Topical Treatment for Cutaneous Mucormycosis of the Upper Extremity.

Mucormycosis is a relatively rare but extremely aggressive fungal infection that commonly affects patients who are compromised hosts. These infections typically come in various patterns: pulmonary, sinus, rhinocerebral, cerebral, cutaneous, or disseminated forms. Treatment usually consists of a combination of antifungal agents and surgical debridement, although morbidity and mortality are high. In this case report, we describe the course of a patient with a disseminated Mucor infection, primarily involving the upper extremities, who was successfully treated with topical and systemic antifungal agents without the need for surgical intervention.

Antegrade Screw Fixation of Medial Malleolus Fractures: A Technique Tip.

Ankle fractures are one of the most common orthopedic injuries and often include medial malleolus fractures. A number of techniques to repair medial malleolus fractures have been described. Depending on the exact fracture pattern, there are cases of medial malleolus fractures that are less amenable to standard fixation strategies. We present an alternative strategy for fixing medial malleolus fractures, in which a screw is placed antegrade across the fracture line. (Journal of Surgical Orthopaedic Advances 29(1):5052, 2020).

Giant Cell Reparative Granuloma in the Thumb Distal Phalanx: A Case Report.

Giant cell reparative granulomas (GCRG) often affect the bones of the hands and the feet. Treatment of this lesion depends on the exact location and amount of localized bony destruction. Ours is the first case report to discuss the nuances of treating this lesion in the thumb distal phalanx. A 19-year-old male presented with lytic, destructive expansion of his left thumb distal phalanx; imaging was suggestive of an aneurysmal bone cyst. Open biopsy was interpreted as giant cell reparative granuloma. Curettage and bone grafting resulted in complete healing of the distal phalanx with an excellent range of motion and interphalangeal joint stability. GCRG is a rare, benign entity typically presenting as a lytic bone lesion. Despite the initial massive bony destruction, this lesion nevertheless healed with curettage and bone grafting with maintained flexor pollicis longus and extensor pollicis longus function, permitting excellent active motion postoperatively.

Recurrence Rates of Dorsal Wrist Ganglion Cysts After Arthroscopic Versus Open Surgical Excision: A Retrospective Comparison.

BACKGROUND: This study directly compares the recurrence rates of dorsal wrist ganglion cysts in patients treated via open surgical excision versus arthroscopic surgical excision. We hypothesized that there would be no difference between recurrence rates with these 2 surgical options. METHODS: We retrospectively reviewed the charts of all patients with a dorsal ganglion cyst undergoing either open or arthroscopic surgical excision at a single academic center with 3 fellowship-trained attending hand surgeons from 2012 to 2017. Charts were identified using Current Procedural Terminology codes and were reviewed using postoperative office notes for preoperative and postoperative symptoms, episodes of recurrence, time at which recurrence occurred, subsequent operations, and outcome at final follow-up. RESULTS: The charts of 172 patients undergoing either arthroscopic or open dorsal ganglion excision were reviewed. Nine of 54 (16.7%) arthroscopic excisions resulted in cyst recurrence, while 8 of 118 (6.8%) open excisions resulted in cyst recurrence (P = .044). Two of 9 (22%) recurrences after arthroscopic ganglion excision versus 2 of 8 (25%) recurrences after open ganglion excision underwent repeat surgical intervention. Time to recurrence, as well as final follow-up, was not statistically different between groups. CONCLUSIONS: Dorsal wrist ganglion cysts are the most common benign soft tissue mass of the upper extremity, but it remains unknown whether arthroscopic or open surgical excision leads to lower recurrence rate. Scant literature exists directly comparing these 2 methods of surgical excision. This study suggests that open excision of dorsal wrist ganglia leads to a lower recurrence rate than does arthroscopic excision.

Pediatric Ulnar-sided Wrist Pain: A Review of the Current Literature.

Patients presenting with ulnar-sided wrist pain can pose a diagnostic and therapeutic challenge to physicians because there are several pathologies with similar signs and symptoms. In comparison with adult patients, other etiologies must be considered in the pediatric patient, given the skeletal immaturity and potential for known or unrecognized syndromes. In addition, these patients may not be able to articulate their symptoms as clearly as an adult patient, further stressing the importance of obtaining a pertinent history and performing a focused physical examination. Having a thorough understanding of the anatomy, the varying pathologies, and the indications for surgical and nonsurgical management will assist in improved patient outcomes.

Subfascial-located contraceptive devices requiring surgical removal.

BACKGROUND: Subdermal etonogestrel implants are highly effective contraceptive methods. Despite standardization of insertion technique by the manufacturer, some implants are inadvertently placed too deeply within or below the plane of the biceps brachii fascia. Placement of these implants in a deep tissue plane results in more difficult removal, which is not always possible in the office setting. In rare cases, surgical removal by an upper extremity surgeon is warranted. CASE PRESENTATION: Here we present 6 cases of etonogestrel implants located in a subfascial plane requiring removal by an upper extremity surgeon. Implants were all localized with plain radiography and ultrasound prior to surgical removal. All cases had implants located in the subfascial plane and one was identified intramuscularly. The average age was 28 years (19-33) and BMI was 24.0 kg/m^2 (19.1-36.5), with the most common reason for removal being irregular bleeding. The majority of cases (5/6) were performed under monitored anesthesia care with local anesthetic and one case utilized regional anesthesia. All implants were surgically removed without complication. CONCLUSIONS: Insertion of etonogestrel contraceptive implants deep to the biceps brachii fascia is a rare, but dangerous complication. Removal of these implants is not always successful in the office setting and referral to an upper extremity surgeon is necessary to avoid damage to delicate neurovascular structures for safe removal.

Combined Upper Extremity and Gluteal Compartment Syndrome Following Illicit Drug Abuse: A Retrospective Case Series.

INTRODUCTION: The purpose of this study was to describe four cases of patients who developed concomitant upper extremity and gluteal compartment syndrome in the context of substance abuse. In somnolent patients unable to provide a reliable physical exam, the healthcare provider must be aware of patients presenting with concomitant upper extremity and gluteal compartment syndrome. METHODS: Retrospective chart review identified cases of the combined upper extremity and gluteal compartment syndrome following illicit drug abuse at a single academic center during the years 2009-2019. RESULTS: During the 11-year period examined, a total of eight patients were diagnosed with compartment syndrome secondary to illicit drug use and prolonged immobilization. Four (50%) patients presented with combined upper extremity and gluteal compartment syndrome. All of these patients underwent prompt surgical release of the affected compartments. All eventually returned to normal activities of daily living. DISCUSSION: Compartment syndrome is primarily a clinical diagnosis, with physical exam being extremely important. In patients presenting with somnolence secondary to illicit drug use, physical exam may not be reliable. It is critical to have a high clinical suspicion in this patient population, understanding that these patients may present with concomitant upper extremity and gluteal compartment syndrome. LEVEL OF EVIDENCE: Level IV, case series.

Skip constructs in spinal muscular atrophy: outcomes of a novel approach for posterior spinal instrumentation and fusion.

PURPOSE: Many children with spinal muscular atrophy (SMA) develop progressive spinal deformity, worsening already compromised pulmonary function and global spinal balance. Early results demonstrate that intrathecal administration of nusinersen, a recent FDA-approved drug, improves motor function and ventilator-free survival, necessitating preservation of intrathecal access when considering PSIF. The purpose of this study is to assess medium-term outcomes of a specialized approach for posterior spinal instrumentation and fusion (PSIF) to preserve intrathecal access in patients with SMA. METHODS: A retrospective review of patients with SMA undergoing PSIF at a single tertiary academic medical center during a 3-year period was completed. To facilitate intrathecal drug administration, the traditional approach to PSIF was modified to "skip" one or more intervertebral levels at the thoracolumbar junction. Clinical notes and radiographs were reviewed for postoperative outcomes including major coronal curve correction and complications, including loss of correction, hardware failure and surgical revision. RESULTS: Eight patients were identified, with a mean age of 12.7 ± 1.6 years and follow-up of 4 years. These patients had a mean preoperative major coronal curve of 56.4°, with mean curve correction of 35.2°. At follow-up, no patients experienced rod breakage, loss of correction, or postoperative chronic pain. Only one patient required revision surgery due to bony overgrowth at the skipped level after three and a half years. CONCLUSION: Implementing the skip construct approach for PSIF in patients with SMA allows for scoliosis correction without compromising intrathecal drug delivery. Follow-up at 4 years reveals no adverse clinical events, hardware failure or loss of correction. LEVEL OF EVIDENCE: IV.

It is not just about the frontal plane: sagittal parameters impact curve progression in AIS patients undergoing brace treatment.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The purpose of this study was to explore the association between pre-brace and in-brace sagittal parameters and curve progression. To date, there has been no published research focused on spinopelvic sagittal parameters and bracing outcomes in AIS. We hypothesize that sagittal spinopelvic parameters are associated with curve progression at 2 years. METHODS: This study included AIS patients with a pre-brace (PB) major curve between 20° and 45°. The outcome was defined as > 10° curve progression or surgery within 2 years of brace initiation. Spinopelvic parameters included C7-Central Sacral Vertebral Line shift (C7-CSVL), thoracic trunk shift, lumbar lordosis (LL), pelvic incidence (PI), T2-T12 thoracic kyphosis (TK) pelvic incidence-lumbar lordosis (PI-LL) mismatch, sagittal vertical axis (SVA), and pelvic tilt (PT). RESULTS: Of 50 patients included in this review, [70% Rigo (RCSO) and 30% Boston (BSO)], 16 (32%) patients demonstrated progression (23% of patients with RCSO vs 53% with BSO; p = 0.034). In patients with more than 30% major coronal curve correction (CCC), 23% had progression. 45% of patients progressed when they achieved ≤ 30% correction (p = 0.108). Among PB sagittal parameters and adjusting for coronal curve, patients with an abnormal PB SVA had 3.1 times increased risk of treatment failure compared with patients who had a normal PB SVA. Patients with PB hypo-LL had a 2.8 times increased risk of treatment failure compared with patients who had normal or hyper-LL. Among IB sagittal parameters, patients who had a normal PB PI-LL had a 3.9 times increased risk of treatment failure when they became mismatched in-brace (IB). Patients who had normal pre-brace kyphosis who became hypo-kyphotic IB had an 8.4 times increased risk of treatment failure compared with patients who maintained normal TK or became hyper-kyphotic. CONCLUSION: These data suggest that we should pay careful attention to sagittal parameters prior to and during brace treatment as braces can control these parameters. LEVEL OF EVIDENCE: Level III.

Variability in stable sagittal vertebra (SSV) during full-length biplanar xrays can affect the choice of fusion levels in patients with adolescent idiopathic scoliosis (AIS).

PURPOSE: Surgical planning for Adolescent Idiopathic Scoliosis (AIS) relies on the coronal and sagittal plane to determine the lowest instrumented vertebra (LIV). Failure to include the stable sagittal vertebra (SSV) within the construct can increase the incidence of postoperative distal junctional kyphosis (DJK). The purpose of this study is to assess the variability of SSV within patients and to identify positional parameters that may lead to its change. METHODS: This is a case-control study of AIS patients with changes in SSV throughout serial radiographs. Radiographic sagittal parameters and hand positioning for the patients with changes in SSV were compared to patients with stable SSV. Additionally, a subgroup analysis was conducted to compare the positional parameters of only the patients with changes in SSV. RESULTS: 46 patients with a mean age of 15 ± 1.8 years old at the time of surgery were included in this study. 33/76 (43.4%) image pairs were found to have a change in SSV. Positional parameters associated with the more distally measured SSV were found to have a more negative sagittal vertebral axis (p = 0.001), more positive pelvic shift (p = 0.023), and more negative Global Sagittal Axis (p = 0.001) when compared to the more proximally measured SSV. CONCLUSION: Significant variability exists in the determination of SSV in AIS patients undergoing serial radiographs. Positional parameters associated with the proximal and distally measured SSV also have variability which indicates that posture has a significant impact on this measure. Surgeons need to be aware of SSV variability during preoperative planning and must consider multiple parameters for the determination of LIV. LEVEL OF EVIDENCE: 3.

Ankle-Brachial Index Testing at the Time of Stress Testing in Patients Without Known Atherosclerosis.

BACKGROUND: Individuals referred for stress testing to identify coronary artery disease may have nonobstructive atherosclerosis, which is not detected by stress tests. Identification of increased risk despite a negative stress test could inform prevention efforts. Abnormal ankle-brachial index (ABI) is associated with increased cardiovascular risk. HYPOTHESIS: Routine ABI testing in the stress laboratory will identify unrecognized peripheral arterial disease in some patients. METHODS: Participants referred for stress testing without known history of atherosclerotic disease underwent ABI testing (n = 451). Ankle-brachial index was assessed via simultaneous arm and leg pressure using standard measurement, automated blood-pressure cuffs at rest. Ankle-brachial index was measured after exercise in 296 patients and 30 healthy controls. Abnormal postexercise ABI was defined as a >20% drop in ABI or fall in ankle pressure by >30 mm Hg. RESULTS: Overall, 2.0% of participants had resting ABI ≤0.90, 3.1% had ABI ≥1.40, and 5.5% had borderline ABI. No patient with abnormal or borderline ABI had an abnormal stress test. Participants who met peripheral arterial disease screening criteria (age ≥65 or 50-64 with diabetes or smoking) tended toward greater frequency of low ABI (2.9% vs 1.0%; P = 0.06) and were more likely to have borderline ABI (0.91 to 0.99; 7.8% vs 2.9%; P = 0.006). Postexercise ABI was abnormal in 29.4% of patients and 30.0% of controls (P not significant). CONCLUSIONS: Ankle-brachial index screening at rest just before stress testing detected low ABI in 2.0% of participants, all of whom had negative stress tests.