Necrotizing soft tissue infection (NSTI) is a feared and potentially morbid postoperative complication requiring prompt surgical intervention. Cutaneous conditions that mimic NSTI have been reported and rarely occur in the postoperative period. Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is a dermatologic condition characterized by fever, neutrophil-predominant leukocytosis, and painful skin lesions. Necrotizing Sweet syndrome (NSS) is an aggressive variant that causes a clinical appearance of localized skin necrosis and histologic evidence of necrotic foci extending to the deep aspects of the soft tissues and involving fascia and/or skeletal muscle. Necrotizing Sweet syndrome can be easily mistaken for NSTI. Contrary to infection, Sweet syndrome and NSS are worsened by surgical intervention due to the phenomenon of pathergy and readily respond to corticosteroid treatment. We present the case of a 54-year-old woman who developed NSS following an uncomplicated fasciectomy for Dupuytren disease.
Publications
2024
Nonunion is a common and costly problem. Unfortunately, there is no widely agreed upon and standardized definition for nonunion. The evaluation of bony union should start with a thorough history and physical examination. The clinician should consider patient-dependent as well as patient-independent characteristics that may influence the rate of healing and evaluate the patient for physical examination findings suggestive of bony union and infection. Radiographs and clinical examination can help confirm a diagnosis of union. When the diagnosis is in doubt, however, advanced imaging modalities as well as laboratory studies can help a surgeon determine when further intervention is necessary.
OBJECTIVES: To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange.
DESIGN: Retrospective review.
SETTING: Eight academic level I trauma centers.
PATIENT SELECTION CRITERIA: Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP.
OUTCOME MEASURES AND COMPARISONS: The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP.
RESULTS: Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008).
CONCLUSIONS: rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures.
LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
PURPOSE: Low-velocity gunshot fractures (LVGFs) are a common type of gunshot-induced trauma with the potential for complications such as infection and osteomyelitis. The effectiveness of antibiotic therapy in LVGFs remains uncertain, leading to ongoing debate about the appropriate treatment. In this review, we evaluate recent updates on the current understanding of antibiotic therapy in LVGFs, how previous studies have investigated the use of antibiotics in LVGFs, and the current state of institutional policies and protocols for treating LVGFs with antibiotics.
METHODS: We conducted a review of PubMed, Embase, and Web of Science databases to identify studies that investigated the use of antibiotics in LVGFs after the last review in 2013. Due to the lack of quantitative clinical trial studies, we employed a narrative synthesis approach to analyze and present the findings from the included primary studies. We categorized the outcomes based on the anatomical location of the LVGFs.
RESULTS: After evaluating 67 publications with the necessary qualifications out of 578 abstracts, 17 articles were included. The sample size of the studies ranged from 22 to 252 patients. The antibiotics used in the studies varied, and the follow-up period ranged from three months to ten years. The included studies investigated the use of antibiotics in treating LVGFs at various anatomic locations, including the humerus, forearm, hand and wrist, hip, femur, tibia, and foot and ankle.
CONCLUSION: Our study provides updated evidence for the use of antibiotics in LVGFs and highlights the need for further research to establish evidence-based guidelines. We also highlight the lack of institutional policies for treating LVGFs and the heterogeneity in treatments among institutions with established protocols. A single-dose antibiotic approach could be cost-effective for patients with non-operatively treated LVGFs. We suggest that a national or international registry for gunshot injuries, antibiotics, and infections could serve as a valuable resource for collecting and analyzing data related to these important healthcare issues.
PURPOSE: The cost of gender-affirming surgery (GAS) is an important component of healthcare accessibility for transgender patients. However, GAS is often prohibitively expensive, particularly as there are inconsistencies in insurance coverages. Variability in hospital costs has been documented for other types of nonplastic surgery procedures; however, this analysis has not been done for GAS. To better understand the financial barriers impairing access to equitable transgender care, this study analyzes the distribution of hospitals that perform genital GAS and the associated costs of inpatient genital GAS.
METHODS: This is a study of the 2016-2019 National Inpatient Sample database. Transgender patients undergoing genital GAS were identified using International Classification of Diseases, Tenth Revision, diagnosis and procedure codes, and patients undergoing concurrent chest wall GAS were excluded. Descriptive statistics were done on patient sociodemographic variables, hospital characteristics, and hospitalization costs. χ2 test was used to assess for differences between categorical variables and Mood's median test was used to assess for differences between continuous variable medians.
RESULTS: A total of 3590 weighted genital GAS encounters were identified. The Western region (50.8%) and Northeast (32.3%) performed the greatest proportion of GAS, compared with the Midwest (9.1%) and the South (8.0%) (P < 0.0001). The most common payment source was private insurance (62.8%), followed by public insurance (27.3%). There were significant differences in the variability of median hospital costs across regions (P < 0.0001). The South and Midwest had the greatest median cost for vaginoplasty ($19,935; interquartile range [IQR], $16,162-$23,561; P = 0.0009), while the West had the greatest median cost for phalloplasty ($26,799; IQR, $19,667-$30,826; P = 0.0152). Across both procedures, the Northeast had the lowest median cost ($11,421; IQR, $9155-$13,165 and $10,055; IQR, $9,013-$10,377, respectively).
CONCLUSIONS: There is significant regional variability in the number of GAS procedures performed and their associated hospitalization costs. The identified disparities in insurance coverage present an area of possible future improvement to alleviate the financial burden GAS presents to gender-discordant individuals. The variability in cost suggests a need to evaluate variations in care, leading to cost standardization.
BACKGROUND: Although dual mobility total hip arthroplasty has become increasingly common in recent years, limited remains known on dual mobility in surgical oncology. This university-based investigation compared dislocation and revision rates of DMs, conventional total hip arthroplasty (THA), and hemiarthroplasties (HAs) for oncological hip reconstruction.
METHODS: An institutional tumor registry was used to identify 221 patients undergoing 45 DMs, 67 conventional THAs, and 109 HAs, performed for 17 primary hip tumors and 204 hip metastases between 2010 and 2020. The median age at surgery was 65 years, and 52% were female. The mean follow-up was 2.5 years. Kaplan-Meier survivorship curves and log-rank tests were done to compare dislocation and revision rates among all 221 patients, after a one-to-one propensity match, based on age, sex, tumor type (metastasis, primary tumor), and tumor localization (femur, acetabulum).
RESULTS: The 5-year survivorship free of dislocation was 98% in DMs, 66% in conventional THAs ( P = 0.03; all P values compared with DMs), and 97% among HAs ( P = 0.48). The 5-year survivorship free of revision was 69% in DMs, 62% in conventional THAs ( P = 0.68), and 92% in HAs ( P = 0.06). After propensity matching, the 5-year survivorship free of dislocation was 42% in 45 conventional THAs ( P = 0.027; compared with all 45 DMs) and 89% in 16 matched HAs ( P = 0.19; compared with 16 DMs with femoral involvement only). The 5-year survivorship free of revision was 40% in matched conventional THAs ( P = 0.91) and 100% in matched HAs ( P = 0.19).
CONCLUSIONS: DMs showed markedly lower rates of dislocation than conventional THAs, with overall revision rates remaining comparable among different designs. DMs should be considered the option of choice for oncological hip reconstruction if compared with conventional THAs. HAs are a feasible alternative when encountering femoral disease involvement only.
LEVEL OF EVIDENCE: III.
BACKGROUND: Osteoporosis is characterized by low bone mineral density (BMD), which predisposes individuals to frequent fragility fractures. Quantitative BMD measurements can potentially help distinguish bone pathologies and allow clinicians to provide disease-relieving therapies. Our group has developed non-invasive and non-ionizing magnetic resonance imaging (MRI) techniques to measure bone mineral density quantitatively. Dual-energy X-ray Absorptiometry (DXA) is a clinically approved non-invasive modality to diagnose osteoporosis but has associated disadvantages and limitations.
PURPOSE: Evaluate the clinical feasibility of phosphorus (31P) MRI as a non-invasive and non-ionizing medical diagnostic tool to compute bone mineral density to help differentiate between different metabolic bone diseases.
MATERIALS AND METHODS: Fifteen ex-vivo rat bones in three groups [control, ovariectomized (osteoporosis), and vitamin-D deficient (osteomalacia - hypo-mineralized) were scanned to compute BMD. A double-tuned (1H/31P) transmit-receive single RF coil was custom-designed and in-house-built with a better filling factor and strong radiofrequency (B1) field to acquire solid-state 31P MR images from rat femurs with an optimum signal-to-noise ratio (SNR). Micro-computed tomography (μCT) and gold-standard gravimetric analyses were performed to compare and validate MRI-derived bone mineral densities.
RESULTS: Three-dimensional 31P MR images of rat bones were obtained with a zero-echo-time (ZTE) sequence with 468 μm spatial resolution and 12-17 SNR on a Bruker 7 T Biospec having multinuclear capability. BMD was measured quantitatively on cortical and trabecular bones with a known standard reference. A strong positive correlation (R = 0.99) and a slope close to 1 in phantom measurements indicate that the densities measured by 31P ZTE MRI are close to the physical densities in computing quantitative BMD. The 31P NMR properties (resonance linewidth of 4 kHz and T1 of 67 s) of ex-vivo rat bones were measured, and 31P ZTE imaging parameters were optimized. The BMD results obtained from MRI are in good agreement with μCT and gravimetry results.
CONCLUSION: Quantitative measurements of BMD on ex-vivo rat femurs were successfully conducted on a 7 T preclinical scanner. This study suggests that quantitative measurements of BMD are feasible on humans in clinical MRI with suitable hardware, RF coils, and pulse sequences with optimized parameters within an acceptable scan time since human femurs are approximately ten times larger than rat femurs. As MRI provides quantitative in-vivo data, various systemic musculoskeletal conditions can be diagnosed potentially in humans.
BACKGROUND: Exacerbated by an aging population, musculoskeletal diseases are a chronic and growing problem in the United States that impose significant health and economic burdens. The objective of this study was to analyze the correlation between the burden of diseases and the federal funds assigned to health-related research through the National Institutes of Health (NIH).
METHODS: An ecological study design was used to examine the relationship between NIH research funding and disease burden for 60 disease categories. We used the Global Burden of Disease (GBD) Study 2019 to measure disease burden and the NIH Research, Condition, and Disease Categories (RCDC) data to identify 60 disease categories aligned with available GBD data. NIH funding data was obtained from the RCDC system and the NIH Office of Budget. Using linear regression models, we observed that musculoskeletal diseases were among the most underfunded (i.e., negative residuals from the model) with respect to disease burden.
FINDINGS: Musculoskeletal diseases were underfunded, with neck pain being the most underfunded at only 0.83% of expected funding. Low back pain, osteoarthritis, and rheumatoid arthritis were also underfunded at 13.88%, 35.08%, and 66.26%, respectively. Musculoskeletal diseases were the leading cause of years lived with disability and the third leading cause in terms of prevalence and disability-adjusted life years. Despite the increasing burden of these diseases, the allocation of NIH funding to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) has remained low compared to other institutes.
INTERPRETATION: Despite the increasing health burden and economic cost of $980 billion annually, the allocation of NIH funding to the NIAMS has remained low compared to other institutes. These findings suggest that the NIH may need to reassess its allocation of research funding to align with the current health challenges of our country. Furthermore, these clinically relevant observations highlight the need to increase research funding for musculoskeletal diseases and improve their prevention, diagnosis, and treatment.
FUNDING: No funding.
PURPOSE: The addition of the remplissage procedure to an arthroscopic Bankart procedure has been shown to improve clinical outcomes, yet at the expense of potentially decreasing shoulder range of motion. The purpose of this study was to assess recurrent instability, range of motion, functional outcomes and rates of return to sport outcomes in patients undergoing an isolated arthroscopic Bankart repair compared to those undergoing arthroscopic Bankart repair in addition to the remplissage procedure.
METHODS: According to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, a search was conducted using three databases (MEDLINE/OVID, EMBASE and PubMed). Retrieved studies were screened based on predefined inclusion and exclusion criteria for comparative studies. Data were extracted and meta-analysis performed using a random-effects model.
RESULTS: A total of 16 studies (13 level III studies, 2 level II studies and 1 level I) were included with a total of 507 and 704 patients in the Bankart plus remplissage and isolated Bankart repair groups, respectively. No studies reported glenoid bone loss of >20% with the least percentage of glenoid bone loss reported among studies being <1%. There was a significantly increased rate of recurrent dislocations (odds ratio [OR] = 4.22, 95% confidence interval [CI]: 2.380-7.48, p < 0.00001) and revision procedures (OR = 3.36, 95% CI: 1.52-7.41, p = 0.003) in the isolated Bankart repair group compared to the Bankart plus remplissage group. Additionally, there were no significant differences between groups in terms of external rotation at side (n.s.), in abduction (n.s.) or at forward flexion (n.s.) at final follow-up. Furthermore, return to preinjury level of sport favoured the Bankart plus remplissage group (OR = 0.54, 95% CI: 0.35-0.85, p = 0.007).
CONCLUSION: Patients undergoing arthroscopic Bankart plus remplissage for anterior shoulder instability have lower rates of recurrent instability, higher rates of return to sport, and no significant difference in range of motion at final follow-up when compared to an isolated arthroscopic Bankart repair. Further large, prospective studies are needed to further determine which patients and degree of bone loss would benefit most from augmentation with the remplissage procedure.
LEVEL OF EVIDENCE: Level III.