Treatment.

OBJECTIVES: Frostbite refers to the freezing of body tissue which is caused by prolonged exposure to cold temperatures and results in tissue destruction. Tissue damage is due to both immediate cold-induced cell death and the more gradual development of localized inflammatory processes and tissue ischemia. A detailed treatment plan based on the current UpToDate literature is needed to decrease morbidity and mortality rates. METHODS: The United States National Library of Medicine (PubMed/Medline), EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews were systematically searched to identify publications relevant to this review. CONCLUSION: In this review, we present the current knowledge on the diagnosis and treatment of frostbite injuries. We then provide an extended and detailed treatment plan, from first aid in the field to treatment of short and long-term complications .

Intrathoracic scapular dislocation following radical surgical chondrosarcoma resection from chest wall.

Locked scapula or intrathoracic scapular dislocation is an extremely rare entity encountered in the emergency department, with very few cases reported in literature. Conservative vs surgical approach in treating intrathoracic scapular dislocation is not well defined in literature. In this case report, we present a rare case of intrathoracic scapular dislocation, following multiple ribs resection due to malignant bone tumour, which was treated by closed manipulation reduction technique.

The role of three dimension computed tomography in Lisfranc injury diagnosis.

PURPOSE: To evaluate the intra/inter observer and diagnostic reliability of 3-dimensional (3D) model reconstruction computed tomography (CT) compared to the traditional two-dimensional (2D) CT when evaluating Lisfranc (LF) injuries. METHODS: A retrospective study was performed on CT studies of patients with clinically suspected LF injuries examined in the emergency department at medium size medical center. Each CT study was evaluated for metatarsal fractures and subluxations employing both standard 2D and 3D CT model reconstruction. Four orthopaedists, 2 senior and 2 residents, were assigned to review and evaluate each CT. Each CT study was reviewed twice by each reader in a randomized order. Descriptive statistics were calculated for all measured variables. The intra-observer and inter-observer agreement Kappa coefficients were calculated to evaluate reliability and reproducibility between and within readers for each modality. RESULTS: The study included 44 patients. Median age was 41.4 years (interquartile range, 23-58). The intra-observer and inter-observer reliability was good (intra-observer; 3D Kappa; 0.76 and 2D Kappa 0.73 p<0.001, inter-observer; 3D Kappa 0.68, 2D Kappa 0.63 and combined 2D and 3D kappa 0.68, p<0.001). Three dimensional CT was found to be more sensitive than 2D CT, specifically when evaluating for second metatarsal dislocation (sensitivity: 70% vs 47%). Combined evaluation of 2D and 3D CT, greatly improved sensitivity rate to 85.7%. In terms of fracture diagnosis, combined evaluation of 2D and 3D CT showed higher sensitivity and specificity rates as compared to 2D or 3D alone. CONCLUSION: The employment of 3D CT in LF injury diagnosis, in isolation and in combination with 2D CT, seems to improve the diagnostic accuracy and reliability between and within observers compared to 2D CT alone.