Posterior Malleolar Fracture Assessment: An Independent Interobserver and Intraobserver Validation of Three Computed Tomography-Based Classifications.

BACKGROUND: Posterior malleolus fractures occur in up to 50% of all ankle fractures. Several classification systems exist for their characterization, especially under CT. However, those classifications do not report the level of agreement or do it incompletely. This study aims to independently assess three posterior malleolus fracture classifications (Haraguchi, Bartonícek/Rammelt, and Mason). METHODS: This study was designed according to the Guidelines for Reporting Reliability and Agreement Studies. Ninety-four CT scans of patients with ankle fractures that had posterior malleolus fractures were included. Posterior malleolus fractures were assessed by six evaluators (three attending foot and ankle surgeons and three orthopaedic surgery residents) according to Haraguchi, Bartonícek/Rammelt, and Mason classifications. All images were reassessed by the same evaluators in a random sequence 3 weeks later. The kappa (k) coefficient was used to determine the interobserver and intraobserver agreement. Statistical significance was established using P < 0.05 with a 95% confidence interval (CI). RESULTS: The interobserver agreement was moderate for Haraguchi, Bartonícek/Rammelt, and Mason classifications with a global k value of 0.52 (95% CI, 0.43 to 0.60), 0.53 (95% CI, 0.46 to 0.61), and 0.54 (95% CI, 0.47 to 0.62), respectively. The intraobserver agreement was substantial for Haraguchi, Bartonícek/Rammelt, and Mason classifications, with an overall k value of 0.70 (95% CI, 0.64 to 0.74), 0.73 (95% CI, 0.68 to 0.78), and 0.73 (95% CI, 0.69 to 0.78), respectively. Interobserver and intraobserver agreement among orthopaedic surgeons and residents had no significant difference. CONCLUSION: The current classifications for posterior malleolus fractures showed a substantial intraobserver agreement. Nevertheless, the interobserver agreement obtained was just moderate for all classifications, independent of the level of expertise of the evaluators.

[Acute kidney injury caused by rhabdomyolysis as a SARS-CoV-2 infection manifestation. Report of one case]. / Insuficiencia renal aguda secundaria a rabdomiolisis como manifestación de infección por SARS-CoV-2.

SARS-CoV-2 infection has a wide spectrum of clinical manifestations secondary to the impairment of different organs, including kidney. Rhabdomyolysis is produced by disintegration of striated muscle and the liberation of its contents to the extracellular fluid and bloodstream. This may produce hydro electrolytic disorders and acute kidney injury. We report a 35-year-old female with a history of SARS-CoV-2 infection who was hospitalized because of respiratory failure and developed renal failure. The etiologic study showed elevated total creatine kinase levels and a magnetic resonance imaging confirmed rhabdomyolysis. The patient required supportive treatment with vasoactive drugs, mechanic ventilation and kidney replacement therapy. She had a favorable evolution with resolution of respiratory failure and improvement of kidney function.

Insuficiencia renal aguda secundaria a rabdomiolisis como manifestación de infección por SARS-CoV-2 / Acute kidney injury caused by rhabdomyolysis as a SARS-CoV-2 infection manifestation: report of one case

SARS-CoV-2 infection has a wide spectrum of clinical manifestations secondary to the impairment of different organs, including kidney. Rhabdomyolysis is produced by disintegration of striated muscle and the liberation of its contents to the extracellular fluid and bloodstream. This may produce hydro electrolytic disorders and acute kidney injury. We report a 35-year-old female with a history of SARS-CoV-2 infection who was hospitalized because of respiratory failure and developed renal failure. The etiologic study showed elevated total creatine kinase levels and a magnetic resonance imaging confirmed rhabdomyolysis. The patient required supportive treatment with vasoactive drugs, mechanic ventilation and kidney replacement therapy. She had a favorable evolution with resolution of respiratory failure and improvement of kidney function.

A novel intraoperative technique seeding morselized bone tissue into pediatric blood culture bottles improves microbiological diagnosis in patients with foot and ankle osteomyelitis.

BACKGROUND: Osteomyelitis, particularly cases involving the foot and ankle, is a challenging situation that frequently leads to amputations and major sequelae. Targeted antibiotics treating an identified pathogen are key to a successful outcome; however, traditional culture methods for bone tissue have poor sensitivity. This study prospectively compared a novel method for obtaining and processing infected bone tissue with the standard technique. METHODS: 107 patients presenting with a diagnosis of osteomyelitis of the foot and ankle between 2008 and 2017 were prospectively included. Diagnosis was done according to clinical, laboratory and imaging findings. We obtained paired samples of bone tissue from all patients; they were processed through a usual culture method (UCM), but they were also morselized and seeded into pediatric blood culture bottles (PBCBs). We compared the culture yield and the number of agents detected using both the McNemar and the Mann-Whitney tests, respectively. RESULTS: We studied 107 patients (63 with diabetic foot infection and 44 with nondiabetic osteomyelitis). The causative agent was identified in 60.7% of cases using the UCM and in 97.2% of cases using PBCBs (p < 0.001). We detected a mean of 1.05 ± 1.03 bacteria using the UCM and 1.67 ± 0.92 bacteria using PBCBs (p < 0.01). CONCLUSION: Cultures using morselized bone seeded in PBCBs identified the causative agent in a significantly larger percentage than the UCM. Additionally, this method identified a larger number of pathogen agents. A better agent identification method has advantages such as identifying more specific antibiotic treatment in these cases.

A New Classification System for Pilon Fractures Based on CT Scan: An Independent Interobserver and Intraobserver Agreement Evaluation.

BACKGROUND DATA: A new pilon fracture classification system based on CT scan data was recently published, showing almost perfect interobserver and intraobserver agreement among the authors who developed it. However, an independent assessment has not been done. OBJECTIVE: To do an independent agreement evaluation of the new pilon fracture classification system with physicians with different levels of expertise in the management of pilon fractures. METHODS: Seventy-one cases of acute pilon fracture were retrospectively collected. Fractures were classified by six evaluators (three foot and ankle surgeons and three orthopaedic surgery residents) using CT scans according to the morphological grading of the new pilon fracture classification system developed by Leonetti et al. Cases were presented to the same evaluators in a random sequence after a 6-week interval to determine intraobserver agreement. The kappa coefficient (κ) was used to determine agreement among evaluators. RESULTS: The interobserver agreement was substantial regarding the main fracture type (I, II, III, or IV), with an overall κ value of 0.69 (0.65 to 0.72). When including the II and III subtypes, the overall agreement was still substantial, with a κ value of 0.61 (95% confidence interval: 0.58 to 0.64). The intraobserver agreement was substantial when considering the main fracture categories (I, II, III, or IV), with a κ value of 0.78 (confidence interval: 0.72 to 0.84), and full agreement at the type level was observed in 76% (324/426) of evaluations. There was no notable difference between the foot and ankle surgeons and orthopaedic surgery residents in the interobserver and intraobserver agreement. CONCLUSION: The new classification system demonstrated substantial interobserver and intraobserver agreement between evaluators with different levels of expertise in the management of pilon fractures. Prospective studies should be done to evaluate its prognostic value and utility in clinical practice.

Cultured autologous bone marrow stem cells inhibit bony fusion in a rabbit model of posterolateral lumbar fusion with autologous bone graft.

Mesenchymal stem cells (MSCs) have been isolated from various tissues and expanded in culture. MSCs add osteogenic potential to ceramic scaffolds when used together. A spinal fusion rabbit model was used to evaluate whether a pellet of cultured, autologous bone marrow MSCs (BMSCs) with osteogenic differentiation could increase the fusion rate when co-grafted with an autologous bone graft compared to autograft alone. Thirty rabbits were randomly assigned to two groups. Group 1 received bone autograft alone and Group 2 received bone autograft plus a pellet of cultured and differentiated BMSCs. Group 2 rabbits had a bone marrow puncture, after which the BMSC were cultured and osteoblastic differentiation was induced. BMSC cultures were obtained from 12 of 15 rabbits. The 27 rabbits underwent a bilateral, L4-L5 intertransverse fusion with an autograft and in Group 2 rabbits a pellet of differentiated BMSCs was added to the autograft. In Group 1, the fusion rate was 53% (8 of 15 rabbits) and in Group 2 the fusion rate was 0% (p<0.05). Adding differentiated BMSCs in a pellet without a scaffold not only failed to increase fusion rate, but completely inhibited bony growth.

Chronic liver failure and concomitant distant infections are associated with high rates of neurological involvement in pyogenic spinal infections.

STUDY DESIGN: A retrospective study of a consecutive series of all patients with pyogenic spinal infections treated at a single institution over a 10-year period. OBJECTIVE: To investigate risk factors for neurologic impairment with pyogenic spinal infections. SUMMARY OF BACKGROUND DATA: Pyogenic spinal infections are frequently associated with neurologic deficit at the time of initial diagnosis. Current evidence suggests that advanced age, diabetes mellitus, rheumatoid arthritis, systemic corticosteroid therapy, impaired immune status, infection with Staphylococcus aureus, and more proximal infections are risk factors for neurologic involvement. To the authors' knowledge, however, the influence of chronic liver failure or concomitant nonspinal infection has not been previously investigated. METHODS: A review of all patients discharged with a diagnosis of pyogenic spinal infection was performed. Data were collected, including age, sex, site of infection, degree of neurologic impairment, bacterial organism isolated, and various medical comorbidities such as diabetes mellitus, rheumatoid arthritis, chronic corticosteroid therapy, chronic liver failure, chronic renal failure, smoking, human immunodeficiency virus infection, intravenous drug abuse, cancer, cardiac disease, and the presence of a distant, nonspinal site of infection. RESULTS: Fifty-five consecutive patients with pyogenic spinal infections were identified. Statistical analysis demonstrated that the presence of an epidural abscess, chronic liver failure, or a distant nonspinal infection were the only significant risk factors for neurologic involvement. CONCLUSION: The current data suggest that chronic liver failure and the presence of a distant nonspinal infection are possible risk factors for neurologic involvement in patients with pyogenic spinal infections. These risk factors have not been previously described. This knowledge warrants closer surveillance for neurologic deficit in patients with these conditions.

Early histologic changes following polymethylmethacrylate injection (vertebroplasty) in rabbit lumbar vertebrae.

STUDY DESIGN: An ex vivo histologic study in rabbits. OBJECTIVE: To evaluate the early histologic effects of polymethylmethacrylate (PMMA) injection on bone and intraosseous neural tissue following vertebroplasty in rabbit lumbar vertebrae. SUMMARY OF BACKGROUND DATA: Vertebroplasty with PMMA is performed to treat painful osteoporotic vertebral fractures. Early pain relief has been consistently documented, but its mechanism has not been elucidated. Among the mechanisms of pain relief may be the immediate stabilizing effects of the cement, and the exothermic reaction during curing, which may lead to intraosseous neural ablation. It has been well established that PMMA can induce thermal osteonecrosis after arthroplasty, but the potential for osteonecrosis after vertebroplasty has not been established. Previous studies have suggested that temperature elevations during cement curing may induce thermal bone necrosis. However, this cause-and-effect relationship has not yet been histologically studied in an animal model. METHODS: Vertebroplasty with PMMA was performed at 2 levels in 12 New Zealand rabbits (24 levels); trochar insertion without PMMA injection was performed at 3 levels each of 2 control animals (6 levels). Sacrifice was performed 24 hours after the procedure. Histologic examination was performed to evaluate the presence of bone or intraosseous neural tissue necrosis. RESULTS: Half of the levels with PMMA showed evidence of necrosis at the bone-cement interface. Almost all (11 of 12) showed only focal necrosis, with only 1 specimen showing necrosis along the entire periphery of the PMMA. The other 12 specimens and all control levels displayed no bone necrosis. There was no evidence of intraosseous neural tissue necrosis in control or PMMA-injected specimens. CONCLUSION: Injection of PMMA in rabbit lumbar vertebral bodies produces early, focal bone necrosis in only half of cases, suggesting that competency of the cement-bone interface is reasonable in most cases. No evidence of intraosseous neural tissue damage was found.