Persistent fever after coronavirus disease 2019 in liver/kidney transplant recipient.

In this case, a 64-year-old male with a history of simultaneous orthotopic liver transplant and cadaveric renal transplant presented five years prior presented with persistent fevers two days after a positive SARS-CoV-2 nasal PCR. A CT scan of the chest on hospital day nine revealed innumerable 1-2 mm nodules in a miliary pattern throughout the lung. (1,3)-ß-D-glucan on hospital day 11 was 133 pg/mL. In this article, the approach, diagnostic and management strategies for patients with persistent fevers after diagnosis of COVID-19 in a transplant recipient are discussed.

When giants talk; robotic dialog during thoracolumbar and sacral surgery.

BACKGROUND: Spinal trauma patients treated in a specialized hybrid operating room (OR) using two robotic systems communicating during surgery. METHODS: Retrospective review of patients with thoracolumbar or sacral fractures who underwent surgical fixation between Jan 2017 to Jan 2020 with robotic-guided percutaneous pedicle screw insertion in the specialized hybrid OR with Robotic flat panel 3D C-arm (ArtisZeego) for intraoperative interventional imaging connected with the robotic-guidance platform Renaissance (Mazor Robotics). RESULTS: Twenty eight surgeries were performed in 27 patients; 23 with traumatic spinal fractures, 4 with multi-level thoracolumbar compression fractures due to severe osteoporosis. Average patient age 49 (range 12-86). Average radiation exposure time 40 s (range 12-114 s). Average radiation exposure dose 11,584 ± SD uGym2 (range 4454-58,959). Lumber levels operated on were between T5 and S2 (shortest three vertebras and longest eight vertebras). 235 (range 5-11) trajectories were performed. All trajectories were accurate in all cases percutaneous pedicle screws placement was correct, without breach noted at the pedicle in any of the cases. No major complications reported. In all cases, follow-up X-rays showed adequate fracture reduction with restoration. CONCLUSIONS: Merging of surgical robotics technologies increases patient safety and surgeon and patient confidence in percutaneous spine traumatic procedures.

Computer-Generated Radiographic Measurements of Distal Radius Fractures: Does It Help With Decision Making?

PURPOSE: Operative management of distal radius fractures (DRFs) has become increasingly common. Age, activity levels, and comorbid conditions are major factors influencing the treatment decision, although operative indications are still controversial. Radiographic parameters (RPs), such as radial inclination, dorsal tilt, and articular step-off, can provide objective support for effective decision making. However, manual measurement of RPs may be imprecise and subject to inconsistency. To address this problem, we developed custom software of an algorithm to automatically detect and compute 6 common RPs associated with DRF in anteroposterior and lateral radiographs. The aim in this study was to assess the effect of this software on radiographic interobserver variability among orthopedic surgeons. Our hypothesis was that precise and consistent measurement of RPs will improve radiographic interpretation variability among surgeons and, consequently, may aid in clinical decision making. METHODS: Thirty-five radiograph series of DRFs were presented to 9 fellowship-trained hand and orthopedic trauma surgeons. Each case was presented with basic clinical information, together with plain anteroposterior and lateral radiographs. One of the 2 possible treatment options was selected: casting or open reduction with a locking plate. The survey was repeated 3 weeks later, this time with computer-generated RP measurements. Data were analyzed for interobserver and intraobserver variability for both surveys, and the interclass coefficient, kappa value, was calculated. RESULTS: The interobserver reliability (interclass coefficient value) improved from poor to moderate, 0.35 to 0.50, with the provided RP. The average intraobserver interclass coefficient was 0.68. When participants were assessed separately according to their subspecialties (trauma and hand), improved interobserver variability was found as well. CONCLUSIONS: Providing computed RPs to orthopedic surgeons may improve the consistency of the radiographic judgment and influence their clinical decision for the treatment of DRFs. CLINICAL RELEVANCE: Orthopedic surgeons' consistency in the radiographic judgment of DRFs slightly improved by providing automatically calculated radiographic measurements to them.

Online Registry of COVID-19-Associated Mucormycosis Cases, India, 2021.

We established an online registry of coronavirus disease-associated mucormycosis cases in India. We analyzed data from 65 cases diagnosed during April-June 2021, when the Delta variant predominated, and found that patients frequently received antibacterial drugs and zinc supplementation. Online registries rapidly provide relevant data for emerging infections.

Maintaining mask momentum in transplant recipients.

The widespread use of facemasks has been a crucial element in the control of the SARS-CoV-2 pandemic.  With mounting evidence for mask efficacy against respiratory infectious diseases and greater acceptability of this intervention, it is proposed that masking should continue after the pandemic has abated to protect some of our most vulnerable patients, recipients of stem cell and solid organ transplants. This may involve not only masking these high-risk patients, but possibly their close contacts and the healthcare workers involved in their care. We review the evidence for mask efficacy in prevention of respiratory viruses other than SARS-CoV-2 and address the burden of disease in transplant recipients.  Although we acknowledge that there are limited data on masking to prevent infection in transplant recipients, we propose a framework for the study and implementation of routine masking as a part of infection prevention interventions after transplantation.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Successful Treatment of Antibiotic-resistant, Poly-microbial Bone Infection With Bacteriophages and Antibiotics Combination.

A patient with a trauma-related left tibial infection associated with extensively drug-resistant Acinetobacter baumannii and multidrug-resistant Klebsiella pneumoniae was treated with bacteriophages and antibiotics. There was rapid tissue healing and positive culture eradication. As a result, the patient's leg did not have to be amputated and he is undergoing rehabilitation.

Outcome of femoral fractures in poliomyelitis patients.

BACKGROUND AND PURPOSE: As patients who were afflicted with poliomyelitis during the outbreaks in the past are aging, lower extremity osteoporotic fractures are becoming more frequent. Fixation in deformed, porotic bone, coupled with muscle weakness and imbalance creates a unique challenge when treating these fractures as does their reduced rehabilitation potential. The aim of this study was to investigate the outcome of femoral fractures in surviving poliomyelitis patients. PATIENTS AND METHODS: Sixty-five patients with 74 femoral fractures were treated between 1990 and 2014. Clinical outcome was assessed using the Parkland and Palmer mobility score, and quality-of-life was assessed using the SF-12® score. RESULTS: Some 84% of the fractures were a result of low-energy mechanisms and occurred in the polio-affected limbs, but nonaffected limbs were also injured owing to low-energy mechanisms in all cases. Fifty-seven fractures were treated operatively. There were nine re-operations (16%), including implant removals, nonunion, peri-implant fractures, and malunion. Some 60% of the patients did not regain their previous ambulatory capacity. Post-operative weight-bearing status did not correlate with the final functional outcome. CONCLUSIONS: Polio patients with femoral fractures have a guarded prognosis for regaining their pre-injury ambulatory capacity. A higher re-operation rate than that with "normal" osteoporotic fractures is expected.

Acanthamoeba endophthalmitis during treatment for cutaneous disease in a renal transplant patient.

Acanthamoeba infections are difficult to diagnose and treat. We present a renal transplant patient who developed Acanthamoeba endophthalmitis on therapy with posaconazole and miltefosine for cutaneous acanthamobiasis. The patient was maintained on intracameral voriconazole injections, and oral azithromycin, fluconazole, and flucytosine. This case highlights novel presentations and treatments for acanthamoebic infection.

Radiographic markers for measuring tibial rotation based on CT-reconstructed radiographs: an accuracy and feasibility study.

OBJECTIVES: Malreduction in the axial plane (malrotation) following tibial fracture surgery is often undiagnosed. A few clinical and radiographic methods have been proposed for measuring tibial rotation intraoperatively, yet have failed to match the accuracy of computed tomography (CT). The aim of this study was to develop radiographic tools for future intraoperative assessment of the tibial shaft rotation profile. METHODS: The setting was a laboratory computerized analysis. Twenty lower limb CT scans were used to construct a three-dimensional (3D) model using AMIRA© software. A virtual 3D cylinder was implanted in the posterior condylar line and in the transmalleolar axis. The 3D models were used to simulate four standard knee and ankle plain radiographs. On each radiograph, four landmarks were depicted by two observers and their relation with the cylinder was measured and analyzed for accuracy and reproducibility. A cadaveric lower leg was implanted with two Kirschner wires. A CT scan was performed in addition to 2D fluoroscopy. The simulated radiographs and the fluoroscopy were compared for accuracy. RESULTS: Measurement of the landmarks showed reliability in most of the knee anteroposterior and ankle mortise radiographs (coefficients of variation < 0.01 and = 0.01) respectively. Cadaveric measurement of the landmarks using real fluoroscopy and simulated radiographs were similar. CONCLUSIONS: To date, no reliable and common methods have been reported for the evaluation of tibial axial rotation. We propose a model in which simple radiographic landmarks can be used to calculate a 3D coordinate system that accurately assesses the axial rotation angle of the tibial shaft.

Use of fully threaded cannulated screws decreases femoral neck shortening after fixation of femoral neck fractures.

BACKGROUND: Femoral neck fractures (FNF) are becoming increasingly common as population ages. Nondisplaced fractures are commonly treated by cancellous, parallel placed, partially threaded cannulated screws (PTS). This allows controlled fracture impaction. However, sliding implants can lead to femoral neck shortening (FNS) that has been shown to be correlated with reduced quality of life and impaired gait pattern. Recently, in our institution we have changed the fixation of FNF to fully threaded screws (FTS) with or without an additional partially threaded screw in order to minimize this phenomenon. The aim of this study was to compare the FNS in patients treated with FTS as compared with our historical controls treated with PTS. PATIENTS AND METHODS: Between 2014 and 2016, 38 patients with FNF were treated with FTS. Out of the 38, 24 were available for radiographic follow-up. 41 patients treated previously with PTS were available as a control group. Radiographic analysis was performed to assess the FNF in three vectors: Horizontal (X), Vertical (Y) and overall (Z) according to the neck-shaft angle. RESULTS: Time for admission to surgery was longer in the PTS group (p = 0.04). Patient demographics and major complication rates were similar in the two patient groups. Average FNS in the X axis was significantly smaller in the FTS group than in the PTS group (2.8 ± 3.6 vs 7.6 ± 4.2 mm, p < 0.01) as well as the Y axis (1.2 ± 2.6 vs 4.9 ± 4.2 mm, p < 0.01) and thus also decreased overall Z shortening (2.3 ± 3.5 vs 6.23 ± 4.5 mm, p < 0.01). There was a tendency towards a more valgus reduction in the PTS (137° vs 134°, p = 0.08). There was a significantly smaller number of FTS patients with moderate (5-10 mm) or severe (> 10 mm) FNS. Screw pull-out > 5 mm occurred in 17/41 patients in the PTS but none in the FTS group (p < 0.01). CONCLUSION: This study proves that use of FTS improves the radiographic results following FNF fixation using cannulated screws.

[FLUOROSCOPIC BASED NAVIGATION IN ORTHOPAEDIC TRAUMA - A REVIEW OF A LARGE CENTER'S EXPERIENCE].

INTRODUCTION: Computer Assisted Orthopaedic Surgery (CAOS) was introduced in the late 1990's and early 2000's. Since then its application in orthopaedic trauma has been utilized mainly as augmented fluoroscopy for intraoperative navigation. From 2010 our center implemented an advanced system allowing further expansion of this technology. AIMS: The aim of this study was to describe the experience with an advanced fluoroscopic based CAOS system in our center. METHODS: The BrainLabTM Trauma 3.0 utilizes a handheld fluoroscope tracker, enables tracking of two anatomical objects and intraoperative planning. We implemented this system for the performance of 126 navigated procedures between the years 2011-2014. The procedures included 58 cases of navigated hip fracture pinning, 9 plate navigation for distal femoral fractures, 19 iliosacral screw insertions, 20 femoral fracture reductions, and 12 other procedures (acetabular screws, osteotomies etc). RESULTS: The mean age of patients was 52 years (range 16-82 years); 46 male and 80 female patients. The mean operating room time was 157 minutes (range 70 to 470 minutes). The average radiation required was 550 rad cm2 (~30 sec fluoroscopic time). Overall estimated additional OR time was estimated as 10-15 minutes for hip pinning, 15-20 minutes for pelvic iliosacral screws and 30-45 minutes of additional OR time for femur fracture reduction for length and rotation. In 5% of cases (6 patients), navigation was aborted due to technical reasons. No misplaced hardware due to the use of navigation was documented. CONCLUSIONS: CAOS is a powerful tool in trauma surgery with 95% success rate, with a reasonable added burden time. Although 3D navigation may be more useful in the pelvis, even two-dimensional navigation increases precision and implant placement. Femoral fracture reduction for accurate length and rotation control is solely enabled by CAOS. In the future, more time efficient and user-friendly systems will enable widespread use of these technologies in orthopaedic trauma.

Use of three-dimensional fluoroscopy to determine intra-articular screw penetration in proximal humeral fracture model.

BACKGROUND: Proximal humeral locking plates have significantly improved the treatment of proximal humeral fractures in recent years; however, they are not devoid of complications. Inadvertent screw penetration into the joint is a well-documented complication. Intraoperative 3-dimensional (3D) imaging may assist in detecting intra-articular implant penetration. This study compared the performance of a standard C-arm fluoroscope with a novel 3D imaging fluoroscope in detecting penetrating implants in a proximal humeral fracture model. METHODS: Zinc-sprayed proximal humerus sawbones were affixed with a proximal humeral locking plate. Six different constructs were assembled. In each specimen, 1 screw, 2 screws, or no screws were inserted 2-mm proud of the articular surface. Each specimen was imaged with a conventional fluoroscope and a 3D imaging fluoroscope. Overall, 36 image sets were prepared for each modality. These were evaluated by 2 fellowship-trained surgeons for intraobserver and interobserver reliability as well for the accuracy of detecting prominent implants in the 2 imaging methods. RESULTS: Overall accuracy for observer A was 89.9% compared with 100% for C-arm fluoroscopy and 3D imaging fluoroscopy (P < .01) and for observer B was 91.1% and 100% (P = .01), respectively. The κ values were 0.74 with C-arm fluoroscopy and 1.0 for the 3D imaging fluoroscopy for observer A, and 0.93 and 1.0, respectively, for observer B. CONCLUSIONS: In a proximal humeral fracture model, C-arm fluoroscopy is a highly accurate imaging modality that can minimize the incidence of penetrating screws into the joint. Further clinical studies are required to establish this modality.

Rehabilitation after musculoskeletal injury: Israeli and South African perspectives.

Rehabilitation for patients sustaining isolated and multiple musculoskeletal injuries due to trauma remains a mainstay of recovery. There are a wide variety of systems in place to manage the rehabilitation process. This article describes the post-traumatic rehabilitation procedures from 2 member countries of the International Orthopaedic Trauma Association, Israel and South Africa. The systems are reflective of the clear differences between these 2 countries with vastly different economic strata and health care systems. In Israel, the rehabilitation programs and resources are most likely the result of the mature social support systems and the trauma experience. In South Africa, the programs are reflective of a two-tier health care system, with patients exposed to varying levels of rehabilitation resources.

Standard clinical and imaging-based small vessel disease parameters associated with mild stroke versus non-mild stroke.

Background: Mild stroke has variable outcomes, and there is an ongoing debate regarding whether the administration of thrombolytics improves outcomes in this subgroup of stroke patients. Having a better understanding of the features of mild stroke may help identify patients who are at risk of poor outcomes. Objective: The objective of this study is to evaluate the association of clinical and imaging-based small vessel disease features (white matter hyperintensities and cerebral microbleeds) with stroke severity and clinical outcomes in patients with mild stroke. Methods: In this retrospective study, mild stroke was defined as a National Institute of Health stroke scale (NIHSS) score <5. Clinical, laboratory and imaging data were compared between patients with mild stroke versus non-mild stroke (NIHSS≥5). Multivariate logistic regression analysis was performed to identify predictors of mild stroke and poor discharge outcome. Results: Among 296 patients included in the study, 131 patients (44%) had mild stroke. On multivariate analysis, patients with mild stroke were three times more likely to have sensory symptoms [odds ratio (OR) = 2.9; 95% confidence interval (CI) = (1.2-6.8)] and four times more likely to have stroke due to small vessel disease (OR = 3.7; 95%CI = 1.4-9.9). Among patients with mild stroke, higher age (OR = 1.1; 95%CI = 1.02-1.1), presence of cerebral microbleed (OR = 4.5; 95%CI = 1.5-13.8), vertigo (OR = 7.3; 95%CI = 1.2-45.1) and weakness (OR = 5.0; 95%CI = 1.2-20.3) as presenting symptoms were more likely to have poor discharge outcome. Conclusion: Sensory symptoms and stroke due to small vessel disease are more common in mild stroke than non-mild stroke. Among patients with mild stroke, presence of cerebral microbleeds on imaging and symptoms of muscle weakness are associated with poor discharge outcome. Larger studies are needed to assess the impact of cerebral microbleed on mild stroke outcomes and risk stratify the benefit of thrombolytics in this group.

New Versus Old-How Reliable Is the New OTA/AO Classification for Trochanteric Hip Fractures?

OBJECTIVE: To evaluate the intraobserver and interobserver reliability of the 2018 OTA/AO trochanteric hip fracture (THF) classification compared with the 1983 OTA/AO Muller classification system. To further delineate the reliability of classifying stable and unstable THF using the 2 classification systems. DESIGN: Radiographic observational study. SETTING: Multicenter, one Level 1 and one Level 2 trauma centers. PARTICIPANTS/PATIENTS: Seventy-three radiographic series of patients treated operatively for THF were evaluated by 6 orthopaedic surgeons. INTERVENTION: The OTA/AO THF classification system was applied by each surgeon to 73 cases in 2 independent assessments performed 4 weeks apart: once by the old classification followed by the new 2018 OTA/AO classification. Each radiographic series included lateral hip and anteroposterior initial radiographs. Eight random cases were duplicated in each of the surveys to evaluate the intraobserver reliability. MAIN OUTCOME MEASUREMENTS: Intraobserver and interobserver of the group, subgroup and fracture stability classification determined by the interclass coefficient (ICC) and Cohen kappa values. RESULTS: The interobserver reliability for the group classification (31A1/A2/A3) was moderate using the new classification, whereas substantial agreement was shown using the old classification (0.49 and 0.69, respectively). The reliability of the fracture stability classification was higher using the old classification (0.70 vs. 0.52). Subgroup classifications interobserver agreement was fair for both classification systems, although lower reliability was shown in the old classification (0.34 vs. 0.31). CONCLUSIONS: The new OTA/AO classification has a lower interobserver reliability for THF classification when compared with the old one.

Is It Safe to Resume Direct Oral Anticoagulants upon Discharge after Hip Fracture Surgery? A Retrospective Study.

This study aimed to examine the incidence rate of early reoperations following hip fracture surgery and determine the safety of resuming direct oral anticoagulants. Many orthopedic surgeons are reluctant to resume chronic anticoagulation therapy for patients after surgical intervention for hip fractures. One of the main reasons is the potential for reoperation in the case of surgical complications. We conducted a retrospective cohort study at an Academic Level I trauma center, reviewing the records of 425 geriatric patients (age > 60) who underwent hip fracture surgery between 2018 and 2020, including a subgroup treated with direct oral anticoagulants prior to hospitalization. The study assessed the incidence rate of complications requiring early reoperation. Out of the 425 patients, only nine (2%) required reoperation within a month after discharge, with two (0.5%) on chronic anticoagulation therapy. None of the reoperations were urgent, and all were performed at least 24 h after re-admission. The findings revealed a very low incidence rate of reoperations in patients who underwent hip fracture surgery, with no reoperations performed within 24 h of re-admission. Consequently, we believe that resuming chronic direct oral anticoagulants is a safe and effective approach when discharging patients after hip fracture surgery.