Fracture or Not: An Easily Mistaken Benign Finding in a Tuberous Sclerosis Patient

Tuberous sclerosis (TSC) is a rare autosomal dominant disorder that can affect multiple organ systems, including the brain, heart, lungs, and skin. Cutaneous manifestations are common, including ungual fibromas, however, these may be mistaken for other pathologies. Here, we present the case of a 14-year-old with TSC complaining of traumatic left little finger pain. Radiographic evaluation revealed cortical scalloping of the nailbed, concerning for a non-displaced fracture. Given the history of TSC, however, this defect may have also represented a periungual fibroma. The patient subsequently underwent conservative management and an eight-month radiographic follow-up showed no osseous remodeling, supporting the diagnosis of periungual fibroma. It is imperative for clinicians to understand the cutaneous manifestations of TSC to aid in proper diagnosis and avoidance of unnecessary treatment. In this case, interval follow-up confirmed the diagnosis and excluded fracture.

How Do Standing Neutral, Supine Lateral, Standing Flexion, and Standing Extension Radiographs Compare in Detecting the Presence and Magnitude of Stable and Dynamic Spondylolisthesis?

BACKGROUND

Clinical guidelines recommend standing radiographs as the most appropriate imaging for detecting degenerative spondylolisthesis, although reliable evidence about the standing position is absent. To our knowledge, no studies have compared different radiographic views and pairings to detect the presence and magnitude of stable and dynamic spondylolisthesis.

QUESTIONS/PURPOSES

(1) What is the percentage of new patients presenting with back or leg pain with stable (3 mm or greater listhesis on standing radiographs) and dynamic (3 mm or greater listhesis difference on standing-supine radiographs) spondylolisthesis? (2) What is the difference in the magnitude of spondylolisthesis between standing and supine radiographs? (3) What is the difference in the magnitude of dynamic translation among flexion-extension, standing-supine, and flexion-supine radiographic pairs?

METHODS

This cross-sectional, diagnostic study was performed at an urban, academic institution between September 2010 and July 2016; 579 patients 40 years or older received a standard radiographic three-view series (standing AP, standing lateral, and supine lateral radiographs) at a new patient visit. Of those individuals, 89% (518 of 579) did not have any of the following: history of spinal surgery, evidence of vertebral fracture, scoliosis greater than 30°, or poor image quality. In the absence of a reliable diagnosis of dynamic spondylolisthesis using this three-view series, patients may have had flexion and extension radiographs, and approximately 6% (31 of 518) had flexion and extension radiographs. A total of 53% (272 of 518) of patients were female, and the patients had a mean age of 60 ± 11 years. Listhesis distance (in mm) was measured by two raters as displacement of the posterior surface of the superior vertebral body in relation to the posterior surface of the inferior vertebral body from L1 to S1; interrater and intrarater reliability, assessed with intraclass correlation coefficients, was 0.91 and 0.86 to 0.95, respectively. The percentage of patients with and the magnitude of stable spondylolisthesis was estimated on and compared between standing neutral and supine lateral radiographs. The ability of common pairs of radiographs (flexion-extension, standing-supine, and flexion-supine) to detect dynamic spondylolisthesis was assessed. No single radiographic view or pair was considered the gold standard because stable or dynamic listhesis on any radiographic view is often considered positive in clinical practice.

RESULTS

Among 518 patients, the percentage of patients with spondylolisthesis was 40% (95% CI 36% to 44%) on standing radiographs alone, and the percentage of patients with dynamic spondylolisthesis was 11% (95% CI 8% to 13%) on the standing-supine pair. Standing radiographs detected greater listhesis than supine radiographs did (6.5 ± 3.9 mm versus 4.9 ± 3.8 mm, difference 1.7 mm [95% CI 1.2 to 2.1 mm]; p < 0.001). Among 31 patients, no single radiographic pairing identified all patients with dynamic spondylolisthesis. The listhesis difference detected between flexion-extension was no different from the listhesis difference detected between standing-supine (1.8 ± 1.7 mm versus 2.0 ± 2.2 mm, difference 0.2 mm [95% CI -0.5 to 1.0 mm]; p = 0.53) and flexion-supine (1.8 ± 1.7 mm versus 2.5 ± 2.2 mm, difference 0.7 mm [95% CI 0.0 to 1.5]; p = 0.06).

CONCLUSION

This study supports current clinical guidelines that lateral radiographs should be obtained with patients in the standing position, because all cases of stable spondylolisthesis of 3 mm or greater were detected on standing radiographs alone. Each radiographic pair did not detect different magnitudes of listhesis, and no single pair detected all cases of dynamic spondylolisthesis. Clinical concern for dynamic spondylolisthesis may justify standing neutral, supine lateral, standing flexion, and standing extension views. Future studies could identify and evaluate a set of radiographic views that provides the greatest capacity to diagnose stable and dynamic spondylolisthesis.

LEVEL OF EVIDENCE

Level III, diagnostic study.

A Unique "Reverse" Crescent Fragment in an Anterior-Posterior Compression Fracture: A Case Report

CASE

We describe a patient with an anterior-posterior compression type pelvic fracture sustained after a motorcycle crash, with pubic symphysis disruption and a "reverse" crescent fragment. The injury force ruptured the anterior sacroiliac ligaments and travelled posterior medially, creating a complete Denis zone 2 sacral fracture, rather than rupturing the posterior sacroiliac ligaments as would be expected. The patient underwent open reduction and internal fixation of the pubic symphysis and closed reduction and percutaneous pinning of the right sacroiliac joint.

CONCLUSIONS

This case presents a unique "reverse" crescent fragment not previously described in the literature as an anterior-posterior compression type III variant.

Postoperative aspirin use and its effect on bone healing in the treatment of ankle fractures

BACKGROUND

There is hesitancy to administer nonsteroidal anti-inflammatories (NSAIDs) within the postoperative period following fracture care due to concern for delayed union or nonunion. However, aspirin (ASA) is routinely used for chemoprophylaxis of deep vein thrombosis (DVT) and is gaining popularity for use after treatment of ankle fractures. The current study examines the incidence of nonunion of operative ankle fractures and risk of DVT in patients who did and did not receive postoperative ASA.

METHODS

A retrospective chart review was performed on all patients treated between 2008 and 2018 for ankle fractures requiring operative fixation by three Foot and Ankle fellowship trained orthopaedic surgeons at a single institution. Demographics, preoperative comorbidities, and postoperative medical and surgical complications were compared between patients who did and did not receive ASA postoperatively. For both groups, union was evaluated by clinical exam as well as by radiograph, for those with 6-week, 12-week, or 24-week follow-up.

RESULTS

Five-hundred and six patients met inclusion criteria: 152 who received ASA and 354 who did not. Radiographic healing at six weeks was demonstrated in 95.9% (94/98) and 98.6% (207/210) respectively (p-value .2134). There was no significant difference in time to radiographic union between groups. The risk of postoperative DVTs in those with and without ASA was not significantly different (0.7% (1/137) vs 1.2% (4/323), respectively; p-value .6305).

CONCLUSION

Postoperative use of ASA does not delay radiographic union of operative ankle fractures or affect the rate of postoperative DVT. This is the first and largest study to examine the effect of ASA on time to union of ankle fractures.

LEVEL OF EVIDENCE

III.

Elective spine surgery with continuation of clopidogrel anti-platelet therapy: Experiences from the community

PURPOSE

This retrospective study aimed to assess the feasibility of continuing clopidogrel therapy during the perioperative period in elective cervical and thoracolumbar surgery.

METHODS

After IRB approval, medical records of patients requiring one or two-level surgery over a two-year period (2015-2017) while receiving clopidogrel were reviewed for relevant outcomes. Over the same period, a control group of patients not receiving clopidogrel perioperatively was formed.

RESULT

In total, 136 patients were included: 37 clopidogrel and 99 control, with a mean age of 64.8 years. Between clopidogrel and control respectively, operative time was 86.7 min and 86.7 min (p = 0.620); blood loss was 127.0 cc and 117.5 cc (p = 0.480); drain output was 171.2 cc and 190.7 cc (p = 0.354); length of stay was 1.8 days and 1.5 days (p = 0.103). Two clopidogrel patients and 1 control patient had complications. Two clopidogrel patients and 1 control patient were readmitted within 30 days.

CONCLUSIONS

Remaining on clopidogrel therapy during elective spine surgery results in no difference in operative time, blood loss, drain output, length of stay, or readmission. Precaution should be taken in cervical procedures as the drain output in clopidogrel patients was increased and complications in this region can be severe.

Comparison of Adductor Canal Block and Femoral Nerve Block for Early Ambulation After Primary Total Knee Arthroplasty: A Randomized Controlled Trial

Purpose: The purpose of this study was to assess the efficacy of adductor canal block (ACB) as compared to femoral nerve block (FNB) in ambulation distance, opioid consumption, and physical therapy participation on postoperative days (PODs) 1 and 2 after total knee arthroplasty (TKA). We hypothesized ACB would have increased the ambulation distance and decreased the opioid consumption in comparison to FNB.

Methods: All elective TKAs at a single institution, age 18 and older, without existing neurologic or anatomic deficit in the operative limb, were considered. Participants were randomized 1:1 to receive either an ACB (AC group) or a FNB (FN group), in addition to standard care. Visual analog pain scores (VAS) and oral morphine equivalents (OMEs) were recorded preoperatively, in post-anesthesia care unit (PACU), and on PODs 1 and 2. Postoperative ambulation distance was recorded on PODs 1 and 2. Patient satisfaction with analgesia and physical therapist-rated participation in therapy sessions was obtained as well. 

Results: From 2014 to 2015, 84 participants were recruited: 41 in FN, and 43 in AC. On POD 1, mean ambulation distances in AC and FN were 70.2 and 48.5 ft, respectively (p = 0.045). On POD 2, mean ambulation distances in AC and FN were 129.0 and 106.4 ft, respectively (p = 0.225). VAS, OME, satisfaction, and physical therapy participation were not significantly different.

Conclusions: Ambulation after TKA is superior with ACB on the first POD, but there is no difference in VAS scores, OME, patient satisfaction, or ambulation on POD 2.

Is Use of Bone Cement for Treatment of Second Metatarsal Stress Fractures Safe? A Case Report

Metatarsal stress fractures are common injuries of the foot and can be a source of chronic pain without appropriate management. Conservative management is first line, but surgery may be indicated in athletes, cases of nonunion, and fractures of the fifth metatarsal. We report a case of a 34-year-old female who presented to clinic for intractable pain of the left foot secondary to a stress fracture of the left second metatarsal, which had been previously treated with injectable acrylic bone cement. Calcium sulfate hydroxyapatite cement has a multitude of applications in orthopedic surgery, but to our knowledge no studies have documented its use in the treatment of metatarsal stress fractures. Our findings suggest that injectable calcium sulfate hydroxyapatite cement is not a suitable stand-alone treatment in fractures of the second metatarsal.