Thyroid Metastasis to the Colon.

Approximately 1% of colorectal cancers can be attributed to metastatic neoplasms originating from other primary sources typically the lung, ovary, breast, prostate, kidney, or skin. Metastasis to the colon from the thyroid however is exceedingly rare. We present a 76-year-old man with a history of papillary thyroid carcinoma WHO presented with colon polyps consistent with carcinoma from his papillary thyroid carcinoma. The findings in this report suggest prompt colorectal cancer screening after thyroid cancer diagnosis and regular screening thereafter.

Follow-up Study on the Effects of Tendon Transfers and Open Reduction on Moderate Glenohumeral Joint Deformity in Brachial Plexus Birth Injury.

BACKGROUND: Soft-tissue contractures about the shoulder in patients with brachial plexus birth injury are common and can lead to progressive shoulder displacement and glenohumeral dysplasia. Open or arthroscopic reduction with musculotendinous lengthening and tendon transfers have become the standard of care. The clinical function and radiographic joint remodeling beyond the first 2 years after surgery are not well understood. METHODS: We performed a follow-up study of 20 patients with preexisting mild to moderate glenohumeral joint deformity who had undergone open glenohumeral joint reduction with latissimus dorsi and teres major tendon transfers and concomitant musculotendinous lengthening of the pectoralis major and/or subscapularis. Prospective collection of Modified Mallet and Active Movement Scale (AMS) scores and radiographic analysis of cross-sectional imaging for glenoid version, humeral head subluxation, and glenohumeral joint deformity classification were analyzed for changes over time. RESULTS: The average duration of radiographic follow-up was 4.2 years (range, 2 to 6 years). The mean glenoid version improved from -31.8° to -15.4° (p < 0.0001). The mean percentage of the humeral head anterior to the middle of the glenoid (PHHA) improved from 9.6% to 30.4% (p < 0.0001). The mean glenohumeral joint deformity score improved from 3.7 to 2.1 (p < 0.0001). CONCLUSIONS: All parameters showed the greatest magnitude of improvement between preoperative measurements and 1 year of follow-up. There were no significant changes beyond the 1-year time point in the Mallet scores, AMS scores, or radiographic outcome measures, possibly because of insufficient power, although trends of improvement were noted for some outcomes. No decline in outcome measures was found during the study period. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of sleeve gastrectomy on hypertension.

The objective of this study was to determine the effect of laparoscopic sleeve gastrectomy (LSG) on blood pressure in private practice settings. This study involved a retrospective review of 870 consecutive adult patients >18 y of age who underwent LSG over a period of 12 mo in a private bariatric surgery center. Data were collected from the preoperative and postoperative follow-up visits at 1, 3, 6, and 12 mo. The study population consists of 694 hypertensive and 176 normotensive patients. From the baseline to 12 mo after LSG, (1) mean body weight/body mass index decreased from 123 kg/44 kg/m2 to 94 kg/34 kg/m2 (P < .001); (2) mean systolic/diastolic blood pressure in hypertensive patients decreased from 131.9/79.9 to 127.6/77.1 mm Hg (P < .001); 3) only mean systolic blood pressure decreased in normotensive patients from 117.5 to 114.0 mm Hg (P < .001). One month after LSG, mean systolic blood pressure had decreased from 131.9 to 126.2 mm Hg (P < 0. 001) and the average number of antihypertensive medications per patient declined from 1.5 at the baseline to 0.6 (P < .001). Over the following 11 mo, blood pressure remained stable despite reduced antihypertensive therapy. Patients requiring more than two antihypertensive agents fell from 49% at the baseline to 22% at 12 mo. Hypertension resolved in 34% of patients. Linear regression analysis showed no association between change in body weight and change in systolic blood pressure. Within 1 mo of LSG, hypertensive patients experienced a significant decline in systolic blood pressure and antihypertensive therapy that remains unchanged at 12 mo in the face of major reductions in antihypertensive medications. Weight loss and blood pressure reduction may not be directly related.

Closed Versus Open Supracondylar Fractures of the Humerus in Children: A Comparison of Clinical and Radiographic Presentation and Results.

BACKGROUND: The purpose of this investigation was to compare the presentation and postoperative results of children treated for open and closed, completely displaced type III supracondylar humerus fractures (SCFs). METHODS: Thirty patients with open and 66 patients with closed, completely displaced type III SCFs were evaluated. Open fractures underwent irrigation and debridement, and all patients were treated by open or closed reduction and pin fixation. Medical records were reviewed to obtain demographic information as well as preoperative and postoperative clinical data regarding mechanism of injury, neurovascular status, associated injuries, postoperative range of motion, infections, and pain. Radiographs were evaluated to quantify displacement, Baumann's angle, humeral capitellar angle, position of the anterior humeral line, and adequacy of reduction. Outcomes were assessed using Flynn criteria. Mean clinical follow-up for the open and closed fracture groups was 8.9 and 5.7 months, respectively. RESULTS: Both groups were similar with respect to age, sex distribution, weight and body mass index, laterality of involvement, and mechanism of injury. At presentation, 35% of closed SCFs and 23% of open SCFs presented with abnormal neurovascular status. There was a higher prevalence of diminished/absent pulses or distal limb ischemia in patients with open injuries (27%) compared with closed fractures (18%). Conversely, severely displaced closed fractures were more commonly associated with nerve injury/palsy at presentation (35%) than those with open fractures (23%). Spontaneous nerve recovery was seen in 87% within 3 to 6 months. Postoperative loss of reduction and malunion were more common in the closed fracture group. However, 84% of patients achieved good-to-excellent results by Flynn criteria, with no appreciable difference based upon open versus closed fractures. CONCLUSIONS: With timely wound and fracture treatment, the clinical and radiographic results of children treated for open SCFs is similar to those with closed type III injuries, with little increased risk for infection, malunion, or neurovascular compromise. LEVEL OF EVIDENCE: Level III.

Regression of Left Ventricular Mass After Bariatric Surgery.

Notwithstanding the presence of hypertension, obstructive sleep apnea, or both, obesity is associated with increased left ventricular (LV) mass. The effects of bariatric surgery on LV mass have been sparsely investigated by M-mode and two-dimensional (2D) echocardiography. Overall, Roux-en-Y gastric bypass, adjustable gastric banding, and sleeve gastrectomy reduce LV mass. However, the reduction in LV mass is extremely variable. Besides duration and severity of obesity, presence of hypertension, obstructive sleep apnea or both, and type of surgical procedures, the inaccuracy of M-mode and 2D echocardiography for assessment of LV mass contributes to the variable effects of bariatric surgery on LV mass. Three-dimensional (3D) echocardiography may obviate the limitations of M-mode 2D echocardiography for assessment of LV mass and allow an accurate appraisal of the effects of bariatric surgery on LV mass.

Early Results of Drilling and/or Microfracture for Grade IV Osteochondritis Dissecans of the Capitellum.

BACKGROUND: Surgical treatment is recommended for patients with unstable osteochondritis dissecans (OCD) of the elbow. However, little information is available comparing the anticipated results from the host of techniques. In this investigation, clinical and radiographic resolution as well as return to sports rates were assessed in adolescent patients following loose body (LB) removal and drilling/microfracture of grade IV lesions. METHODS: We reviewed 21 adolescents treated with LB removal and drilling/microfracture for grade IV elbow OCD. Patients with additional elbow pathology, prior elbow surgery, or <1 year follow-up were excluded. Clinical resolution was defined as resolution of tenderness and radiographic resolution as resolution of edema on magnetic resonance imaging (MRI). Return to sport rates and Timmerman scores were assessed. Mean clinical and MRI follow-up times were 2.2±1.19 and 2.4±1.54 years, respectively. Clinical and radiographic parameters associated with clinical and/or radiographic resolution or return to sports were determined using penalized likelihood logistic regression. Wilcoxon signed-rank tests were used to evaluate the change in range of motion and in Timmerman scores. RESULTS: Fifteen (71.4%) patients had either clinical or radiographic resolution at most recent follow-up. Nine (50%) had complete resolution on MRI, whereas 13 (61.9%) were nontender at their follow-up. Four patients with recurrent LBs underwent revision surgery. There were no complications in the 21 index procedures. Eighteen (85.7%) patients returned to any sport, whereas 14 (66. 7%) returned to their primary sport. Elbow flexion and extension improved by medians of 12 and 21 degrees, respectively (P=0.002, 0.01). Timmerman scores improved by a median of 30 (P=0.001). Shorter duration of symptoms correlated with smaller OCD lesions (P=0.03) and with improved clinical or radiographic resolution and return to sport rates. CONCLUSIONS: The majority of patients with grade IV elbow OCD achieves clinical and/or radiographic resolution and return to sports 2 years after LB removal and drilling/microfracture. Recurrence may be seen, however, and further investigation is needed to assess the efficacy of this technique compared with other treatment strategies. LEVEL OF EVIDENCE: Level IV.

Preoperative electrocardiograms for nonsyndromic children with hand syndactyly.

PURPOSE: To examine the efficacy of preoperative electrocardiogram (EKG) screening for Timothy syndrome, a rare and fatal condition characterized by prolonged QT, in children referred for syndactyly release. METHODS: We reviewed the records of nonsyndromic syndactyly patients seen by a hand surgeon at our institution between 2007 and 2013. All underwent a preoperative screening EKG for Timothy syndrome. We reviewed the medical records for demographics, presentation, EKG results, and operative findings, and calculated median age at the time of EKG and surgery and frequency distributions for sex, side affected, EKG result, and clinical finding. The mean patient charge for EKG and interpretation was calculated. RESULTS: We identified 128 syndactyly patients, 72% of which were boys. Median age at the time of EKG testing and syndactyly release was 1 year. A total of 92% of patients had normal EKG results; one patient exhibited a prolonged QT. Ten patients (8%) had further cardiac evaluation because of the EKG result and were found to be normal on repeat testing. No patient met QT threshold for Timothy syndrome and all patients were cleared for surgery. The minimum patient charge for EKG testing was $183. CONCLUSIONS: To improve patient safety, some have advocated preoperative EKG testing for all children undergoing syndactyly release to rule out Timothy syndrome. Analysis of our experience failed to yield an instance of Timothy syndrome over a 7-year period. Although EKG charges were relatively low, costs resulting from additional testing, cardiology consultation, and provider and parent time should be considered. Our study does not support routine EKG testing for children referred for syndactyly release, and we have abandoned this practice. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.