Prevalence and Clinical Significance of Antiphospholipid Antibodies in Hospitalized Patients With COVID-19 Infection.

BACKGROUND: Coronavirus disease 2019 (COVID-19) infection is associated with an increased risk of arterial thromboembolic events (ATE) and venous thromboembolic events (VTE). Hypercoagulability associated with COVID-19 infection is multifactorial, and underlying pathogenic mechanisms potentially responsible for thrombosis include inflammation resulting in endothelial damage, platelet activation and the presence of antiphospholipid antibodies (APAs). Antiphospholipid antibody syndrome is one of the very few causes which is associated with venous and arterial thromboembolic events. COVID-19 patients have a high prevalence of APAs as well as both ATE and VTE, but their clinical significance in COVID-19 patients is not fully understood yet. OBJECTIVES: In this study, we intend to find the prevalence of APAs in hospitalized COVID-19 patients at the time of diagnosis and determine whether their presence has any clinical significance. METHODS: This is a retrospective single-institution study involving patients hospitalized for the management of COVID-19 infection at The University of Toledo Medical Center. After obtaining approval from the biomedical institutional review board at The University of Toledo, antiphospholipid antibody (APA) testing was done on pre-stored blood samples of these patients and hospital charts were reviewed till six months from the positive COVID-19 test result. Two groups were created based on the patients' APA testing results (APA positive and APA negative) and used for statistical comparison. Any patients with positive lupus anticoagulant (LA) or abnormal titers APA antibodies were labeled as positive. Demographic data, prognostic outcomes and laboratory values were compared either using Mann-Whitney U-test for continuous variables or Fisher's exact test for categorical variables. RESULTS: The prevalence of APAs in hospitalized COVID-19 patients at the time of diagnosis was 39.3% in this study. There was no difference in demographic variables between the APA-positive and APA-negative groups. The prevalence of APAs was higher in smokers, where 91% of the APA-positive patients were smokers. There was no statistically significant difference in prognostic outcomes including six-month mortality between APA-positive and APA-negative patients. The comorbidity profile was the same in the two groups. APA-positive patients were found to have lower nadir of absolute lymphocyte count and higher nadir levels of C-reactive protein during hospitalization. CONCLUSIONS: The prevalence of APA positivity in hospitalized COVID-19 patients is higher in our study than in historical studies involving non-COVID-19 hospitalized patients, particularly in smokers. However, there is no correlation between APA positivity and prognostic outcomes including six-month mortality. At this point, it is unclear whether APAs are just bystanders or have a pathogenic role. Routine testing of APA in COVID-19 patients is not indicated. Further prospective studies to elucidate the persistence and clinical implications of APAs are needed.

Inappropriate antibiotic administration in the setting of Charcot arthropathy: A case series and literature review.

AIMS: Differentiating Charcot neuropathic osteoarthropathy (CN) from infection is challenging. The diagnosis of CN is often missed or delayed, resulting in inappropriate and delayed treatment. We hypothesized that the misdiagnosis of CN results in inappropriate antibiotic prescriptions and explore the sequelae of unnecessary antibiotic use. METHODS: A retrospective review of patient electronic medical records from January 2010 to December 2017 was conducted for those diagnosed with CN after being referred to an orthopaedic foot and ankle specialist. RESULTS: Our review showed 58 of 103 (56%) patients received antibiotics on the date, or within the next 7 days, of referral to foot and ankle orthopaedic specialist. The antibiotic of choice given on referral were as follows: Sulfamethoxazole/Trimethoprim 18 of 58 (31%), doxycycline 13 of 58 (22%), clindamycin 13 of 58 (22%), cephalexin 9 of 58 (16%), minocycline 5 of 58 (9%). CONCLUSION: Missed diagnoses for CN are common and result in complications stemming from inappropriate treatment, delays in appropriate therapy, and may accelerate antibiotic resistance. Misdiagnosis of CN contributes to the inappropriate use of prescription antibiotics.

A Systematic Review of the Outcome Evaluation Tools for the Foot and Ankle.

Background. The goal of this systematic review is to determine the most commonly used outcome measurement tools used by foot and ankle specialists and determine their limitations, such as whether they are validated, have floor/ceiling effects, and so on. Methods. A literature search was conducted to identify primary publications between January 1, 2012 and July 1, 2017 that concern care of the foot and ankle and use any established grading criteria to evaluate patients. Results. In 669 publications, 76 scoring systems were used. The 10 most common were American Orthopaedic Foot and Ankle Score (AOFAS), visual analog scale (VAS), Short Form-36 (SF-36), Foot Function Index (FFI), Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), SF-12, Short Musculoskeletal Function Assessment (SMFA), Ankle Osteoarthritis Scale (AOS), and Foot and Ankle Disability Index (FADI). AOFAS was used in 393 articles, VAS in 308, and SF-36 in 133 publications. AOFAS, VAS, and SF-36 were used to evaluate 23,352, 20,759, and 13,184 patients respectively. AOFAS and VAS were used simultaneously in 172 publications. Conclusion. While there are many different scoring systems available for foot and ankle specialists to use to assess or demonstrate the effectiveness of treatments, the AOFAS, while it is an unvalidated scoring system, is the most commonly used scoring system in this review. Clinical Relevance. This review presents data about commonly used patient reported outcomes systems in foot and ankle surgery. Levels of Evidence: Level III: Systematic review.

Idiopathic Peroneal Tenosynovitis Caused by a Previously Undiagnosed Auto-immune Condition.

In this case report, we present a unique case of idiopathic peroneal tenosynovitis in an otherwise healthy patient, presenting with a three-month history of pain over the lateral aspect of the right foot. Imaging revealed that fluid distention and synovial thickening distend the common peroneal tendon sheath and peroneus longus and brevis tendon sheaths. The patient was managed operatively with excision of the peroneus longus tendon, a side-to-side tenodesis, and Bröstrom-Gould lateral ankle ligament repair. Histologic examination was suggestive of a chronic inflammatory process possibly due to underlying autoimmune etiology. At three-month follow-up, the patient reported complete resolution of pain and is resuming normal activities without difficulty.

A Comparison of Removal Rates of Headless Screws Versus Headed Screws in Calcaneal Osteotomy.

BACKGROUND: Calcaneal osteotomy has been used to successfully treat both valgus and varus hindfoot deformities. Pain associated with implanted hardware may lead to further surgical intervention for hardware removal. Headless screws have been used to reduce postoperative hardware-associated pain and accompanying hardware removal, but data proving their effectiveness in this regard is lacking. The purpose of this study is to compare the rates of removal of headed and headless screws utilized in calcaneal osteotomy. METHODS: We conducted a retrospective chart review of 74 patients who underwent calcaneal osteotomy between January 2010 and December 2014. The cohort was divided into 2 groups by fixation method: a headed screw and a headless screw group. Bivariate associations between infection or hardware removal, and screw type, screw head width, gender, smoking status, alcohol, hypertension, diabetes, hyperlipidemia, age, and body mass index were assessed using t-tests and Fisher's exact/χ2 tests for continuous and discrete variables, respectively. RESULTS: Headed screws were removed more frequently than headless screws (P < .0001): 15 of 30 (50%) feet that received headed screws and 4 of 44 (9%) of feet that received headless screws underwent subsequent revision for screw removal. In all cases, screws were removed because of pain. The calcaneal union rate was 100% in both cohorts. CONCLUSION: The rate of screw removal in calcaneal osteotomies is significantly lower in patients who receive headless screws than in those receiving headed screws. LEVELS OF EVIDENCE: Level IV.

A Systematic Review of Current Surgical Interventions for Charcot Neuroarthropathy of the Midfoot.

Charcot neuroarthropathy of the foot, or Charcot foot, is a pathologic entity of the foot, associated with diabetes mellitus. Owing to the increase of diabetes mellitus in developed nations worldwide, the prevalence of Charcot foot has been increasing. The initial treatment of Charcot foot is often conservative, with methods including bracing, casting, and the use of customized orthopedic shoes. However, many cases of Charcot foot eventually require surgery, because the consequent destabilization of the foot associated with bone, joint, and nerve injury due to the pathology eventually leave patients unable to walk independently. The present systematic review analyzed the published data regarding surgical interventions for midfoot Charcot deformities and estimated the rates of common complications occurring with the surgical modalities studied. The main outcomes of interest analyzed in the present study were postoperative amputation and bony fusion. The included cohort of patients with Charcot foot was very heterogeneous in terms of the demographic and comorbid characteristics. However, even with this heterogeneity, the present study should provide useful information to surgeons in terms of the outcomes after some of the common surgical procedures for midfoot Charcot.

Microsurgical Removal of Microcatheter in the Middle Cerebral Artery During Resection of an Arteriovenous Malformation Resection.

Surgical resection is the current standard of therapy for the treatment of arteriovenous malformation (AVM). Endovascular embolization is commonly used as an adjunct prior to surgical resection because it is believed to reduce the risk of intraoperative bleeding. Embolization has been associated with other complications including visual deficits, vessel perforation, and catheter adhesion. Catheter adhesion in which retained segments are contained within the embolization cast are not necessarily cause for concern, but retention of larger portions may confer an increased risk of thrombus formation. Such cases warrant the removal of the retained segments or the patient may suffer serious complications including death related to cerebrovascular events. In this case report, we describe a unique case of catheter adhesion in which the extension of the feeding catheter and the length of the introducer was left in its entirety down to the entry portion at the level of the groin and later retrieved in its entirety by craniotomy.

Gravity Stress Radiograph Revealing Instability at the First Metatarso-Cuneiform Joint in Lisfranc Injury.

Lisfranc injuries are commonly missed in the acute setting, largely due to subtle findings that often require weightbearing radiographs or more complex imaging for diagnosis. The long-term consequences of missed injuries are debilitating osteoarthritis of the midfoot, but this may be prevented with appropriate diagnosis and treatment. This case study presents a Lisfranc injury initially diagnosed by gravity stress radiograph. While used for other injuries, there is no literature on the use of gravity stress radiographs for diagnosis of Lisfranc injuries. The use of this simple technique to accurately diagnose Lisfranc injuries may improve detection and patient outcomes.

Arthroscopic Treatment of Synovial Chondromatosis in the Ankle Joint.

Synovial chondromatosis of the ankle is rare and sparsely documented. Traditional surgical intervention is open loose body excision and synovectomy. Upon literature review, only two other cases were found to be managed arthroscopically. We report a case of synovial chondromatosis in a 54-year-old man leading to pain and limited range of motion of his ankle. This unique case of extensive nodule formation was treated via a three-port arthroscopic approach. Removal of loose bodies and synovectomy were successfully performed arthroscopically. A total of 76 loose bodies were removed and synovectomy performed using a 3.5 mm diameter full radius shaver. This case demonstrates that a three-port arthroscopic approach can provide adequate treatment while maintaining the superior risk profile inherent to arthroscopic intervention.