Operative Fixation of a Humeral Shaft Periprosthetic Fracture After IlluminOss: A Case Report.

CASE: An 82-year-old man sustained a periprosthetic fracture after IlluminOss photodynamic bone stabilization system (PBSS) stabilization for an impending pathologic fracture. Nonoperative management was unsuccessful, and he subsequently underwent operative fixation, which featured lag screw fixation of the spiral distal humeral shaft fracture and osteotomy followed by plate fixation of the pathologic humeral shaft fracture. CONCLUSION: This is the first article to report this complication with IlluminOss PBSS stabilization and details regarding revision surgery.

Monoblock tapered stems in management of UCS B2 and B3 periprosthetic fractures in revision total hip arthroplasty.

Aims: United Classification System (UCS) B2 and B3 periprosthetic fractures in total hip arthroplasties (THAs) have been commonly managed with modular tapered stems. No study has evaluated the use of monoblock fluted tapered titanium stems for this indication. This study aimed to evaluate the effects of a monoblock stems on implant survivorship, postoperative outcomes, radiological outcomes, and osseointegration following treatment of THA UCS B2 and B3 periprosthetic fractures. Methods: A retrospective review was conducted of all patients who underwent revision THA (rTHA) for periprosthetic UCS B2 and B3 periprosthetic fracture who received a single design monoblock fluted tapered titanium stem at two large, tertiary care, academic hospitals. A total of 72 patients met inclusion and exclusion criteria (68 UCS B2, and four UCS B3 fractures). Primary outcomes of interest were radiological stem subsidence (> 5 mm), radiological osseointegration, and fracture union. Sub-analysis was also done for 46 patients with minimum one-year follow-up. Results: For the total cohort, stem osseointegration, fracture union, and stem subsidence were 98.6%, 98.6%, and 6.9%, respectively, at latest follow-up (mean follow-up 27.0 months (SD 22.4)). For patients with minimum one-year of follow-up, stem osseointegration, fracture union, and stem subsidence were 97.8%, 97.8%, and 6.5%, respectively. Conclusion: Monoblock fluted stems can be an acceptable modality for the management of UCS B2 periprosthetic fractures in rTHAs due to high rates of stem osseointegration and survival, and the low rates of stem subsidence, and revision. Further research on the use of this stem for UCS B3 periprosthetic fractures is warranted to determine if the same conclusion can be made for this fracture pattern.

Does improved external rotation following reverse shoulder arthroplasty impact clinical outcomes in patients with rotator cuff pathology and external rotation less than 0°?

BACKGROUND: The purpose of this study was to (1) evaluate whether improved external rotation (ER) in patients with preoperative ER <0° impacts their clinical outcomes following reverse shoulder arthroplasty (RSA) for rotator cuff (RC) pathology and (2) describe the differences in preoperative factors and postoperative outcomes in this patient population. Our hypothesis was that clinical outcomes would not be affected by improvement in ER using a lateralized glenosphere design. METHODS: We retrospectively reviewed 55 patients with preoperative ER <0° who underwent primary RSA for RC pathology with lateralized glenosphere. Pre- and postoperative physician-reported ER was blindly measured using a videographic review of patients externally rotating their arm at the side. Patients were evaluated using 5 different patient-reported outcome score thresholds, measured at 12 months postoperatively: (1) minimal clinically important difference (MCID) for American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores (ie, ≥20-point increase); (2) MCID for Simple Shoulder Test (SST) scores (≥2.4-point increase); (3) visual analog scale (VAS) for pain score >0; (4) mean ASES score (≥75); and (5) mean SST score (≥6.8), each of which was used to stratify the patients into 2 groups-greater than or equal to vs. less than the threshold. This resulted in 5 different evaluations comparing the 2 groups for any difference in postoperative ER or preoperative factors, including Hamada and Goutallier scores. RESULTS: Regardless of the measured outcome, there was no difference in either postoperative physician- or patient-reported ER between patients who achieved scores higher or lower than the thresholds. Both Hamada and Goutallier score distributions were not different between groups across all the evaluated outcomes. Patients who achieved the MCID for ASES had worse preoperative VAS pain (7 vs. 4, P = .011) and SST (1 vs. 3, P = .020) scores. Across all outcome thresholds, except MCID for SST, pain reduction (ΔVAS) was significantly more pronounced in patients exceeding the thresholds. Improved forward flexion rather than ER was observed in those who achieved the ASES (160° vs. 80°, P = .020) and SST MCIDs (150° vs. 90°, P = .037). Finally, patients who exceeded the thresholds experienced higher satisfaction rates. CONCLUSION: Improvement in ER does not appear to impact patient-reported outcome measures, including ASES and SST in patients with preoperative ER <0° undergoing RSA with a lateralized glenosphere. Patients with more severe pain and worse function at baseline experience less postoperative pain and clinically significant improvement in their reported outcomes.

Medications Available for Weight Reduction in Elective Total Joint Arthroplasty.

Arthroplasty in patients with elevated body mass index results in increased rates of reoperation, instability, revision, and infection. Preoperative weight loss may reduce the complication rate associated with orthopaedic surgery. In addition to lifestyle modification, anti-obesity medications are available to help patients to reduce their preoperative weight. Currently, there are 6 U.S. Food and Drug Administration (FDA)-approved anti-obesity medications in the United States: phentermine, orlistat, phentermine with topiramate extended release (ER), lorcaserin, sustained release (SR) naltrexone with bupropion, and liraglutide. Anti-obesity medications potentially provide a new way to optimize patients before surgery and to ensure successful recovery postoperatively.

The Grave Consequences of Late Presentation and Management of Rare Double Left Ventricle Chamber With Cardiomyopathy.

A double­chambered left ventricle is a rare congenital anomaly. We present the case of a 26-year-old man with such anomaly who presented with congestive heart failure. After this diagnosis was confirmed with echocardiography, surgical removal of the anomalous band and replacement of the regurgitant deformed mitral valve were performed. Postoperatively, the patient deteriorated, and no corrective response was associated with surgery. Herein we discuss what we have learned from this rare case and how it may apply to the management of similar cases in the future.

Acute Myocardial Ischemia Secondary to Embolization of Left Atrial Myxoma to Coronary Artery.

Cardiac myxoma is the most common primary cardiac tumor. Rarely it can present with systemic or coronary embolization due to fragmentation of the tumor mass. We present a case of a young male who presented with an acute myocardial ischemia secondary to embolization of a left atrial myxoma originating from the left atrium. The patient underwent successful emergency surgical management of both the myxoma and the occlusion of the coronary artery. In this scenario, the surgery is the only effective treatment. The case also highlights the significance of performing emergency echocardiography in the setting of acute myocardial ischemia to look for possible associated pathology which can inform management plan.

Resident Knowledge and Perception of Pain Management.

Chronic pain involves a complex mechanism that afflicts 50 million adults in the United States and incurs societal costs upwards of $560 billion annually. The consequences of this epidemic have resulted in an epidemic of its own, with the opioid crisis becoming a top priority in healthcare. Historically, the sub-optimal practices of overprescribing opioids and inadequate monitoring of iatrogenic addiction have contributed to this problem. If progress is to be made in this area, it is imperative that we examine how future physicians are being trained to manage pain. We examined internal medicine resident knowledge regarding pain as well as their satisfaction with medical school preparation in this regard using two surveys: The Knowledge and Attitudes Survey Regarding Pain (KASRP) and The Medical School Pain Curriculum Survey (MSPCS). Residents scored an overall 60.7% on the knowledge assessment survey, and less than 50% of respondents agreed that their medical school curriculum had prepared them sufficiently. This suggests that improvements can be made in medical school curricula regarding pain management education to better train physicians on how to manage pain, particularly in an era that demands expertise in this area.

Combined Coronary Artery Bypass Grafting and Extra-anatomic Ascending Aorta to Bifemoral Grafting Through Median Sternotomy.

A high proportion of patients with severe systemic atherosclerotic disease present with the involvement of both the coronary and aortoiliac arteries. For these patients with multiple comorbidities and high surgical risk, it is critical to minimize the overall physiologic burden of the operation when possible. Furthermore, with severe or complete occlusion of vascular supply to the lower extremities, it is beneficial to avoid two-stage surgeries because of the high risk of irreversible ischemia necessitating amputation. In select cases, a single combined operation without entering the abdominal cavity may be a reliable option. We present a case with excellent results using the technique of coronary artery bypass grafting (CABG) and extra-anatomic ascending aorta to bifemoral grafting through median sternotomy and subcutaneous tunneling. Furthermore, there is a wide variation in anticoagulation reversal practices among surgeons after performing these combined grafting operations. We administered only half of the ideal calculated protamine dose for reversal of heparinization, which achieved favorable results in our patient. Overall, with symptomatic occlusion of the coronary and aortoiliac arteries, combined CABG and extra-anatomic aortobifemoral grafting with subcutaneous tunneling is a reliable surgical option. The indication for this approach should be tailored to the anatomy of the lesion and the urgency of the clinical scenario.

Pneumomediastinum After Dental Filling: A Rare Case Presentation.

Pneumomediastinum and subcutaneous emphysema is an uncommon potentially life-threatening complication of dental procedures. Common causes of pneumomediastinum after dental procedures include tooth extraction, preparation, restorative treatment, endodontic treatment, and subgingival curettage that are associated with the use of handpieces and high-pressure air/water syringes. Herein, we present a case of pneumomediastinum with subcutaneous emphysema in a 40-year-old female who underwent two dental fillings and presented to our hospital with chief complain of facial swelling and odynophagia. The patient was managed conservatively, had an uneventful hospital course, and fully recovered. This case underlines the need for prompt diagnosis and management because of the risk of airway compromise, air embolism, and infection. The mechanism, clinical presentation, differential diagnosis, and complications are also reviewed.

Accidental ketosis-induced polyuria in a toddler: a case report.

BACKGROUND: In the pediatric population, parental concern of recent onset frequent or large volume urination in young children is common. CASE PRESENTATION: A 2-year-old male with no significant past medical history and unremarkable family history was brought to his pediatrician by his mother who reports that the child had been "soaking through his diapers" for the previous two to 3 days. Mother states that patient has not had an appreciable change in the number of wet diapers per day, just the perceived weight/volume of each diaper. The patient's mother denied any recent illness, apparent abdominal pain, dysuria, or recent changes in his bowel movements. She similarly denied polydipsia, polyphagia, or gross hematuria in the patient. Patient's diet consists of eating a low carbohydrate with mostly high protein and fat diet that was similar to the paleo-type diet consumed by her and her husband. Meals over the recent days were even lower in carbohydrates than usual as the family was actively trying to consume healthier food options. On physical exam the child was found to be afebrile with a normal physical exam. A urine dipstick was performed and was positive for 2+ ketones and 1+ protein. Urine leukocytes and nitrites were negative, as was urinary glucose. A fingerstick blood glucose sample was 83 mg/dL. Based on the patient's physical examination, laboratory findings, and the history which revealed a very-low carbohydrate diet, a preliminary diagnosis of ketosis-induced polyuria was made. The patient's mother was advised to incorporate a greater portion of carbohydrates into her son's diet, with a follow-up scheduled for the following week. At the follow-up appointment the mother reports that she had continued the patient's carbohydrate intake and the excessive urine amount per wet diaper has not returned. Repeat urine dipstick confirmed the resolution of the ketonuria and proteinuria. CONCLUSION: This case illustrates the inadvertent consequences that can occur when parents impose new fad diets on their young children. The recent increase in the popularity of fad diets makes the consideration of alternative diets important to review in the patient history and subsequently include in the differential diagnosis of polyuria.

Hepatic Artery Aneurysm in the Setting of Acute Pancreatitis and Giant Cell Arteritis.

Visceral artery aneurysms are rare with an incidence of 0.1%-0.2%. Of these, 20% are hepatic artery aneurysms (HAAs). Despite the potential of remaining asymptomatic for long periods of time, the risk of rupture for HAAs is 20%-80%. Treatment includes operative management with open or endovascular techniques. HAA in the setting of pancreatitis has been reported in two prior cases outside of the United States. However, there have been no cases describing the association of HAA and giant cell arteritis (GCA). We present a rare case of an 80-year-old male with a history of GCA who was found to have developed HAA following an episode of acute pancreatitis that was repaired surgically with an open technique. To our knowledge, the association between HAA with acute pancreatitis and GCA has not been reported before.

Asynchronous Bilateral Obturator Hernias: A Suggested Approach to Reduce Morbidity of Obturator Hernias.

Obturator hernias (OHs) are rare pelvic hernias that involve the protrusion of intraperitoneal or extraperitoneal organs or tissues through the obturator foramen. Risk factors for OH patients include female gender, chronic disease, age, malnourishment, history of multiple pregnancies, anatomical enlargement of obturator foramen, increased intraabdominal pressure, and defective collagen metabolism. Since OHs have the highest mortality rate of all abdominal hernias, prompt diagnosis and treatment are critical. Prior research has demonstrated an increased likelihood of bilateral OHs relative to unilateral. We present the case of a 79-year-old female who presented with an obstructed OH six months after an operation for an OH on the contralateral side. Due to the potential morbidity and mortality associated with OHs and delay in discovery, we suggest evaluation and treatment of the contralateral side in patients who present with unilateral OHs.

Abdominal Apoplexy: A Case Study of Idiopathic Spontaneous Lesser Sac Hematoma.

Idiopathic spontaneous intraperitoneal hemorrhage (ISIH) is a rare event associated with high mortality. There have been multiple case reports of spontaneous rupture of middle colic pseudoaneurysms in the literature. Herein, we present a case of a 51-year-old female that presented with spontaneous rupture of the middle colic artery and associated massive intraabdominal hematoma without findings of a pseudoaneurysm. The patient underwent a computed tomography (CT) scan as an outpatient 24 hours prior to the onset of the bleeding due to abdominal pain without findings of hematoma or aneurysm of the mesenteric vessels. Subsequently, the patient underwent emergent exploratory laparotomy with findings of a massive hematoma in the lesser sac and spontaneous bleeding from the middle colic artery that was ligated. The patient had an uneventful postoperative course and fully recovered. To our knowledge, this is the second reported case of idiopathic bleeding from the middle colic artery without evidence of a pseudoaneurysm based on a current review of the literature.

A Challenging Diagnosis of Eosinophilic Cholangitis Requiring Resection of Extrahepatic Bile Ducts.

Eosinophilic cholangitis (EC) is a rare benign disease characterized by transmural eosinophilic infiltration of the biliary tree that may result in biliary stricture and obstructive jaundice. The pathophysiology remains unknown but is theorized to involve an allergic mechanism. EC is diagnostically challenging as it may mimic cholangiocarcinoma (CCA) clinically and radiographically and involves a broad differential diagnosis including benign and malignant pathologies. In addition to tumor markers, ultrasonography, contrast-enhanced computed tomography (CT), and magnetic resonance cholangiopancreatography (MRCP), proper evaluation of malignant processes may need biopsy through endoscopic retrograde cholangiopancreatography (ERCP) and surgical exploration. We present the case of a 47-year-old female diagnosed with EC upon exploratory laparotomy.

An Unusual Presentation of a Cardiac Foreign Body in a Pediatric Patient.

Cardiac foreign bodies (FBs) are rare. Their etiology can be attributed to penetrating injuries although they are also often found incidentally. The approach for removal of these FBs is variable and patient dependent. Although there is debate regarding indications for removal, there is a general consensus that symptomatic FBs presenting acutely, as well as asymptomatic FBs posing a greater risk of complication to the patient, should be removed. We present the case of a 14-year-old patient with a cardiac FB and a step-wise approach for removal.

Diaphragmatic Hernia Repair Using Biosynthetic Tissue Reinforcement Patch: A Case Series Experience.

Diaphragmatic hernias are commonly encountered by general surgeons. However, repair is often fraught with complications and recurrence. The use of extracellular matrix scaffolds for repair of damaged tissues through constructive remodeling is an effective surgical adjunct. Herein, we describe the repair of diaphragmatic hernias using GORE® BIO-A® Tissue Reinforcement patch in a series of patients.

An Unusual Presentation of Arteriovenous Malformation in a Pediatric Patient.

Arteriovenous malformations (AVMs) are defined as tortuous connections between arteries and veins that bypass the capillary system. Cerebral AVMs are rare with a general prevalence of 0.5%-1% with approximately one-fifth of these being diagnosed in infancy or childhood. Although most AVMs go undetected, the most common presenting symptom is hemorrhage. Despite a broad differential diagnosis for syncope described in the pediatric literature, there has been no report of AVM as the underlying etiology. We present a case of a seven-year-old female who presented with a single syncopal episode and was later found to have a large AVM involving mainly the thalamus on the right side and the basal ganglia with large intraventricular draining veins into the galenic venous system. To our knowledge, this is the only case reported of an AVM presenting as syncope in a pediatric patient.

Persistent Shoulder Pain Due to a Suprascapular Nerve Injury in the Setting of Trauma.

Suprascapular neuropathy is a rare cause of shoulder pain with an injury to the nerve intrinsically related to the anatomy and course of the suprascapular nerve. The common etiologies of a suprascapular nerve injury include repetitive overhead activity, rotator cuff pathology, and compression of the nerve at either the suprascapular or the spinoglenoid notch secondary to space-occupying lesions. Although uncommon, suprascapular nerve damage has been associated with scapular fractures previously. However, there is a scarcity of literature describing a suprascapular nerve injury as the etiology of persistent shoulder pain after trauma. We present the case of a 52-year-old male who was struck by a motor vehicle, suffered a scapular fracture, and developed persistent shoulder pain secondary to a suprascapular nerve injury diagnosed 15 months post trauma.

A Novel 3D Printed Titanium Implant for Anterior Cervical Discectomy and Fusion.

Cervical spondylosis is a common age-related disorder that results in pain, radiculopathy, and myelopathy. A retrospective chart and radiograph review of a 50-year-old male who underwent surgical treatment for correction of cervical radiculopathy was performed. Immediately after surgery the patient reported complete relief of his preoperative arm pain. In two weeks, he had recovered full strength and sensation. Six months postoperatively, the patient reported relief of all pain and complete recovery of strength and sensation. Anterior cervical discectomy and fusion (ACDF) with an open architecture titanium implant was successfully utilized to improve cervical radiculopathy. This technique increases the likelihood of fusion and improved patient outcome. The objective of the report is to highlight the treatment of cervical radiculopathy through anterior cervical discectomy and fusion with a 3D printed titanium alloy with an arched design and large porous openings. This is one of the first reports using this interbody device in a multilevel procedure.