The Ulnar Olecranon-Coronoid Notch Angle Affects Terminal Elbow Extension in Children and Adolescents.

BACKGROUND: Limitations to terminal elbow extension (TEE) in pediatric populations have been commonly associated with the degree of ligamentous laxity and not bony factors. Ligamentous laxity, quantified through the Beighton score, is criticized for unreliably assessing joint mobility. This study aims to show that the olecranon-coronoid notch angle (OCNA) affects TEE in healthy children and adolescents. METHODS: A retrospective study of 711 pediatric patients treated for upper extremity and shoulder injuries was cross-sectionally studied at 2 tertiary centers from 2014 to 2021. Radiographs were used to measure the OCNA, humerocondylar angle, proximal anterior ulnar angle, and the presence of secondary centers of ossification. A 2-axis goniometer measured clinical TEE to a firm endpoint. The statistical analysis studied the relationships between OCNA and TEE and the effect that age and sex have on these measurements. RESULTS: Increased TEE was associated with increased OCNA (P<0.001) when accounting for age and sex. The average OCNA was 30.0 degrees (7.5 degrees), and the average TEE was 5.6 degrees (8.0 degrees). There was a difference in OCNA between subjects who had elbow hypoextension, normal TEE, and elbow hyperextension (P<0.001). The most common injuries were distal radius fractures (182, 26%), elbow sprains and contusions (111, 16%), distal both bone forearm fractures (95, 14%), single or both bone shaft fractures (77, 11%), and supracondylar fractures (74, 11%). CONCLUSION: These results show that the orientation of the opening of the olecranon-coronoid notch influences the arc of TEE motion in a healthy pediatric population. The notch restrains TEE by activating the bony block mechanism between the olecranon apophysis and the olecranon fossa. The measurement of the OCNA can serve as a reproducible and quantitative method to predict hypomobility to hypermobility of TEE motion. LEVEL OF EVIDENCE: Prognostic study: Level II.

Do Intra-articular Corticosteroid Injections Prior to Total Knee Arthroplasty Increase Postoperative Complication Rates: A Retrospective Review.

There is conflicting literature suggesting that intra-articular corticosteroid injections before total knee arthroplasty (TKA) may lead to an increase in the rate of postoperative complications, specifically periprosthetic joint infection (PJI). Thus, this retrospective review of all TKAs performed at a large, urban hospital will add valuable evidence to help guide future patient care. After exclusion criteria, we retrospectively reviewed 417 patients who received a TKA from a group of fellowship-trained orthopaedic surgeons between 2009 and 2016 at a single academic medical center. Minimum follow-up time was 1 year. Patients were separated into two groups: those who received a preoperative intra-articular corticosteroid injection and those who did not receive an injection. Subgroups were created based on the timing of their most recent preoperative injection: 0 to 3 months, 3 to 6 months, 6 to 12 months, 12+ months, and an unknown time period. Postoperative outcomes for PJI, revision TKA, and manipulation under anesthesia (MUA) were analyzed via a Chi-square test. No statistically significant postoperative differences were observed between groups: PJI (p = 0.904), revision TKA (p = 0.206), and MUA (p = 0.163). The temporal subgroups also failed to demonstrate a statistically significant result: PJI (p = 0.348), revision TKA (p = 0.701), and MUA (p = 0.512). This study revealed no absolute or temporal association between preoperative, intra-articular corticosteroid injections, and complications after TKA. Because these injections are a commonly used treatment modality prior to TKA, further studies should be conducted on a nationwide basis to draw more concrete conclusions.

Preventing Tommy John Surgery: The Identification of Trends in Pitch Selection, Velocity, and Spin Rate Before Ulnar Collateral Ligament Reconstruction in Major League Baseball Pitchers.

BACKGROUND: Ulnar collateral ligament (UCL) reconstruction is a common surgery among Major League Baseball (MLB) pitchers that results in a significant number of missed games. Little has been reported regarding game-by-game trends that can identify those on the verge of becoming injured. PURPOSE: To determine if there is a patterned change in MLB pitchers' pitch selection, velocity, or spin rate in games leading up to Tommy John surgery that may predict subsequent UCL surgery. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of MLB pitchers who underwent primary UCL reconstruction between 2009 and 2019 was performed. Pitch characteristics were evaluated on a game-by-game basis for the 15 games leading up to surgery. A Mann-Kendall trend test was used to identify trends in pitch selection, velocity, and spin rate for multiple pitch types. A Kendall τb correlation coefficient was identified, with values closer to 1 or -1 signifying a stronger monotonic trend. RESULTS: A total of 223 MLB pitchers underwent UCL reconstruction in the time period. In the 15 games leading up to surgery, decreases in pitch velocity for 4-seam fastballs (τb = -0.657; P < .001), 2-seam fastballs (τb = -0.429; P = .029), and sliders (τb = -0.524; P = .008) were significantly associated with game number closer to injury. There was a significant positive association in the spin rate for cutters (τb = 0.410; P = .038) and a significant negative association in spin rate for 4-seam fastballs over the course of these 15 games (τb = -0.581; P = .003). In addition, there was a significant positive association in the percentage of curveballs thrown (τb = 0.486; P = .013). CONCLUSION: The study results suggest that there is a patterned change in certain pitch statistics in MLB pitchers in the games leading up to Tommy John surgery. Although the absolute change from game to game may be small, it may be possible for these trends to be monitored before a player becomes injured, thus reducing the significant burden Tommy John surgery places on these athletes.

Is There an Association Between Authors' Conflicts of Interest and Outcomes in Clinical Studies Involving Autologous Chondrocyte Implantation?

BACKGROUND: Autologous chondrocyte implantation (ACI) is an increasingly popular technique for the treatment of articular cartilage defects. Because several companies have financial interests in ACI, it is important to consider possible conflicts of interest when evaluating studies reporting outcomes of ACI. PURPOSE: To determine whether there is an association between authors' financial conflicts of interest and the outcomes of ACI studies. STUDY DESIGN: Cross-sectional study. METHODS: A search of PubMed and MEDLINE databases for "autologous chondrocyte implantation" was performed. Clinical studies published after 2012 through May 15, 2019, and in English were included. Studies were determined to have financial conflicts of interest if any contributing author had relevant conflicts, either self-reported in the published study's disclosures section or reported online in the American Academy of Orthopaedic Surgeons Disclosure database or the Centers for Medicare & Medicaid Services Open Payments database. The outcomes of each study were rated as favorable, equivocal, or unfavorable based on predefined criteria and then tested for association with conflicts of interest through use of the Fisher exact test. RESULTS: A total of 79 studies met the inclusion criteria. Nearly all studies were of level 3 or 4 evidence. Conflicts of interest were established in 51.90% of studies (n = 41). Conflicts that were not self-reported by the authors were discovered in 18% of studies. The level of evidence was not associated with conflict of interest. No statistically significant difference was found in the rate of favorable outcomes between studies with conflicts (92.68%) and those with no conflicts (81.58%) (P = .126). Publications by US authors were more likely to have financial conflicts of interest (P = .003). CONCLUSION: Favorable results were reported in a majority of studies involving ACI. No statistical association was found between the frequency of favorable outcomes and the presence of financial conflicts of interest, country of authorship, or level of evidence. There was a trend toward more favorable outcomes in studies with conflicts of interest. Additionally, nearly 20% of publications had possible conflicts found online that were not self-reported. It is critical for orthopaedic surgeons to judiciously evaluate published studies and consider financial conflicts of interest before performing ACI techniques on patients.

Effect of marital status on patient-reported outcomes following total hip arthroplasty: a matched analysis with minimum 2-year follow-up.

INTRODUCTION: Mental health and patient expectation have been identified as key predictors of recovery following THA; however, there is limited literature examining the effects of social support and marital status on patient-reported outcomes (PROs). METHODS: Data were prospectively collected and retrospectively reviewed for patients who underwent THA between July 2008 and January 2016. Patients were included if they underwent primary THA during this period and if they had documented preoperative marital status of married, divorced, or never married. Married patients were group matched to non-married patients (divorced or never married) with similar sex, age, body mass index (BMI), gender distribution, and frequency of surgical approach. RESULTS: There were 414 married patients and 98 non-married patients who were eligible and had minimum 2-year follow-up. Mean PROs were significantly worse in the non-married group than the married group for the following measures: modified Harris Hip Score (p = 0.002), Harris Hip Score (p = 0.002), Forgotten Joint Score (p = 0.04), and the physical portions of the Veterans RAND (p = 0.025) and Short Form (p = 0.02) surveys. CONCLUSIONS: Our study demonstrated inferior absolute PRO scores at latest follow-up for patients who were non-married compared to married following THA. These results show that while total hip replacement may still yield clinical benefit in all patients, non-married patients may ultimately achieve an inferior functional status, and expectations should be adjusted accordingly. Physicians should assess levels of psychosocial support in their patients prior to undergoing hip arthroplasty in order to optimise results.

Chronic Exertional Compartment Syndrome of the Leg Management Is Changing: Where Are We and Where Are We Going?

Chronic exertional compartment syndrome (CECS) is one of the wide range of causes of exercise-related leg pain in athletes. It is defined as a transient increase in compartment pressures during activity, which causes pain, because of the inability of the fascial compartments to accommodate and is usually relieved by cessation of exercise. Exercise-induced leg pain in the athletic population is a common complaint, with reports of up to 15% of all runners arriving to initial evaluation with this presentation. Often, this lower-extremity exertional pain is grouped into the common term of "shin splints" by athletes, which is a nondiagnostic term that implies no specific pathology. It may, however, encompass much of the differential for CECS, including medial tibial stress syndrome, muscle strain, and stress fracture. Improving diagnostic techniques, as well as treatments, will continue to help athletes and patients with leg pain in the future.

Low Preoperative Albumin Levels Predict Adverse Outcomes After Total Joint Arthroplasty.

BACKGROUND: Low albumin levels have previously been shown to be a risk factor for increased complications in the 30-day postoperative period after total hip or knee arthroplasty. In this study, we examined the effect that albumin levels have on complications in all total joint primary arthroplasties or revisions (shoulder, elbow, wrist, hip, knee, ankle, and fingers). METHODS: Patients who underwent a primary total joint arthroplasty or revision from 2005 to 2015 and who had preoperative serum albumin concentration levels recorded were identified from the U.S. National Surgical Quality Improvement Program (NSQIP) database. Patients were grouped into those with normal serum albumin concentrations (≥3.5 g/dL) and those who were hypoalbuminemic (<3.5 g/dL); hypoalbuminemia was subdivided into quartiles for statistical analysis. Univariate analyses were conducted with use of the Student t test for categorical outcomes and the chi-square test for continuous variables. Following univariate analysis, all significant comorbidity variables for both the primary and revision arthroplasty groups were used in a multivariate regression analysis to determine independent association of hypoalbuminemia and postoperative outcomes. RESULTS: Using available data from 2005 to 2015, 135,008 patients fit the eligibility criteria, including those who had undergone primary arthroplasty (n = 125,162) and those who had undergone revision arthroplasty (n = 9,846). The revision arthroplasties included the shoulder (2%), hip (46%), and knee (52%), and the primary arthroplasties included the shoulder (3%), hip (39%), knee (57%), and other (1%). We found that patients who had lower albumin levels had a greater rate of postoperative complications including cardiac arrest, myocardial infarction, cerebrovascular accident, organ or space surgical site infection, sepsis, septic shock, pneumonia, renal insufficiency in general, unplanned intubation, return to the operating room within 30 days, urinary tract infection, and wound infection (all p < 0.005). CONCLUSIONS: There was a significant difference in 30-day postoperative complications between patients with normal preoperative albumin levels and those with low albumin levels after all primary total joint arthroplasties or revisions. Patients with low albumin levels were at significantly increased risk for infection, pneumonia, sepsis, myocardial infarction, and other adverse outcomes. Further research is needed to develop interventions to improve serum albumin concentrations preoperatively to mitigate adverse outcomes. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A systematic review of upper extremity neuropathy following total hip arthroplasty.

BACKGROUND: There is a paucity of literature describing upper extremity neuropathy following the procedure. We performed a systematic review of upper extremity neuropathy following total hip arthroplasty (THA) to provide characteristics regarding the incidence, suspected aetiology, and outcomes of such complications. METHODS: A systematic review of the literature was performed which investigated the COCHRANE and Medline databases regarding "peripheral neuropathy total hip arthroplasty" and "nerve palsy associated total hip arthroplasty." Studies were excluded if they were not Level I, II, or III of evidence or had incomplete reported data. Studies were evaluated and data was extracted for the analysis if they met all inclusion criteria. Data extracted was compiled to assess nerve injury, aetiology, and resolution of symptoms. RESULTS: The search included 77 articles and 4 were selected for inclusion. A total of 21,346 patients underwent a THA with 40 of those cases resulting in an upper extremity nerve injury yielding a complication rate of 0.20%. The most likely aetiology of the upper extremity neuropathy was a compression neuropathy related to improper patient positioning of the contralateral/ipsilateral arm. Full resolution was reported in 74.42% of these cases (32 of 43 cases). CONCLUSIONS: Upper extremity neuropathy following THA is a rare complication that presents with variations of sensory and motor deficits. A thorough attention to proper positioning of the upper extremity is necessary to mitigate this risk.

Return to Play in Amateur Soccer Players Undergoing Hip Arthroscopy: Short- to Mid-Term Follow-Up.

PURPOSE: To describe patient-reported outcomes (PROs) and return to play at any level in amateur soccer players undergoing hip arthroscopy for femoroacetabular impingement syndrome at short- to mid-term follow-up. METHODS: Data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy between March 2009 and June 2014. Patients who participated in amateur soccer within 1 year prior to surgery and intended to return to their sport after hip arthroscopy for femoroacetabular impingement syndrome were considered for inclusion in our study. Patients were excluded if they had a preoperative Tönnis osteoarthritis grade of 2 or greater, previous ipsilateral hip conditions or hip surgical procedures, or Workers' Compensation status. The patients from the initial group who had preoperative and minimum 2-year postoperative measures for the modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale for pain were included in our final group. In addition to PROs, data regarding the patients' return to soccer, surgical complications, and secondary surgical procedures were collected. RESULTS: A total of 41 patients were eligible for inclusion in our study, of whom 34 (82.9%) had a mean follow-up period of 47.4 months. Five patients were not eligible because they did not intend to return to soccer. There were 15 male hips (44.1%) and 19 female hips (55.9%). The mean age at surgery was 20.8 ± 7.4 years. All PROs and the visual analog scale score improved significantly from preoperatively to latest follow-up. Of the 34 patients, 27 (79.4%) returned to soccer. Of the patients who returned to soccer, 19 (70.4%) were competing at the same level or a higher level compared with their highest level within 1 year of surgery. Regardless of competitive level, 21 patients (77.8%) reported that their athletic ability was the same as or higher than it was within 1 year of surgery. CONCLUSIONS: Hip arthroscopy was associated with significant improvements in PROs for amateur soccer players. There was a high level of return to soccer and a high proportion of patients whose competitive level was similar or improved. As such, hip arthroscopy is a good option for soccer players, in the absence of underlying osteoarthritis, presenting with hip pathology. LEVEL OF EVIDENCE: Level IV, case series.

Greater Trochanteric Pain Syndrome: An Intraoperative Endoscopic Classification System with Pearls to Surgical Techniques and Rehabilitation Protocols.

Over the past decade, understanding of disorders compromising greater trochanteric pain syndrome (GTPS) has increased dramatically. Nonsurgical treatment options include physical rehabilitation and activity modification, anti-inflammatory as well as biologic injections into the peritrochanteric compartment, and administration of oral analgesics. Multiple open and endoscopic treatment options exist when nonsurgical management is unsuccessful in patients with refractory lateral-sided hip pain, with or without weakness. No true consensus exists within the literature regarding operative techniques of GTPS or postoperative rehabilitation protocols. We present an endoscopic classification system of GTPS with 5 distinct types, which seems to correlate well with preoperative diagnoses and postoperative rehabilitation protocols. The classification system is intuitive, and the corresponding surgical techniques are reproducible for surgeons treating peritrochanteric pathology. Level of Evidence: I (hip); II (extra-articular, impingement).

Arthroscopic Lysis of Adhesions With Manipulation Under Anesthesia Versus Manipulation Alone in the Treatment of Arthrofibrosis After TKA: A Matched Cohort Study.

Arthrofibrosis following total knee arthroplasty (TKA) is a debilitating complication. Treatment options include physical therapy, manipulation under anesthesia (MUA), and arthroscopic lysis of adhesions (ALOA) with or without MUA. The authors studied 70 patients with arthrofibrosis after TKA treated with MUA or ALOA plus MUA. In this matched cohort study, 35 patients were treated with MUA and 35 patients were treated with ALOA plus MUA. Total knee arthroplasty followed by MUA was performed by 2 surgeons and TKA followed by MUA plus ALOA was performed by 1 surgeon at 1 institution. Electronic records were used to collect information and match cohorts based on age, sex, body mass index, diabetes mellitus, perioperative range of motion (ROM), and timing of the procedure for arthrofibrosis. The combination of MUA and ALOA yielded changes in ROM: a 72.7% increase 4 to 12 weeks after index TKA (P=.032), a 50.0% increase 12+ weeks after TKA (P=.032), and a 99.8% increase in patients with a pre-manipulation ROM of 0° to 60° (P=.001). Manipulation under anesthesia yielded a 49.2% increase 4 to 12 weeks after TKA (P=.161), a 27.0% increase 12+ weeks after TKA (P=.161), and a 68.8% increase in patients with pre-manipulation ROM of 0° to 60° (P=.084). Patients treated with ALOA plus MUA had greater increases in ROM (P=.026) and final knee flexion (P=.028) compared with those treated with MUA alone. Arthrofibrosis following TKA is a complication that often requires additional procedures. Traditionally, ALOA is added 3+ months from index TKA, when abundant scar formation has occurred. This study found a benefit to ALOA plus MUA compared with MUA alone, with the largest benefit in patients whose pre-manipulation ROM was 0° to 60°. [Orthopedics. 2019; 42(3):163-167.].

A Case Report of a Radial Nerve Palsy Following Uncomplicated Total Hip Arthroplasty.

INTRODUCTION: Nerve injury is a known complication of total hip arthroplasty (THA), but it is most commonly seen in the lower extremities. There is, however, minimal discussion about the incidence of upper extremity nerve palsies, specific to the radial nerve, during THA for a patient in the lateral decubitus position. The radial nerve can be injured while in the lateral decubitus position due to poor positioning of the posterior part of the humerus onto the hard surgical table causing compression of the nerve. In THA, this is significant due to the lateral decubitus position being the primary position for the patient in posterior and lateral approaches. We report a case of radial nerve palsy following uncomplicated THA in the lateral decubitus position. CASE REPORT: A 49-year-old male presenting with symptoms of the left radial nerve palsy on post-operative day number one from a right (contralateral) THA. The patient has a body mass index of 22.15 and was undergoing a right THA with a posterior approach. He was placed in the lateral decubitus position with an axillary roll in place for approximately 2 h and 45 min. Occupational therapy, orthopedics, and electromyography were used to evaluate the patient in the post-operative time for his radial nerve palsy. CONCLUSION: Our case report demonstrates a rare nerve palsy complication that can be associated with positioning in THA surgeries. Knowledge of this complication can be used to avoid pressure points in future THA surgeries in the lateral decubitus position.

Recent National Trends and Outcomes in Total Ankle Arthroplasty in the United States.

Total ankle arthroplasty (TAA) is an evolving option for treating ankle arthritis. We assessed the national trends in usage and perioperative outcomes of TAA in the United States. International Classification of Diseases, 9th revision (ICD-9), codes were used to search the National Hospital Discharge Survey database for TAA from 1997 to 2010. Patient demographics, comorbidities, hospitalization length, discharge disposition, blood transfusion, lower extremity deep vein thrombosis, pulmonary embolism, and mortality data were gathered. Trends were evaluated using linear regression with Pearson's correlation coefficient, and statistical comparisons were performed using Student's t test and z-test for proportions with significance at p = .05. We identified 120 patients with TAA. TAA demonstrated a positive correlation with time (r = 0.57), significantly increasing from 2.4 cases per 100,000 admissions from 1997 to 2003 to 3.5 cases per 100,000 from 2004 to 2010 (p = .04). The mean age was 57.8 (range 19 to 83) years. The mean number of comorbidities was 4.5 (range 1 to ≥7). Although patient age remained stable (p = .21), the mean number of comorbidities significantly increased from 4.0 from 1997 to 2003 to 4.8 from 2004 to 2010 (p = .02); 8 patients (6.7%) had diabetes, 71 (59.2%) had primary osteoarthritis, and 35 (29.2%) had posttraumatic arthropathy. The mean length of stay significantly decreased from 3.1 to 2.3 days (p = .03). Three patients (2.5%) required a blood transfusion. No deep vein thrombosis or PE was diagnosed. No patients died during the operative admission; 95 patients (87%) were discharged home and 14 (13%) required a skilled rehabilitation facility. Discharge patterns showed no significant change with time (p = .59). Usage of TAA in the United States has increased nearly 50% over the past 14 years. TAA was associated with shorter hospitalization, infrequent rehabilitation facility requirements, and few perioperative complications.

Return to Play Among Golfers Undergoing Hip Arthroscopy: Short- to Mid-term Follow-up.

There are approximately 25 million amateur golfers in the United States, making up almost 10% of the entire US population. The purpose of this study was to evaluate short-term outcomes and rates of return to sport among recreational golfers who underwent hip arthroscopy for the treatment of labral tears. Data were prospectively collected and retrospectively reviewed for patients who underwent hip arthroscopy by one surgeon between August 2008 and February 2015. Exclusion criteria were previous ipsilateral hip surgeries or conditions, preoperative Tönnis osteoarthritis grade greater than 1, or workers' compensation status. Patients who played golf at a recreational level within 1 year prior to their surgery, attempted to return to golf postoperatively, and had preoperative and minimum 2-year postoperative measures for the modified Harris hip score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale for pain were included in the final cohort. Data on return to sport, surgical complications, and secondary surgeries were recorded. Of the 49 patients eligible for inclusion, 40 (81.6%) had minimum 2-year follow-up at a mean of 51.0 months. Mean age at surgery was 49.1 years. All patient-reported outcomes and visual analog scale scores were significantly improved at latest follow-up. Thirty-six (90%) of the 40 patients returned to golf after surgery. Hip arthroscopy leads to significant improvement in patient-reported outcomes and a high rate of return to sport for recreational golfers presenting with labral tears. Therefore, it is a good treatment option for this patient population. [Orthopedics. 2018; 41(4):e545-e549.].

Revisiting Orthopaedic Surgery Residents' Views of the CDC and AAOS Precautionary Guidelines for HIV.

BACKGROUND: The purpose of the present study was to evaluate how orthopaedic residents' views and behaviors toward the human immunodeficiency virus (HIV) have changed over the past 25 years. METHODS: Between May 2017 and June 2017, an electronic survey was distributed to residents who were enrolled orthopaedic residency programs in the United States. The survey included questions based on the revised 2012 American Academy of Orthopaedic Surgeons (AAOS) and Centers for Disease Control and Prevention (CDC) guidelines for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) transmission prevention. Every program in the United States was contacted to avoid selection bias. Categorical data were analyzed with use of the chi-square goodness-of-fit test for the comparison of current and historical results. The null hypothesis of no change between survey results in 1992 and 2016 was set at p > 0.05. Numerical data were analyzed with use of the chi-square goodness-of-fit test with subsequent p value calculations to determine deviation from expected values between the 2 study years. RESULTS: The present study demonstrated that there have been compelling changes in residents' attitudes and behaviors with respect to HIV. Current residents are more aware of and compliant with their institutional safety protocols. They are also more accepting of treating HIV-positive patients. However, current residents underestimate the risk of HIV transmission from needle-stick injury and are less aware of proper timing for post-exposure prophylactic medication administration. CONCLUSIONS: The present study indicates that there has been a compelling positive change in perception and prevention of HIV transmission by orthopaedic residents in the past 25 years but that there is still room for improvement.

Systemic Blastomyces Infection Presenting as a Soft-Tissue Infection of the Finger: A Case Report.

CASE: A thirty-eight-year-old male patient presented with fusiform swelling of the left ring finger after minor trauma. After medical evaluation by the emergency department, primary care service, and rheumatology service, he was referred to the orthopaedic service, where he underwent 2 surgical debridements. Cultures from the second surgery revealed a diagnosis of blastomycosis, and the patient was treated with intravenous amphotericin B followed by oral itraconazole. CONCLUSION: Our case report demonstrates a rare presentation and diagnosis of blastomycosis. Knowledge of atypical infections such as this can allow for earlier diagnosis and more appropriate treatment.

Autologous staged fat tissue transfer in post-traumatic lower extremity reconstruction.

Autologous fat tissue transfer for aesthetic reconstruction has been described in the literature for soft tissue damage as early as 1893. One area that has yet to be described is the role of fat grafting in post-traumatic lower extremity injuries. In this case report, we present a patient who had significant injury to her right lower extremity and presented for reconstruction. The patient is a 52-year-old female who presented to clinic after a right lower extremity traumatic injury that required multiple re-operations, which lead to dense scarring and volume loss along the extremity inferior to the knee joint. The patient received two staged autologous fat injections and reported positive outcomes. Our case report demonstrates the utility of fat transfer in reconstruction of the lower extremity in staged fashion. Further research in the refinement of this technique and patient follow-up will lead to better graft survival and reconstructive outcomes.