Treatment of Mpox with Suspected Tecovirimat Resistance in Immunocompromised Patient, United States, 2022.

Reports of tecovirimat-resistant mpox have emerged after widespread use of antiviral therapy during the 2022 mpox outbreak. Optimal management of patients with persistent infection with or without suspected resistance is yet to be established. We report a successfully treated case of severe mpox in California, USA, that had suspected tecovirimat resistance.

Case Report: Mpox - Not Just a Rash.

Mpox (formally monkeypox) is an Orthopoxvirus associated with both zoonotic and person-to-person spread. Human mpox classically presents with rash and systemic symptoms. Although sporadic outbreaks of mpox have occurred worldwide, the 2022 outbreak is the first of pandemic significance. Thousands of geographically dispersed cases were reported beginning in May 2022. The clinical presentations and outcomes of mpox infection have varied greatly based on viral clade. Further guidance is needed for clinicians to diagnose and treat this emerging infection. We present five clinical vignettes of confirmed cases diagnosed in June and July 2022 in northern California to demonstrate the range of mpox disease, including myocarditis, pharyngitis, epididymitis, and proctitis. We note a significant overlap with HIV infection and a high rate of concurrent sexually transmitted infection. Given the heterogenous presentations of mpox disease, clinicians should maintain a high degree of suspicion in patients with oropharyngeal or genital lesions, proctitis, or new rash.

Myocarditis Attributable to Monkeypox Virus Infection in 2 Patients, United States, 2022.

We report 2 immunocompetent and otherwise healthy adults in the United States who had monkeypox and required hospitalization for viral myocarditis. Both patients were unvaccinated against orthopoxviruses. They had shortness of breath or chest pain and elevated cardiac biomarkers. No immediate complications were observed. They were discharged home after symptoms resolved.

Outcomes of Arthroscopic Anterior Labroligamentous Periosteal Sleeve Avulsion Lesions: A Minimum 2-Year Follow-up.

BACKGROUND: Anterior labroligamentous periosteal sleeve avulsion (ALPSA) lesions can occur in recurrent anterior shoulder instability, which may lead to the labrum scarring medially to the glenoid. ALPSA lesions have also been associated with greater preoperative dislocations, larger Hill-Sachs lesions, and greater degrees of glenoid bone loss. Therefore, patients with these lesions have historically had a higher failure rate after repair, with nearly double the recurrent instability rate compared with those undergoing standard arthroscopic Bankart repair. PURPOSE: To compare minimum 2-year outcomes of arthroscopic mobilization and anatomic repair of ALPSA lesions with those after standard arthroscopic Bankart repair. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Consecutive patients who underwent arthroscopic repair of ALPSA lesions were matched in a 1-to-3 fashion to patients who underwent standard Bankart repair by age, sex, number of previous ipsilateral shoulder instability surgical procedures, and number of anchors used. Patient-reported outcome (PRO) scores were compared preoperatively and postoperatively (American Shoulder and Elbow Surgeons [ASES]; 12-Item Short Form Health Survey [SF-12] Physical Component Summary [PCS]; Single Assessment Numeric Evaluation [SANE]; shortened version of Disabilities of the Arm, Shoulder and Hand; and satisfaction). Recurrent instability, on- versus off-track Hill-Sachs lesion, and reoperation rates were analyzed. RESULTS: A total of 100 shoulders (25 ALPSA and 75 Bankart) with an overall mean age of 25.7 years were evaluated. Patients in the ALPSA group demonstrated significant improvements in the ASES (preoperative, 74.8; postoperative, 89.7; P = .041) and SF-12 PCS (preoperative, 46.9; postoperative, 53.4; P = .021) scores but not the SANE score (preoperative, 65.2; postoperative, 75.3; P = .311). Patients in the Bankart group had significant improvements in all outcome scores at final follow-up: ASES (preoperative, 67.1; postoperative, 90.3), SANE (preoperative, 58.0; postoperative, 85.7), and SF-12 PCS (preoperative, 45.3; postoperative, 52.9) (all P < .001). There were no significant differences in PRO scores between the groups preoperatively or postoperatively (P > .05). The median satisfaction for the ALPSA group was 10 of 10 and for the Bankart group it was 9 of 10 (P = .094). There was a significantly higher rate of recurrent dislocation in the ALPSA group (8/25 [32.0%]) compared with the Bankart group (10/75 [13.3%]) (P = .040). Additionally, 5 patients (20.0%) in the ALPSA group underwent revision surgery at a mean of 5.6 years, and 8 patients (10.7%) in the Bankart group underwent revision surgery at a mean of 4.4 years (P = .311). CONCLUSION: Despite improvements in the recognition of and surgical techniques for ALPSA lesions, they still lead to significantly higher postoperative dislocation rates; however, no differences in PRO scores were found. These findings highlight the importance of early surgical interventions in anterior shoulder instability with the hope of lessening recurrent instability and the risk of developing an ALPSA lesion, as well as careful assessment of the quality of soft tissues and other risk factors for recurrence when considering what type of shoulder stabilization procedure to perform.

Shoulder Pathology on Magnetic Resonance Imaging in Asymptomatic Elite-Level Rock Climbers.

BACKGROUND: The prevalence of findings on shoulder magnetic resonance imaging (MRI) is high in asymptomatic athletes of overhead sports. PURPOSE/HYPOTHESIS: The purpose of this study was to determine the prevalence of atypical findings on MRI in shoulders of asymptomatic, elite-level climbers and to evaluate the association of these findings with clinical examination results. It was hypothesized that glenoid labrum, long head of the biceps tendon, and articular cartilage pathology would be present in >50% of asymptomatic athletes. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 50 elite climbers (age range, 20-60 years) without any symptoms of shoulder pain underwent bilateral shoulder examinations in addition to dedicated bilateral shoulder 3-T† MRI. Physical examinations were performed by orthopaedic sports medicine surgeons, while MRI scans were interpreted by 2 blinded board-certified radiologists to determine the prevalence of abnormalities of the articular cartilage, glenoid labrum, biceps tendon, rotator cuff, and acromioclavicular joint. RESULTS: MRI evidence of tendinosis of the rotator cuff, subacromial bursitis, and long head of the biceps tendonitis was exceptionally common, at 80%, 79%, and 73%, respectively. Labral pathology was present in 69% of shoulders, with discrete labral tears identified in 56%. Articular cartilage changes were also common, with humeral pathology present in 57% of shoulders and glenoid pathology in 19% of shoulders. Climbers with labral tears identified in this study had significantly increased forward elevation compared with those without labral tears in both active (P = .026) and passive (P = .022) motion. CONCLUSION: The overall prevalence of intra-articular shoulder pathology detected by MRI in asymptomatic climbers was 80%, with 57% demonstrating varying degrees of glenohumeral articular cartilage damage. This high rate of arthritis differs significantly from prior published reports of other overhead sports athletes.

Multilocular Thymic Cyst in a Patient with Untreated HIV/AIDS: Case Report and Review of the Literature.

BACKGROUND: Multilocular thymic cysts (MTCs) in adults with human immunodeficiency virus (HIV) are rarely reported. CASE PRESENTATION: We describe a case of symptomatic MTC in a male with untreated HIV. A presumptive diagnosis was established based on radiographic imaging and biopsy. Pathologic diagnosis and exclusion of malignancy were ultimately confirmed following thymectomy. In conjunction with starting antiretroviral therapy, the patient recovered well post-operatively with a resolution of his presenting symptoms. CONCLUSION: Our case report and review of the literature serve to highlight MTCs as an important clinical entity occurring in persons with HIV.

Autograft Versus Allograft: The Evidence in Hip Labral Reconstruction and Augmentation.

BACKGROUND: Labral augmentation and labral reconstruction have emerged as essential procedures for restoring the anatomic and functional characteristics of the hip joint in patients with a deficient hip labrum or irreparable labral tear. HYPOTHESIS/PURPOSE: The purpose of this study was to compare allograft and autograft hip labral reconstruction and augmentation. We hypothesized that autografts would entail fewer revision arthroscopic procedures. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Patients were identified who underwent labral reconstruction or labral augmentation using iliotibial band (ITB) allograft or ITB autograft performed by a single surgeon between 2011 and 2017. Patient-reported outcome measures collected before surgery and at minimum 2-year follow-up included the following: Hip Outcome Score Activities of Daily Living and Hip Outcome Score Sports-Specific Subscale and, at follow-up, patient satisfaction (range, 1-10, with 10 being very satisfied). Patients followed a standardized rehabilitation protocol after surgery with relative individualization to address each patient's needs. For continuous variables, comparisons between allografts and autografts were made using Student t tests or Mann-Whitney tests. Categorical comparisons were assessed using chi-square or Fisher exact test. Multiple logistic regression was performed to determine the influence of graft choice on risk of revision or THA. RESULTS: A total of 205 hips met 2-year inclusion criteria. ITB allografts were used for 55 patients (37 augmentations, 18 reconstructions) and ITB autografts for 150 patients (34 augmentations, 116 reconstructions). Females represented a greater proportion of allograft versus autograft patients (71% vs 46%, respectively; P = .001). Overall, autograft patients had larger alpha angles (66.6° vs 59.1°; P = .001) and longer grafts (46 vs 41 mm; P = .03) compared with allograft patients. A total of 13 (23.6%) patients required revision surgery in the allograft group compared with 11 (7.3%) in the autograft group (P < .001). After controlling for sex, procedure (reconstruction vs augmentation), and previous surgery, the odds of revision were higher for allograft patients (OR, 4.1; 95% CI, 1.5-11.6). No significant differences in conversion to THA were observed between groups (allograft = 9%; autograft = 6%; P = .50), even after adjustment for the above covariates (OR, 2.3; 95% CI, 0.6-7.9). No differences in postoperative patient-reported outcome measures or patient satisfaction were observed between groups. CONCLUSION: Labral augmentation or reconstruction with autograft has a significantly lower revision rate than labral augmentation or reconstruction with allograft.

Reliability of Plain Radiographs Versus Magnetic Resonance Imaging to Measure Tibial Slope in Sports Medicine Patients: Can They Be Used Interchangeably?

BACKGROUND: The slope of the tibial plateau has been proposed as a reason for failure of anterior cruciate ligament reconstruction. PURPOSE: To evaluate the interobserver reliability of measurements of tibial slope on radiographs versus magnetic resonance imaging (MRI) scans and to assess whether the modalities can be used interchangeably for this purpose. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: This retrospective study included 81 patients aged 18 to 30 years who were evaluated in a sports medicine setting for knee pain and who had lateral knee radiographs as well as knee MRI scans on file. Medial and lateral tibial plateau slope measurements were made by 3 blinded reviewers from the radiographs and MRI scans using graphic overlay software. The paired t test was used to compare measurements of the medial tibial plateau slope (MTPS) and lateral tibial plateau slope (LTPS) from radiographs and MRI scans. Intraclass correlation coefficients (ICCs) were calculated to determine intra- and interobserver reliability of measurements within each imaging modality, and Pearson correlation coefficients were calculated to determine the relationship between measurements on radiographs versus MRI scans. RESULTS: Imaging from 81 patients were included. The average MTPS was significantly larger on radiographs compared with MRI scans (8.7° ± 3.6° vs 3.7° ± 3.4°; P < .001), and the average LTPS was also significantly larger on radiographs compared with MRI scans (7.9° ± 3.4° vs 5.7° ± 3.7°; P < .001). ICC values indicated good to excellent intraobserver agreement for all imaging modalities (ICC, 0.81-0.97; P ≤ .009). The ICCs for interobserver reliability of MTPS and LTPS measurements were 0.92 and 0.85 for radiographs, 0.87 and 0.83 for MRI based off the subchondral bone, and 0.86 and 0.71 for MRI based off the cartilage, respectively (P < .001). Medium correlation was noted between radiographic and MRI measurements; Pearson correlation coefficients for radiographic versus subchondral MRI measurements were 0.30 and 0.37 for MTPS and LTPS, respectively. CONCLUSION: The average MTPS and LTPS were significantly larger on radiographs compared with MRI scans. Although tibial slope measurements using radiography and those using MRI are reliable between individuals, the measurements from radiographs and MRI scans cannot be used interchangeably, and caution should be used when interpreting and comparing studies using measurements of the tibial slope.

Posterior Glenoid Reconstruction Using a Distal Tibial Allograft.

Posterior shoulder instability is increasingly recognized and diagnosed in young athletes. These patients often present with vague shoulder pain rather than the frank instability commonly seen with anterior instability. Three common causes of posterior shoulder instability are congenital retroversion, a single traumatic event, or repetitive microtrauma with erosive effects. The critical determination when deciding on the appropriate treatment of posterior shoulder instability is the presence and degree of glenoid bone loss. In patients without bone loss, arthroscopic procedures have a high success rate with a failure rate of less than 10% and an 89% return-to-sport rate. The determination of the critical amount of bone loss that would permit an arthroscopic procedure is controversial, but recent reports that attempt to quantify the critical bone loss value posteriorly have ranged from 13.5% to 20%. This Technical Note describes our preferred method of open surgical treatment of posterior shoulder instability with posterior glenoid bone loss using an intra-articular distal tibial allograft.

Bilateral preretinal hemorrhage associated with Kikuchi-Fujimoto disease.

PURPOSE: To present a case of a patient with human immunodeficiency virus (HIV) disease and Kikuchi-Fujimoto disease (KFD) who presented with a unique pattern of retinopathy. OBSERVATIONS: A 7-year-old Taiwanese girl with HIV disease who was recently diagnosed with KFD had a sudden onset of blurry vision in both eyes one month after her KFD systemic symptoms had relatively resolved. Ophthalmic examination showed decreased visual acuity in both eyes (OU). On fundus examination, she had bilateral preretinal, subhyaloid, and vitreous hemorrhage that was more severe than anemic retinopathy. CONCLUSION: Ocular manifestations in Kikuchi-Fujimoto disease are rare; however, if they occur, presentations may vary. The exact etiology of the disease has remained elusive and controversial. This case is the first report of a patient with HIV disease and KFD presenting with ocular involvement. Furthermore, bilateral preretinal, subhyaloid, and vitreous hemorrhage, which was beyond anemic retinopathy, is an unprecedented manifestation of KFD that has not been previously reported. This case highlights the necessity for clinicians to consider all possible differential diagnoses when evaluating patients with similar findings to identify the best therapeutic approach and avoid unnecessary treatment.

Medial Biplanar Closing-Wedge Distal Femoral Osteotomy Using an Articulated Tensioning Device for Controlled Osteotomy Closure.

Isolated lateral compartment arthritis or focal chondral defects in the setting of genu valgum in young, active individuals can be treated with a varus-producing distal femoral osteotomy with or without cartilage treatment. Both medial closing-wedge and lateral opening-wedge techniques have been described, with neither demonstrating clear superiority. The objective of this Technical Note is to describe a technique of biplanar medial opening-wedge with controlled reduction using an articulated tensioning device to achieve a safe, reproducible result.

Arthroscopic Fixation of an Anterior Labroligamentous Periosteal Sleeve Avulsion (ALPSA) of the Shoulder.

Anterior labroligamentous periosteal sleeve avulsions represent a diagnostic and treatment challenge. They are associated with a higher number of preoperative dislocations, as well as longer chronicity, and commonly result in a scarred and medialized labrum and periosteal sleeve complex. Anterior labroligamentous periosteal sleeve avulsion lesions therefore may be commonly overlooked. The complexity of the injury pattern has been associated with double the failure rate of standard Bankart lesions after arthroscopic repair. The purpose of this article is to describe our preferred arthroscopic technique for achieving full mobilization of the labral-periosteal complex and restore it to its anatomic location using a knotless, all-suture anchor construct.

The Association Between Tibial Slope and Revision Anterior Cruciate Ligament Reconstruction in Patients ≤21 Years Old: A Matched Case-Control Study Including 317 Revisions.

BACKGROUND: There is evidence that tibial slope may play a role in revision risk after anterior cruciate ligament reconstruction (ACLR); however, prior studies are inconsistent. PURPOSE: To determine (1) whether there is a difference in lateral tibial posterior slope (LTPS) or medial tibial posterior slope (MTPS) between patients undergoing revised ACLR and those not requiring revision and (2) whether the medial-to-lateral slope difference is different between these 2 groups. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We conducted a matched case-control study (2006-2015). Cases were patients aged ≤21 years who underwent revision surgery after primary unilateral ACLR; controls were patients aged ≤21 years without revision who were identified from the same source population. Controls were matched to cases by age, sex, body mass index, race, graft type, femoral fixation device, and post-ACLR follow-up time. Tibial slope measurements were made by a single blinded reviewer using magnetic resonance imaging. The Wilcoxon signed rank test and McNemar test were used for continuous and categorical variables, respectively. RESULTS: No difference was observed between revised and nonrevised ACLR groups for LTPS (median: 6° vs 6°, P = .973) or MTPS (median: 4° vs 5°, P = .281). Furthermore, no difference was found for medial-to-lateral slope difference (median: -1 vs -1, P = .289). A greater proportion of patients with revised ACLR had an LTPS ≥12° (7.6% vs 3.8%) and ≥13° (4.7% vs 1.3%); however, this was not statistically significant after accounting for multiple testing. CONCLUSION: We failed to observe an association between revision ACLR surgery and LTPS, MTPS, or medial-to-lateral slope difference. However, there was a greater proportion of patients in the revision ACLR group with an LTPS ≥12°, suggesting that a minority of patients who have more extreme values of LTPS have a higher revision risk after primary ACLR. A future cohort study evaluating the angle that best differentiates patients at highest risk for revision is needed.

Mediastinal Mucormycosis: Case report, review of literature and treatment with continuous liposomal amphotericin B irrigation.

Mediastinal mucormycosis is an uncommon but lethal infection associated with an 83% mortality. We describe a case of fatal Rhizopus microsporus mediastinitis despite three exploratory mediastinal surgeries and complementary systemic and mediastinal irrigation with liposomal amphotericin B. We further review the literature on surgical and antifungal management of mediastinal mucormycosis.

The Effect of Obesity on Operative Times and 30-Day Readmissions After Anterior Cruciate Ligament Reconstruction.

PURPOSE: To understand the effect of obesity on operative times and 30-day readmission rates after arthroscopic anterior cruciate ligament reconstruction (ACLR). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology billing codes to identify all patients aged 18 years and older who underwent ACLR between 2007 and 2014. The Student t test was used for continuous variables, and the χ-square or Fisher exact test was used for categorical variables. Multivariate analysis was conducted to identify factors associated with 30-day readmission. RESULTS: We identified 9,000 patients who underwent ACLR. In the readmission analysis, the total readmission rate was 0.70%. After multivariate analysis, a body mass index (BMI) of 40 or greater was associated with a significantly increased risk of 30-day readmission (odds ratio, 3.06; 95% confidence interval, 1.09-8.57). An operative time of less than 80 minutes was associated with a decreased risk of readmission (odds ratio, 0.40, 95% confidence interval, 0.18-0.92). In the operative-time analysis, the mean operative time was 100.7 minutes. Older age was predictive of decreasing operative time, with the operative time being 32.75 minutes shorter in patients aged 65 years or older than in those younger than 25 years. After multivariate analysis, class II obesity (BMI of 35-39.9) predicted an increase of 7.11 minutes and class III obesity (BMI ≥ 40) predicted an increase of 8.70 minutes compared with normal weight (BMI of 18.5-24.9). CONCLUSIONS: Obesity is associated with longer operative times and increased 30-day readmissions after ACLR, with patients with a BMI of 40 or greater having over 3 times the risk of readmission compared with patients with a normal weight. Male sex, black race, and younger age are all also associated with increased operative times. LEVEL OF EVIDENCE: Level III, observational, retrospective cohort study.

Chronic Medial Epicondyle Avulsion: Technique of Fragment Excision and Ligament Reconstruction With Internal Brace Augmentation.

Medial epicondyle fracture nonunions of the elbow may lead to symptomatic instability in the high-demand or overhead athlete. These injuries are challenging to treat surgically because of the small residual bony fragment, the scarred and shortened chronically injured ulnar collateral ligament (UCL), which prevents it from being mobilized and reduced to its native position. To date, most described methods aim at reducing the displaced fragment and achieving union with the humerus. This usually can only be accomplished by releasing of the scarred UCL to mobilize the fragment. The scarred and attenuated residual ligament is then repaired to restore stability but is often inadequate to sustain high-level valgus loads. We describe a technique of excision of the bony fragment and UCL reconstruction with allograft, augmented with internal brace to provide medial stability to the elbow. The described method allows proper tensioning of the graft and provides immediate and secure fixation.

Splenic rupture from babesiosis, an emerging concern? A systematic review of current literature.

Babesiosis is a relatively common tick-borne parasitic infection of erythrocytes primarily affecting the northeastern United States. Babesiosis' prevalence and presentation have earned it the monikers "malaria of the northeast" and "Nantucket fever". Clinical presentation ranges from asymptomatic infection to severe infection including acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulopathy (DIC) or death. Since 2008, there have been a number of reports of splenic rupture in patients with the disease. We seek to provide a further understanding of this process, with the report of a case of splenic rupture followed by a systematic review of the current literature. We found that 87% of splenic rupture secondary to babesiosis occurred in male patients who are otherwise healthy, with an average of 56 years. Computed tomography is a reliable mode of diagnosis, and hemoperitoneum is the most common imaging finding. Patients with splenic rupture due to human babesiosis were successfully treated by various management strategies, such as conservative non-operative approach, splenic artery embolization, and splenectomy. The modality of treatment depends on patient's clinical course and hemodynamic stability, although spleen conserving strategy should be considered first whenever possible.

Carbon Dioxide Insufflation of the Knee in the Treatment of Full-Thickness Chondral Defects With Micronized Human Articular Cartilage.

BioCartilage (BC) is dehydrated, minced human hyaline articular cartilage that was developed as an adjunct to microfracture surgery to help stimulate the bone marrow and stem cells to form hyaline-like tissue in full-thickness chondral defects. The minced pieces of BC require a dry environment for application and can easily be disrupted by residual moisture of saline solution in the surrounding tissues. We present a technique of carbon dioxide insufflation during knee arthroscopy as a means of maintaining a dry environment for preparation of the bony bed during BC augmentation of microfracture surgery. This technique is safe and provides more than adequate visualization, as well as a dry environment, to make the arthroscopic application of BC significantly more efficient.