Strength after the arthroscopic Latarjet procedure: Are shoulder internal rotation, elbow flexion & supination strength decreased?

Background: The Latarjet procedure is an effective shoulder stabilizing surgery, however, the procedure results in an alteration of anatomy that may result in shoulder and elbow weakness. Thus, the purpose of this study was to assess post-operative shoulder and elbow strength after the Latarjet procedure. We hypothesized that shoulder and elbow strength are not affected after the procedure. Methods: The study group consisted of patients that had undergone the arthroscopic Latarjet procedure. An isokinetic dynamometer was used to evaluate the strength of bilateral shoulder internal rotation, elbow flexion, forearm supination using peak torque (N/m), as well as grip strength (kilograms). Shoulder range of motion and the potential effects of hand dominance were further analysed. Results: Nineteen patients with a mean age of 29 years and an average follow up of 47 months were included. Shoulder internal rotation strength, elbow flexion and forearm supination strength and grip strength were not significantly different when compared to the non-operative side (p > 0.13). The range of shoulder external rotation was significantly reduced (p < 0.001) on the Latarjet side. Conclusion: The results from this study demonstrate no statistically significant differences in the strength of shoulder internal rotation, elbow flexion, forearm supination or grip strength despite the surgical alterations to the subscapularis and conjoint tendon.

The association between lower limb fractures and weight gain in adults: a prospective analysis of body mass index trends.

PURPOSE: Despite understanding the connection between obesity and fracture risk, there is limited research on the implications of lower limb fractures on subsequent changes in body mass index (BMI). Our study aimed to assess the impact of lower limb fractures on BMI alterations over an 18-month period. METHODS: A multi-center, prospective cohort study was conducted between January 2021 to June 2023, involving 494 adults with lower limb fractures. Participants were recruited within 2 weeks post-injury and were assessed for demographics, injury details, and weight at seven distinct time points. By 18 months, the primary outcome was the mean weight gain. RESULTS: The average age of the participants was 39 (± 12.7) with a baseline weight and BMI of 80.4 kg and 27.6, respectively. At the 18-month follow-up, 75% of patients experienced an average weight increase in 4 kg (± 5.39 kg), equating to a BMI rise of 1.39 (± 1.88). Most patients attributed weight changes to their injury, with nearly half expressing distress from their weight change. Only 37% believed that they had resumed their previous activity levels by the final follow-up. Approximately 31% of the patients sought some form of external weight management care in the form of nutritionist advice, training programs, medication and weight management procedures. CONCLUSIONS: Lower limb fractures significantly affect weight gain over an 18-month period, with substantial psychological and physical consequences. Healthcare providers should anticipate potential weight gain post-fracture and incorporate strategies addressing both physical and mental aspects of rehabilitation to enhance recovery outcomes. Early and even immediate weight bearing may play a pivotal role in mitigating weight changes and returning the patient to their previous level of activity. Further detailed studies focusing on different fractures and postoperative interventions are recommended.

Operative treatment of distal radius fractures involving the volar rim-A systematic review of outcomes and complications.

PURPOSE: Distal radius fractures involving the volar rim are a subset of unstable and extremely distal fractures involving the volar lunate and/or scaphoid facets. Volar rim fractures (VRF) are challenging to manage and different treatment options have been described. This study aimed to compare outcomes and assess the rates of complications and implant removal for different treatment methods of wrist fractures involving VRF. METHODS: A systematic review of studies published in MEDLINE, EMBASE, Web of Science and Cumulative Index to Nursing and Allied Health literature (CINAHL) was conducted to assess the operative outcomes of VRF. Data on patient demographics, implant usage, postoperative outcomes, complications, and implant removal were compiled. RESULTS: Twenty-six studies met the inclusion criteria with a total of 617 wrists. The most commonly used implants were 2.4 mm variable-angle volar rim plate (DePuy Synthes) (17.5%), Acu-Loc II (Acumed) (14%) and standalone hook plates (13%). The average outcome measures were Q-DASH (10.9 ± 7), MWS (85.8 ± 7.5), PRWE (15.9 ± 12.1), and DASH (14 ± 8.5). The overall complication rate was 14% (n = 87), with 44% (n = 38) involving flexor tendon problems. The implant removal rate was 22%, with routine removal being performed in 54% and non-routine removal in 46% of cases. CONCLUSION: The current treatment of VRF yields favorable functional outcomes across different treatment options. However, these fractures have a high rate of complications and re-interventions, particularly for symptomatic implants. LEVEL OF EVIDENCE: Therapeutic IV.

Posterior Hip Dislocation in Association With Anterior Column Acetabular Fracture, Femoral Head Fracture, and Sciatic Nerve Injury: A Case Report.

CASE: Posterior hip dislocations are classically associated with posterior acetabular wall fractures. We report the case of a 29-year-old man presented after a motorcycle accident with an unusual combination of injuries that included posterior hip dislocation, anterior column acetabulum fracture, femoral head fracture, and sciatic nerve injury. At the final follow-up, excellent outcomes were obtained with complete recovery of the sciatic nerve injury. CONCLUSION: A favorable outcome may be achieved in young patients who sustain this unusual compilation of ipsilateral anterior acetabulum fracture, posterior hip dislocation, femoral head fracture, and sciatic nerve injury with meticulous preoperative surgical planning and tailored patient management.

Pain, Pattern and Polytrauma - Predictors of Sexual Dysfunction in Pelvic Fractures: A Retrospective Multicenter Analysis.

Objectives: In the local and cultural setting of high trauma rates and a reserved outlook on sexual function, this study examines the incidence and underlying factors of sexual dysfunction (SD) following pelvic fractures. Methods: A Multi-center retrospective cohort analysis performed in two general hospitals and one tertiary orthopedic center with collection between 2017 and 2019. Consecutive patients with pelvic fractures between January 2017 and February 2019 were followed up at 18-24 months to screen for new-onset SD using the International Index of Erectile Function-5 (IIEF-5) and Female-Sexual-Function-Index-6 (FSFI-6). Additional variables include age, sex, Young-Burgess classification, urogenital injury, injury severity score, persisting pain, sacroiliac disruption, intervention and if sexual health was discussed or patient referred for sexual healthcare. Results: One-hundred and sixty-five patients (n = 165) were included, (83%) male, (16%) female with a mean age of 35.1 years (Range 18-55). Fracture patterns included lateral compression (LC) (51.5%), anteroposterior compression (APC) (27.7%), and vertical shear (VS) (20.6%). The urogenital injury occurred in 10.3%. The mean IIEF-5 and FSFI-6 scores were 20.8 and 24.7 in males and females, respectively. A total of 40 males (29%) scored below the 21 cut-off scores for SD, while only one female (3.7%) scored below the corresponding score of 19. Of all participants reporting sexual dysfunction, 56% discussed sexual health with their providers, while 46% of these patients were referred for further management. Significant predictive factors for SD using a multivariate logistic regression model include increasing age (OR-1.093, p = 0.006), APC III (OR 88.887, p = 0.006), VS (OR-15.607, p = 0.020), persisting pain (OR 3.600, p = 0.021) and increasing injury severity score (OR 1.184, p <0.001). Conclusion: SD is common among pelvic fractures, and risk factors include APC or VS type fractures, increasing age, increasing injury severity score, and persisting pain. Providers should ensure patients are screened for SD and referred appropriately as patients may not willingly disclose underlying symptoms.

Successful nonoperative treatment of a closed posteromedial ankle dislocation without associated fractures - a case report.

Pure ankle dislocations occurring in the absence of malleolus fractures are extremely rare injuries. These injuries often present with high-energy trauma and ligamentous injury. Comprehensive research is not available due to the rarity of the injury. However, recent literature has supported treatment by nonoperative means. This case report aims to discuss a similar case and offer insight into the prognosis of such injuries. Case presentation: A previously healthy 26-year-old male was diagnosed with a closed posteromedial ankle dislocation without associated fractures. Reduction was performed under procedural sedation and confirmed with postreduction radiographs. The patient was immobilized and scheduled for serial follow-up in the outpatient department. Weight bearing was gradually introduced at 6 weeks along with physiotherapy. The American Orthopedic Foot and Ankle Score was 90 and 100 at 6 months and 1 year follow-up, respectively. Return to sports was possible at 1 year postinjury. Range of motion was normal apart from a 5-8° ankle dorsiflexion deficit. Radiographs, computed tomography, and MRI were unremarkable with longer term follow-up. Conclusion: Patients who sustain pure ankle dislocations with an intact distal tibiofibular syndesmosis can expect favorable outcomes with immobilization, splinting, and gradual rehabilitation, as evident by the high American Orthopedic Foot and Ankle Score and the time to return to sports. This case report serves to provide prognostic information and anticipate outcomes in patients with similar injuries.

Circumferential periosteal block versus hematoma block for the reduction of distal radius and ulna fractures: a randomized controlled trial.

PURPOSE: To assess the analgesic efficacy of the circumferential periosteal block (CPB) and compare it with the conventional fracture hematoma block (HB). METHODS: This study was a prospective single-center randomized controlled trial performed in a national orthopedic hospital. Fifty patients with displaced distal radius (with or without concomitant ulna) fractures requiring reduction were randomized to receive either CPB or HB prior to the reduction. Pain was sequentially measured using the visual analogue scale (VAS) across three stages; before administration of local anesthesia (baseline), during administration (injection) and during manipulation and immobilization (manipulation). Further, the effect of demographic factors on the severity of pain was analyzed in multivariate regression. Finally, complications and end outcomes were compared across both techniques. RESULTS: Patients receiving CPB experienced significantly less pain scores during manipulation (VAS = 0.64) compared with HB (VAS = 2.44) (p = < 0.0001). There were no significant differences between groups at baseline (P = 0.55) and injection (P = 0.40) stages. CONCLUSION: The CPB provides a superior analgesic effect over the conventional HB with no documented complications in either technique. LEVEL OF EVIDENCE: Therapeutic Level II.

Intraoperative arthrography favorably impacts the early outcome of operatively managed fractures of the lateral humeral condyle displaced 1-5 mm in children.

BACKGROUND: Controversy exists surrounding the optimal approach to managing pediatric lateral humeral condyle fractures (LHCF). The difficulty in assessing the articular surface using radiography and the intra-articular element potentially involved make LHCF susceptible to complications and delayed diagnoses. Arthrography has been used to delineate the articular surface to aid in deciding whether closed or open reduction is necessary. However, there has been scarce evidence to determine the accuracy of using radiography versus arthrography to predict articular disruption in LHCF displaced 1-5 mm. This study assesses; (1) the utility of intraoperative arthrography in modifying the method of operative reduction, (2) the accuracy of plain radiography in identifying articular integrity, and (3) the clinical outcomes of early operative treatment. METHODS: This was a single-center prospective study that involved operatively treated pediatric LHCF with a displacement of 1-5 mm. Patient demographics, radiographic displacement, predicted radiographic articular integrity, articular integrity on arthrograms, modification of management and follow-up clinical outcomes were obtained. RESULTS: A total of 72 patients were included with a mean displacement of 2.6 mm and a mean follow-up of 16 months. The articular surface was disrupted in 21% of patients. The reduction method (open versus closed) was modified in 15 patients (21%) after an intraoperative arthrogram. Out of 25 patients with displacement < 2 mm, four of which (15%) had disrupted articular surface and were subsequently treated with open reduction internal fixation (ORIF). While eleven patients with > 4 mm displacement had an intact articular hinge that were managed with closed reduction and percutaneous pinning (CRPP). All patients achieved union with no documented major complications. The ability of radiography to discriminate between disrupted/ intact articular integrity decreases as displacement decreases. CONCLUSIONS: Data from this study suggest using the degree of displacement measured on plain radiography is insufficient in predicting articular integrity for fractures displaced 1-5 mm. The use of arthrography guides reduction method and adequacy, avoiding scenarios of unnecessary open reduction and insufficient closed reduction. Further, a significant amount of outliers exist that have intact articular hinges above 4 mm and disrupted hinges below 2 mm of displacement. Finally we report favorable outcomes using a lower threshold for early operative treatment.

Predictors of mortality and length of stay after hip fractures - A multicenter retrospective analysis.

Background: The ubiquity of hip fractures pose a substantial burden on public health services worldwide. There is widespread geographical variation in mortality rates and length of stay after hip fractures. The current study investigates both the predictors of; (1) one-year mortality and (2) length of hospital stay (LOS) in adults aged 60 years or older. We aim to identify the risk factors and quantify the extent of influence they have on both outcomes. Methodology: A retrospective multi-center cohort study identified consecutively documented hip fractures between January 2013 and September 2018. A multivariate regression analysis of 603 patients was performed to determine independent factors affecting mortality and total LOS. Results: The study sample included 603 patients with a total one-year mortality rate of 20.6% (n = 124). Predictors of mortality included; longer LOS, increasing age, inability to return to baseline mobility and comorbid burden. The mean overall LOS was 15.1 days, and 22.6 days in the mortality group. Predictors of increased LOS included; previous hip fractures, comorbid burden; diabetic, cerebrovascular disease and smokers. Return to baseline mobility status was associated with reduced LOS. Conclusion: Patients with a longer length of stay, inability to return to baseline mobility status, higher ASA scores, previous hip fractures and longer time to surgery had a higher mortality rate. Determinants of a longer LOS include; increased time to surgery, impeded postoperative mobility status, fixation rather than joint replacement and comorbid burden. A multifaceted approach to preoperative optimization and postoperative recovery is crucial in order to address all possible modifiable factors.

The Importance of Scar Cosmesis across the Surgical Specialties: Factors, Perceptions, and Predispositions.

Existing disparities in the perception of scars between patients and practitioners can translate into undesirable physical and psychological outcomes. An understanding of the determinants of surgeons' perceptions on the importance of scar cosmesis is a first step toward bridging this gap. Methods: In an online survey, surgeons were asked about the extent to which various patient and technical factors affect the importance of scar cosmesis. Additional data were obtained on surgeon characteristics, including their specialty, gender, years of experience, and work sector to investigate potential relationships. Results: A total of 303 responses were obtained from surgeons across six specialties. Based on the survey, the importance of scar cosmesis was rated highest among plastic surgeons and obstetricians and gynecologists, and lowest among orthopedic and vascular surgeons. Compared with surgeons in private practice, publicly employed surgeons' rating of the importance of cosmesis was lower. The patient's request for a cosmetic outcome was the most highly rated factor. Regarding the influence of patient demographics on surgeons' attitudes, scar cosmesis in young and female patients was favored in comparison with older and male patients. Factors that reduced the importance of cosmesis were emergency and late-night surgeries followed by lengthy procedures, large incisions, and busy operative lists. Conclusions: These initial findings highlight a need to investigate means of fostering a more holistic, impartial approach toward scar cosmesis, as well as addressing potential workplace barriers that may prevent surgeons from seeking a more cosmetic result. Greater alignment between the priorities of surgeons and patients may manifest in objective and subjective improvements in patient's scars and well-being.

Traumatic orthopedic consultations in COVID-19 inpatients - A cross sectional analysis of results and a review of lessons in tele-orthopedics.

INTRODUCTION: COVID-19 has led to intricate global challenges, among these, the impact on emergency and elective orthopedic services. Patients with COVID-19 often complain of musculoskeletal symptoms. The subsequent orthopedic consultations require careful assessment of possible inpatient trauma and to rule out any injuries that require active management. METHODS: A retrospective cross-sectional analysis involving 13,580 admitted patients in a national quarantine center between March 2020 and April 2021. All patients with orthopedic consultations were included in the study, and were assessed by orthopedic surgeons in person. Patients were further evaluated for age, sex, presence of trauma, cause for consultation, diagnosis and management. RESULTS: Seventy-five orthopedic consultations were included, 44% females and 56% males. Of the 75 consultations, 29 (38%) were related to a history of inpatient trauma. Of the 29 cases, 11 sustained fractures of the distal radius, proximal humerus, femoral neck, clavicle and ankle. Four of which were treated operatively. DISCUSSION AND CONCLUSION: Inpatient orthopedic consultations must be assessed carefully to avoid misdiagnoses. Elderly or frail patients are more likely to both; sustain trauma and fractures. Potential limitations of tele-orthopedics may be apparent here, especially in the presence of technological incompetence and high likelihood of fractures.

A torque induced iatrogenic fracture of the humeral shaft in proximal humeral fracture plating - A case report and biomechanical perspectives.

INTRODUCTION: Proximal humerus fractures are common amongst the elderly and osteoporotic cohorts. Common treatment methods include proximal locking plates. In this case, we describe an iatrogenic fracture of the proximal humeral shaft during screw insertion under power. Similar cases have not been described previously in open reduction and internal fixation of a proximal humerus fracture. Further, we focus particularly on precautionary measures that aim to avoid such complications that may lead to considerable morbidity. CASE PRESENTATION: We describe a case of a 65 year old osteoporotic female who underwent open reduction internal fixation of a proximal humerus fracture complicated by an unusual iatrogenic humeral fracture at the level of insertion of the distal screw, likely secondary to inserting the proximal locking screws under power. CONCLUSION: In this case, we explore the possible factors leading to the fracture and precautionary measures to avoid them. The rate of iatrogenic intraoperative fractures are likely underreported and have not been described in open reduction and internal fixation of an existing fracture. The underlying factors that may predispose to such complications have not been previously described in similar cases. This case serves as a warning of an unanticipated complication and describes the potential biomechanical factors involved.

Prevalence, predictors and outcomes of bleeding events in patients with COVID-19 infection on anticoagulation: Retrospective cohort study.

BACKGROUND: This study aims to examine risk factors and complications associated with bleeding events in patients with COVID-19 who are on anticoagulation. MATERIAL AND METHODS: We conducted retrospective review of all patients who were admitted with COVID-19 and developed bleeding events between March and June 2020. Data were analyzed in accordance with three major outcomes. Mortality within 30 days of bleeding episode, resolution of the bleeding event, and the type of bleeding event. RESULTS: Of 122 bleeds, there was 55 (28 %) gastrointestinal (GI) bleeds. Overall mortality was 59 % (n = 72). The prevalence of therapeutic invasive interventions was 11.5 % (n = 14) all were successful in resolving the bleeding event. We found that having a GI bleeds was associated with higher risk of mortality compared to non-GI bleeds (p = 0.04) and having occult bleeds to be associated with 15 times increased risk of mortality (OR 15, 95%CI 1.97-29.1, p = 0.01). Furthermore, patients who were on no anticoagulation (none) (OR 0.1, 95%CI 0.01-0.86, p < 0.00), on prophylactic dose anticoagulation (OR 0.07, 95%CI 0.02-0.28, p = 0.03) or intermediate dose anticoagulation (OR 0.36, 95%CI 0.09-1.34, p = 0.13) were less likely to die than patients on therapeutic dose. CONCLUSIONS: The best approach to manage COVID-19 bleeding patients is to prioritize therapies that manage sepsis induce coagulopathy and shock over other approaches. In COVID-19 patients' routine prescription of supra-prophylactic dose anticoagulation should be revisited and more individualized approach to prescription should be the norm. Regardless of the cause of bleeding event it appears that the majority of bleeding events resolve with noninvasive interventions and when invasive interventions were necessary, they were associated with high success rate despite the delay.

Intra-gastric balloons - The past, present and future.

Obesity is a complex metabolic illness that is interrelated to a plethora of complications that predispose to avoidable morbidity and mortality. The considerable impact of obesity has invited various therapies ranging from lifestyle advice, pharmacotherapy, endoscopic bariatric therapy and ultimately surgery. Intragastric balloons are space-occupying therapies that aim to increase satiety through mechanical and neuroendocrine mechanisms. Their prevalence is owed to their ease of administration and general safety. However, long term data concerning safety and efficacy is scarce when considering the various types of balloons in use. In this review, we discuss the intragastric balloon comprehensively in terms of efficacy, safety, limitations and future direction.

Caution against precaution: A case report on silent hypoxia in COVID-19.

INTRODUCTION: Silent hypoxia is an entity that has been described in patients diagnosed with COVID-19. It is typically described as objective hypoxia in the absence of proportional respiratory distress. The physiological basis for this phenomenon is controversial, and its prognostic value is unclear. We present a case below, of a 66-year-old female presenting with severe hypoxia that was managed without mechanical ventilation. PRESENTATION OF CASE: A 66 year old female with multiple comorbidities initially presented with a cough, fever and an oxygen saturation of 70% on room air in the absence of respiratory distress or altered mentation. She subsequently tested positive for COVID-19 and was admitted to the intensive care unit; received oxygen via high flow nasal cannula and continuous positive pressure mask. The patient remained in the intensive care unit for 40 days under close observation and exhibited multiple episodes of silent hypoxia on weaning oxygen. She was discharged on room air with an oxygen saturation >90% after 56 days. The patient was not intubated during her stay. DISCUSSION AND CONCLUSION: Clinicians face a clinical dilemma on whether to intubate a "silently hypoxemic" patient, who displays hypoxia out of proportion to clinical examination. The decision is confounded by a lack of clear evidence on whether the benefits of precautionary intubation outweighs the risks, especially in the current COVID-19 pandemic. A recent paradigm shift that recommends delaying intubation further displays the need for clearer analysis of the situation. Our case demonstrates a favorable outcome of the latter approach, yet emphasizes a case-by-case approach until clearer recommendations are available.

Severe ischemic complications in Covid-19-A case series.

INTRODUCTION: Covid-19 has the propensity to result in a wide array of manifestations. Recently, thromboembolic complications of Covid-19 have been denoted in literature. We report 5 cases of Covid-19 positive patients with no significant comorbidities who developed 1st time episodes of either; acute limb ischemia or bowel ischemia. MATERIAL AND METHODS: This is a retrospective observational study analyzing the clinical characteristics and outcomes of five Covid-19 positive patients. Five patients aged 38-60 presented to our institution from 1st April to 1st June and were diagnosed with Covid-19 pneumonia, subsequently developing severe vascular complications. None of our patients included had any history of thromboembolism nor risk factors that could justify the presentations. PRESENTATION OF CASES: Patient 1; presented with bowel ischemia as a first presentation. Patient 2 and 3 developed unsalvageable lower limb ischemia secondary to partial to complete occlusion of infra-renal aorta. Patient 4 presented with acute upper limb ischemia due to complete occlusion of the axillary and brachial artery. Patient 5 developed bilateral lower limb unsalvageable ischemia secondary to aortic bifurcation occlusion. All patients tested Covid-19 positive upon admission, and received standard care. DISCUSSION AND CONCLUSION: The thromboembolic complications seen in our cases were devastating and resulted in significant mortality and morbidity. All vessels affected were medium-large vessels. None of our cases had any significant predisposing medical conditions or history of thromboembolic or ischemic events. A high index of suspicion is necessary when evaluating such patients regardless of thromboembolic history. Appropriate anticoagulation regimens are essential. Our cases add to the currently increasing severe thromboembolic complications of Covid-19.

Amyloid goiter - A rare case report and literature review.

INTRODUCTION: Amyloid goiter is a rare presentation of thyroid swelling, which occurs with either primary or secondary amyloidosis. This condition must be differentiated from other types of goiters or malignancies. Even though the thyroid is extensively involved by amyloid, patients are usually euthyroid, but many different presentations and overlaps have been reported. Currently the treatment is surgical resection of the thyroid gland. CASE PRESENTATION: We report a case of a 53-year-old previously healthy male who presented with a 2 year history of a progressively enlarging painless neck swelling. The patient was euthyroid and denied any associated symptoms. The patient subsequently underwent an uneventful total thyroidectomy along with an unremarkable follow up and was diagnosed with primary amyloidosis involving only the thyroid gland confirmed by histopathology. DISCUSSION AND CONCLUSION: Amyloid goiter is a rare entity; a high index of suspicion is required in patients with an enlarging thyroid gland and a concomitant history of chronic inflammatory processes or plasma cell dyscrasia. FNA biopsy should be performed to exclude the top differential of primary thyroid malignancy. Thyroidectomy is necessary for definitive diagnosis and symptom relief. Every effort should be made to delineate the extent of the disease, and in those previously healthy plasma cell dyscrasia should be excluded.

Malignant adenomyoepithelioma of the breast: A case report.

INTRODUCTION: Malignant breast adenomyoepithelioma (AME) is a rare subtype of breast cancer. AME is mostly a benign disease that uncommonly undergoes malignant transformation. PRESENTATION OF CASE: Here we present a case of a young, previously healthy female who initially presented with a painless breast lump. The patient underwent wide local excision for atypical cells with squamous metaplasia by core biopsy, but final histopathology showed AME with carcinoma. Thus, a mastectomy and a sentinel lymph node biopsy was undertaken. The patient had an uneventful recovery and no recurrence after the second surgery. DISCUSSION AND CONCLUSION: Malignant transformation of adenomyoepithelioma is reported in a small number of cases. Benign AME may be treated with wide local excision as recurrence is rare locally. Whereas malignant AME tends to be treated with simple mastectomy with or without lymph node biopsy.