Avulsion fractures of the scaphoid and triquetrum in a 15 year- old male.

Avulsion fractures of the perilunate ligaments occur in isolation, and multiple fractures are typically not seen in the same carpus. We present a case of a 15-year-old male who injured his wrist during football practice. He presented without wrist dislocation or deformity. Radiographs demonstrated avulsion fractures to the proximal pole of the scaphoid and proximal radial aspect of the triquetrum. The patient was immobilized with an upper extremity thumb spica cast; however, there was persistent non-union of both fractured segments. Magnetic resonance imaging confirmed avulsions at the site of the scapholunate and lunotriquetral ligaments, with both ligaments relatively intact. At the last follow-up, one year after the initial injury, the patient had a normal clinical exam, with no pain and full wrist range of motion despite fracture non-union at both locations. This is a unique injury with an unclear mechanism and complicated management.

Limb salvage reconstruction: Radiologic features of common reconstructive techniques and their complications.

Limb salvage surgery refers to orthopaedic procedures designed to resect tumors and reconstruct limbs. Improvements in managing malignant bone lesions have led to a dramatic shift in limb salvage procedures. Orthopaedic surgeons now employ four main reconstructive procedures: endoprosthesis, autograft, bulk allograft, and allograft prosthetic composite. While each approach has its advantages, each technique is associated with complications. Furthermore, knowledge of procedure specific imaging findings can lead to earlier complication diagnosis and improved clinical outcomes. The aim of this article is to review leading reconstructive options available for limb salvage surgery and present a case series illustrating the associated complications.

MRI Evaluation of Posterior Capsular Dehiscence After Posterior Approach Total Hip Arthroplasty.

INTRODUCTION: To our knowledge, no previous study has evaluated the use of MRI to diagnose posterior capsule dehiscence after posterior approach total hip arthroplasty (THA) with capsular repair and its association with postoperative posterior hip dislocation. METHODS: A retrospective chart review of patients who underwent posterior approach THA with capsulotomy repair was performed. Patients were identified who subsequently underwent MRI, and these studies were evaluated for signs of posterior capsular disruption. Each chart was then evaluated for episodes of postoperative hip dislocation. RESULTS: Six hundred seventy-five patients were included in the retrospective review. Thirty-two patients (17 women [aged 37 to 78 years] and 15 men [aged 34 to 80 years]) met the inclusion criteria. Fifteen patients of 32 (48.4%) developed posterior capsule dehiscence after repair (group 1). Seventeen patients of 32 (51.6%) did not have MRI evidence of posterior capsule dehiscence (group 2). In group 1, 2 patients of 15 (13.3%) experienced a posterior hip dislocation. No group 2 patients experienced a posterior hip dislocation. Overall, only 2 patients of 32 (6.3%) developed posterior hip dislocations. In group 1, 12 patients of 15 (80%) developed dehiscence at the lateral capsule margin at the greater trochanter suture repair site. The two patients in group 1 with posterior hip dislocations displayed MRI evidence of capsular dehiscence in this region. Two patients of 15 (13.3%) in group 1 demonstrated dehiscence at the central third of the posterior capsule, whereas 1 patient of 15 (6.6%) in group 1 demonstrated dehiscence at the medial/acetabular margin. No significant difference was found between the dislocation rates between groups 1 and 2 (P = 0.212). The distribution of capsular dehiscence (lateral, middle, and medial capsule) in group 1 was significant (P = 0.0006). DISCUSSION: MRI can effectively diagnose capsular dehiscence in patients who have undergone posterior THA. Most repaired capsules failed in the lateral repair region. MRI offers the potential to identify patients with a higher risk of implant dislocation. LEVEL OF EVIDENCE: Therapeutic level III.

Lumbrical Tear in Major League Baseball Player Throwing 4-Seam Fastballs: A Case Report.

CASE: We present the case of a major league pitcher with persistent finger pain, loss of pitch control, and loss of pitch velocity after an injury during a game. This pitcher only throws fastballs and prefers to only use a 4-seam technique. On examination of the affected hand, it is found that he had tenderness along the palmar iinterosseous near the base of the third metacarpal and no tenderness along the distribution of the flexor digitorum profundus (FDP) tendon. The patient had full range of motion of the third digit. Magnetic resonance imaging revealed partial thickness tears of the second and third lumbricals. DISCUSSION: Proposed injury was secondary to the 4-seam fastball technique, which pulls apart the FDP of the second and third digit, as well as the FDP of third and fourth digit. This increases the distance between the origins of the second and third lumbricals, leading to strain and tearing. The increased pitch count of the player also may have contributed to the injury. After rest and gradual tossing program, the pitcher was able to return to a preinjury level of function at 6 weeks. One year out from injury, the patient continued to pitch and remained pain free.

Systemic Complications and Radiographic Findings of Opioid Use and Misuse: An Overview for Orthopedic Surgeons.

Amid growing concern about the misuse of prescribed opioids, the rising rates of opioid use disorder, and the use of illicit opioids, clinicians in ambulatory, inpatient, and operative environments are encountering opioid-related complications in their patients. These complications can affect multiple organ systems including cardiovascular, pulmonary, gastrointestinal, and neurologic and are related to excess opioid levels in the body or contamination from non-sterile injection. It is important for the orthopedic surgeon to have a general understanding of the pathologies associated with opioid use disorder and their appearance on diagnostic imaging. This article reviews image findings of several complications, organized in a systems-based approach, for the orthopedic surgeon.

Radiographic Musculoskeletal Findings Indicating Opioid Misuse: An Overview for Orthopedic Surgeons.

BACKGROUND: Given the high prevalence of musculoskeletal conditions in the USA, it is important for orthopedic surgeons to promptly identify patients who may be at risk for opioid misuse. QUESTIONS/PURPOSES: The aim of this literature review was to elucidate various musculoskeletal pathologies and complications, as seen on imaging, that may indicate opioid misuse or opioid use disorder. METHODS: A literature search was conducted using the PubMed, Scopus, and Cochrane Library databases for articles related to imaging findings associated with chronic opioid use or misuse in orthopedic patients. Two independent reviewers conducted the search utilizing pertinent Boolean operations. RESULTS: We reviewed 36 full-text articles and categorized the radiographic evidence of opioid misuse as follows: soft-tissue radiologic findings, cellulitis, necrotizing fasciitis, abscess formation, retained needles, discitis, myopathy and rhabdomyolysis, osteomyelitis, septic arthritis, and septic thrombophlebitis. CONCLUSION: Knowledge of the radiologic findings of opioid misuse will assist orthopedic surgeons in making timely diagnoses that may alter therapeutic regimens for their patients.

Supplemental Fixation of Inner Graft Limbs in All-Inside, Quadrupled, Single-Tendon Anterior Cruciate Ligament Reconstruction Graft Construct Yields Improved Biomechanical Properties.

PURPOSE: To compare the time-zero load to failure of a quadrupled, single-tendon, all-inside anterior cruciate ligament (ACL) reconstruction graft construct with (supplemented) and without the incorporation of inner-limb whipstitch sutures (control) into a tibial suspensory fixation button. METHODS: Eight matched pairs of peroneus longus tendons were prepared according to a quadrupled, all-inside ACL soft-tissue graft technique with 1 side serving as a control and the contralateral side supplemented. The constructs were biomechanically tested for strain in the inner and outer limbs during a preconditioning protocol, single-cycle load to failure, and elongation of the whole construct. RESULTS: Ultimate load to failure was significantly higher in the supplemented group: 797.5 ± 49.6 N (95% confidence interval [CI], 763.13-831.87 N) versus 719.6 ± 69.6 N (95% CI, 671.38-767.82 N; P = .044). Less graft elongation at failure was observed in the supplemented group (3.1 ± 1.5 mm; 95% CI, 2.07-4.17 mm) versus the control group (21.0 ± 21.2 mm; 95% CI, 6.31-35.69 mm; P = .052). The number of grafts undergoing a 5-mm or greater change in length at failure was 1 of 8 in the supplemented group versus 5 of 8 in the control group (P = .038). CONCLUSIONS: Inner-limb supplemental tibial fixation results in higher time-zero load to failure and decreased graft elongation in a quadrupled, single-tendon, all-inside ACL reconstruction graft construct. CLINICAL RELEVANCE: The weak point of a single-tendon, quadrupled, all-inside ACL graft construct is the tendon-to-tendon suturing to secure the inner limbs of the graft. Adding supplemental fixation by incorporating the sutures from the inner limb to the tibial suspensory fixation button leads to a higher time-zero load to failure and decreased graft elongation.

Patient-Reported Knee Outcome Scores With Soft Tissue Quadriceps Tendon Autograft Are Similar to Bone-Patellar Tendon-Bone Autograft at Minimum 2-Year Follow-up: A Retrospective Single-Center Cohort Study in Primary Anterior Cruciate Ligament Reconstruction Surgery.

BACKGROUND: Quadriceps tendon (QT)-bone autografts used during anterior cruciate ligament (ACL) reconstruction have provided comparable outcomes and decreased donor-site morbidity when compared with bone-patellar tendon-bone (BPTB) autografts. No study has directly compared the outcomes of the all-soft tissue QT autograft with that of the BPTB autograft. HYPOTHESIS: Patient-reported knee outcome scores and rates of postoperative complication after primary ACL reconstruction with QT autografts are no different from BPTB autografts at a minimum 2-year follow-up. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A total of 75 patients who underwent primary autograft ACL reconstruction with QT or BPTB autografts between January 1, 2015, and March 31, 2016, at a single hospital center were contacted by telephone and asked to complete the International Knee Documentation Committee (IKDC) Subjective Knee Evaluation, Tegner activity level scale, and Lysholm knee scoring scale. Information about the subsequent surgeries performed on the operative knee was also collected. Statistical analysis was performed using the Kruskal-Wallis test and the Fisher exact test for categorical data. RESULTS: Fifty patients (28 QT, 22 BPTB) completed the surveys at a mean follow-up of 33.04 months (range, 24-44 months). For the QT versus the BPTB group respectively, the median IKDC scores were 94.83 (interquartile range [IQR], 7.61) versus 94.83 (IQR, 10.92) (P = .47), the median Tegner scores were 6 (IQR, 2.5) versus 6 (IQR, 2.75) (P = .48), and the median Lysholm scores were 95 (IQR, 9) versus 95 (IQR, 13) (P = .27). Additionally, 2 QT patients and 3 BPTB patients required follow-up arthroscopy for arthrolysis (P = .64). There was 1 graft failure in the QT group requiring revision surgery. CONCLUSION: There was no statistical difference in patient-reported knee outcomes or graft complication rates between the QT and BPTB autograft groups at a minimum 2-year follow-up after primary ACL reconstruction. This study highlights that the all-soft tissue QT autograft may be a suitable graft choice for primary ACL reconstruction.

Anterolateral ligament injuries on magnetic resonance imaging and pivot-shift testing for rotational laxity.

Maintaining anterolateral rotational stability of the knee requires a complex set of structures, most notably the anterior cruciate ligament. However, lateral knee structures such as the anterolateral ligament (ALL) also play an important role. There has been controversy over the role the ALL plays in an ACL deficient knee to maintain rotational stability. In this study, we examined ACL deficient knees with and without intact ALLs, for rotatory laxity using a pivot shift examination. This was graded using International Knee Document Committee (IKDC) criteria. MRI was used to view the ALL and its status. We found no statistically significant difference in rotational stability of ACL deficient knees, with or without intact ALLs. We did however find a statistically significant association between injury to the ALL and other concomitant lateral structures such as the lateral collateral ligament, biceps femoris tendon, and iliotibial band. This supports that the ALL works in concert with the other lateral structures in the knee and the ACL, to provide rotational stability. This suggests that as an isolated structure, the ALL's contribution to clinical rotational stability is not significant, even in the presence of an ACL tear.

Intraosseous schwannomas involving the sacrum: Characteristic imaging findings and review of the literature.

Background and purpose Sacral intraosseous schwannomas represent a rare subset of schwannomas. The existing literature detailing the radiographic appearance of intraosseous schwannomas is limited. The aim of this study is to formally characterize the radiological appearance of sacral intraosseous schwannomas to differentiate them from other lytic lesions. Materials and methods Imaging studies of 13 pathologically proven intraosseous schwannomas were reviewed from multiple institutions by fellowship-trained radiologists. A PubMed search was performed and identified four papers pertaining to the imaging characteristics of sacral intraosseous schwannomas. The results of these papers were compared to findings from our cases. Results All tumors had heterogeneous signals and were predominately solid but cystic components with fluid-fluid levels were present. The tumors caused a mass effect but none infiltrated the surrounding soft tissues. Post-contrast T1-weighted images revealed heterogeneous enhancement in all 13 tumors and four possessed non-enhancing cysts. A literature review identified 16 other cases of sacral intraosseous schwannomas forming a total of 29 cases examined. Conclusions Sacral intraosseous schwannomas should be considered in the differential diagnosis for both radiologists and pathologists when dealing with large expansile, lytic lesions, with well-defined sclerotic margins involving the sacrum. This is particularly important in middle-aged adults presenting with pathology centered around S2-3.

MRI findings in bucket-handle tears of the triangular fibrocartilage complex.

The triangular fibrocartilage complex (TFCC) is an intricate ligamentous and cartilaginous structure that helps transmit axial load across the wrist, and provide stability to the ulnocarpal and distal radioulnar joints (DRUJ). Because the blood supply to the TFCC varies depending on location, certain types of tears are more amenable to surgical repair than others. Since Palmer proposed his classification system of TFCC tears in 1989, only 1 case of a "bucket-handle" type tear has been reported. In this article, we describe two new cases of bucket-handle tears of the TFCC. In both cases, the torn fragment was displaced into a previously undescribed location (intra-articular DRUJ and prestyloid recess). Because this type of injury pattern has not been previously well characterized in the literature and such cases rarely reported, MRI findings have not been fully described and its implications on clinical management have largely yet to be determined.

Systematic characterization of porosity and mass transport and mechanical properties of porous polyurethane scaffolds.

One of the key challenges in porous scaffold design is to create a porous structure with desired mechanical function and mass transport properties which support delivery of biofactors and development of function tissue substitute. In recent years, polyurethane (PU) has become one of the most popular biomaterials in various tissue engineering fields. However, there are no studies fully investigating the relations between porosity and both mass transport and mechanical properties of PU porous scaffolds. In this paper, we fabricated PU scaffolds by combining phase inversion and salt (sodium chloride) leaching methods. The tensile and compressive moduli were examined on PU scaffolds fabricated with different PU concentrations (25%, 20% and 15% w/v) and salt/PU weight ratios (9/1, 6/1, 3/1 and 0/1). The mass transport properties of PU scaffolds including hydraulic permeability and glucose diffusivity were also measured. Furthermore, the relationships between the porosity and mass transport and mechanical properties of porous PU scaffold were systemically investigated. The results demonstrated that porosity is a key parameter which governs both mass transport and mechanical properties of porous PU scaffolds. With similar pore sizes, the mass transport and mechanical properties of porous PU scaffold can be described as single functions of porosity regardless of initial PU concentration. The relationships between scaffold porosity and properties can be utilized to facilitate porous PU scaffold fabrication with specific mass transport and mechanical properties. The systematic approach established in this study can be applied to characterization of other biomaterials for scaffold design and fabrication.

Perforin-2 Protects Host Cells and Mice by Restricting the Vacuole to Cytosol Transitioning of a Bacterial Pathogen.

The host-encoded Perforin-2 (encoded by the macrophage-expressed gene 1, Mpeg1), which possesses a pore-forming MACPF domain, reduces the viability of bacterial pathogens that reside within membrane-bound compartments. Here, it is shown that Perforin-2 also restricts the proliferation of the intracytosolic pathogen Listeria monocytogenes Within a few hours of systemic infection, the massive proliferation of L. monocytogenes in Perforin-2(-/-)mice leads to a rapid appearance of acute disease symptoms. We go on to show in cultured Perforin-2(-/-)cells that the vacuole-to-cytosol transitioning of L. monocytogenesis greatly accelerated. Unexpectedly, we found that in Perforin-2(-/-)macrophages,Listeria-containing vacuoles quickly (≤ 15 min) acidify, and that this was coincident with greater virulence gene expression, likely accounting for the more rapid translocation of L. monocytogenes to its replicative niche in the cytosol. This hypothesis was supported by our finding that aL. monocytogenes strain expressing virulence factors at a constitutively high level replicated equally well in Perforin-2(+/+)and Perforin-2(-/-)macrophages. Our findings suggest that the protective role of Perforin-2 against listeriosis is based on it limiting the intracellular replication of the pathogen. This cellular activity of Perforin-2 may derive from it regulating the acidification of Listeria-containing vacuoles, thereby depriving the pathogen of favorable intracellular conditions that promote its virulence gene activity.

Efficacy and safety of oral solithromycin versus oral moxifloxacin for treatment of community-acquired bacterial pneumonia: a global, double-blind, multicentre, randomised, active-controlled, non-inferiority trial (SOLITAIRE-ORAL).

BACKGROUND: Community-acquired bacterial pneumonia (CABP) is a leading cause of morbidity and mortality, and treatment recommendations, each with specific limitations, vary globally. We aimed to compare the efficacy and safety of solithromycin, a novel macrolide, with moxifloxacin for treatment of CABP. METHODS: We did this global, double-blind, double-dummy, randomised, active-controlled, non-inferiority trial at 114 centres in North America, Latin America, Europe, and South Africa. Patients (aged ≥18 years) with clinically and radiographically confirmed pneumonia of Pneumonia Outcomes Research Team (PORT) risk class II, III, or IV were randomly assigned (1:1), via an internet-based central block randomisation procedure (block size of four), to receive either oral solithromycin (800 mg on day 1, 400 mg on days 2-5, placebo on days 6-7) or oral moxifloxacin (400 mg on days 1-7). Randomisation was stratified by geographical region, PORT risk class (II vs III or IV), and medical history of asthma or chronic obstructive pulmonary disease. The study sponsor, investigators, staff, and patients were masked to group allocation. The primary outcome was early clinical response, defined as an improvement in at least two of four symptoms (cough, chest pain, sputum production, dyspnoea) with no worsening in any symptom at 72 h after the first dose of study drug, with a 10% non-inferiority margin. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT-01756339. FINDINGS: Between Jan 3, 2013, and Sept 24, 2014, we randomly assigned 860 patients to receive solithromycin (n=426) or moxifloxacin (n=434). Patients were followed up to days 28-35 after first dose. Solithromycin was non-inferior to moxifloxacin in achievement of early clinical response: 333 (78·2%) patients had an early clinical response in the solithromycin group versus 338 (77·9%) patients in the moxifloxacin group (difference 0·29, 95% CI -5·5 to 6·1). Both drugs had a similar safety profile. 43 (10%) of 155 treatment-emergent adverse events in the solithromycin group and 54 (13%) of 154 such events in the moxifloxacin group were deemed to be related to study drug. The most common adverse events, mostly of mild severity, were gastrointestinal disorders, including diarrhoea (18 [4%] patients in the solithromycin group vs 28 [6%] patients in the moxifloxacin group), nausea (15 [4%] vs 17 [4%] patients) and vomiting (ten [2%] patients in each group); and nervous system disorders, including headache (19 [4%] vs 11 [3%] patients) and dizziness (nine [2%] vs seven [2%] patients). INTERPRETATION: Oral solithromycin was non-inferior to oral moxifloxacin for treatment of patients with CABP, showing the potential to restore macrolide monotherapy for this indication. FUNDING: Cempra.