Metagenomic next-generation sequencing in osteoarticular infections with a focus on pediatrics: current concepts and clinical applications.

Osteoarticular infections (OAI) are a significant cause of morbidity and mortality. Cultures and serology are some of the gold standards for identifying infection but are often unable to provide a timely diagnosis or a diagnosis at all. Genetic testing offers capabilities that other modalities lack. Polymerase chain reaction has multiple versions with various costs and turnaround times. This technology has become implemented in multiple pediatric center OAI diagnostic protocols. There is sufficient literature documenting effectiveness in certain clinical situations, especially with fastidious organism diagnosis, but significant limitation still exists. Metagenomic next-generation sequencing is an unbiased or hypothesis-free modality with the capability to detect the genetic material of bacteria, viruses, parasites, fungi, and humans from a single sample. Potential benefits include pathogen identification unaffected by antimicrobial administration, detection of fastidious organisms more quickly, delineation of pathogens in polymicrobial infections, antimicrobial susceptibility, and avoidance of invasive procedures. It is a resource-intensive modality with little standardization of the complex processes. Appropriate use and definitive clinical impact have yet to be determined.

Overstuffing the patellofemoral compartment in total knee arthroplasty: a systematic review.

Purpose: To systematically review and analyze the data available in the literature to evaluate the role of patellofemoral overstuffing in affecting clinical outcomes following primary total knee arthroplasty. Methods: A systematic literature review was conducted following the PRISMA guidelines. Only studies including primary total knee arthroplasty in the setting of osteoarthritis with a quantifiable method of measuring patellofemoral overstuffing using pre- and post-operative x-rays or advanced imaging, as well as reported subjective and/or objective patient outcomes in relation to patellofemoral overstuffing were included. Extracted data included patellofemoral overstuffing quantitative measurement method, outcome measurements, follow-up, patient demographics, author, and publication details. Descriptive analysis was provided for the available literature. Results: There were six included articles with a total of 2325 TKAs assessed. All papers found no significant effect on clinical outcomes when the amount of PFJ overstuffing was within reason. Conclusion: The amount of overstuffing that routinely takes place seems to be within tolerable limits and does not create a significant difference in clinical outcomes. Nevertheless, it is recommended to recreate the anatomic dimensions of the PFJ in order to best obtain a joint that is within this safe margin of error.

Symptomatic Nonunion After a Tibial-Sided Posterior Cruciate Ligament Avulsion Fracture Treated with Open Repair: A Case Report.

CASE: A 30-year-old man was in a motorcycle accident resulting in an avulsion fracture of the tibial insertion of the posterior cruciate ligament (PCL). After 19 months of nonoperative treatment, the patient presented with a nonunion and symptoms of pain and instability. He was treated with an open repair with screw fixation through a posterior approach. Six months postoperatively, the patient returned to his work as a heavy laborer with full range of motion and no instability. CONCLUSION: PCL avulsion fracture nonunion results in symptoms of swelling, pain, and instability. These symptoms can be treated with screw fixation through a posterior approach.

Multiple Lesion Matrix-Induced Chondrocyte Implantation Procedure in a Collegiate Football Athlete: A Case Report.

CASE: A 21-year-old male division I collegiate athlete presented for right knee pain, effusion, and mechanical symptoms. The patient was found to have 2.4 × 2-cm medial patellar facet, 1 × 0.8-cm central trochlea, and 2.5 × 3-cm lateral femoral condyle articular cartilage defects on arthroscopy. The patient was treated with a matrix-induced autologous chondrocyte implantation (MACI) procedure for all 3 lesions. At 9 months postoperatively, the patient returned to full American football activities and remains asymptomatic 16 months postoperatively. CONCLUSION: Multiple lesions and lesions involving the patellofemoral joint can be treated with a MACI procedure with short-term promising results in high-demand athletes.

Chronic Multifocal Osteomyelitis - Is Mycobacterium avium Complex Really the Culprit? A Case Report in an Adult Female.

Introduction: There are reports which describe multiple lytic lesions seen on X-ray resulting from a non-tuberculous Mycobacterium skeletal infection in immunocompetent adults and children. AdditionallyIn addition, similar multifocal lesions have also been described in chronic recurrent multifocal osteomyelitis (CRMO) which is more common in children but has have rarely been reported in adults. We present a case of a 47-year-old female who presented with multiple osteolytic lesions and discuss how her diagnosis overlaps with CRMO and multifocal non-tuberculous osteomyelitis associated with Mycobacterium avium complex (MAC). Case Report: A 47-year-old female presented with a mass at her left sternoclavicular joint. Biopsy of the lesion showed acute and chronic inflammation suggesting osteomyelitis. The patient was on intravenousIV antibiotics with some improvement. After three 3 ½ and a half months, she was having knee pain and imaging showed another lesion and a bone scan found a third. Delayed cultures grew Mycobacterium avium complexMAC but ultimately the patient improved when she was taking naproxen for multifocal osteomyelitis. Conclusion: Multifocal lytic lesions on imaging in an adult can be multifocal osteomyelitis that, like in pediatric patients, may be treated best with nonsteroidal anti-inflammatory medications as with the patient in this case.

Surgical Treatment of Pectoralis Major Muscle Ruptures: A Systematic Review and Meta-analysis.

BACKGROUND: Pectoralis major muscle (PMM) tendon ruptures are becoming more common. Multiple techniques for fixation of the avulsed tendon to its humeral insertion have been described. None of these techniques has been reviewed to compare outcomes in efforts to establish a first-line surgical technique. PURPOSE: To systematically review and analyze the data available in the literature to establish a clinically superior surgical technique and time frame in which surgery should occur. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic literature review was conducted. Only studies reporting the surgical techniques and outcomes of PMM repair were included. Data including patient age, injury mechanism, type and extent of the rupture, time from injury to surgery, surgical technique, outcome including complications, steroid use, location and year of publication, and activity level were extracted from the included studies. Statistical and descriptive analyses were conducted on the available literature. RESULTS: Of 259 cases from studies that provided the timing of repair, 72.6% (n = 188) were repaired acutely, while the remaining were repaired more than 8 weeks after the injury. There was no statistical difference found in the outcomes of these repairs. There were 265 cases included in the statistical analysis comparing the outcomes of surgical techniques. The odds of an excellent/good outcome were significantly better for the transosseous suture (TOS) compared with the unicortical button (UCB) technique (odds ratio [OR], 6.28 [95% CI, 1.37-28.75]; P = .018) and also for the suture anchor (SA) compared with the UCB technique (OR, 3.40 [95% CI, 1.06-10.85]; P = .039). The odds of an excellent/good outcome were not significantly different when comparing the TOS, SA, and TOS with trough techniques to one another. The probability of complications was highest with the TOS with trough technique (12.0%), although the odds of having a complication were not statistically significant for any single technique compared with the others. CONCLUSION: The low quality of evidence available limited this review. There were no significant differences observed in the outcomes of PMM repair based on the timing of repair. The TOS and SA techniques had statistically significantly greater odds of resulting in an excellent/good outcome compared with the UCB technique, but 1 study that contributed to this analysis may have statistically skewed the results for the UCB technique. Therefore, all 3 surgical techniques are accepted options, and the best technique is that with which the surgeon is most proficient and comfortable. Comparative research with a greater level of evidence is needed to determine a definitive first-line surgical technique.