Delayed presentation of compartment syndrome of the thigh secondary to quadriceps trauma and vascular injury in a soccer athlete

AbstractIntroductionCompartment syndrome isolated to the anterior thigh is a rare complication of soccer injury. Previous reports in the English literature on sports trauma-related compartment syndrome of the thigh are vague in their description of the response of thigh musculature to blunt trauma, magnetic resonance imaging (MRI) findings of high-risk features of compartment syndrome, vascular injury in quadriceps trauma, and the role of vascular study in blunt thigh injury.Case reportWe present herein the rare case of a 30-year-old man who developed thigh compartment syndrome 8 days after soccer injury due to severe edema of vastus intermedius and large thigh hematoma secondary to rupture of the profunda femoris vein. MRI revealed “blow-out” rupture of the vastus lateralis. Decompressive fasciotomy and vein repair performed with subsequent split-skin grafting of the wound defect resulted in a good functional outcome at 2-years follow-up.ConclusionA high index of suspicion for compartment syndrome is needed in all severe quadriceps contusion. Vascular injury can cause thigh compartment syndrome in sports trauma. MRI findings of deep thigh muscle swelling and “blow-out” tear of the vastus lateralis are strongly suggestive of severe quadriceps injury, and may be a harbinger of delayed thigh compartment syndrome

Comparison of a simplified skin pointer device compared with a skeletal marker for knee rotation laxity : a cadaveric study using a rotation-meter

AIM : To compare the measurements of knee rotation laxity by non-invasive skin pointer with a knee rotation jig in cadaveric knees against a skeletally mounted marker. METHODS : Six pairs of cadaveric legs were mounted on a knee rotation jig. One Kirscher wire was driven into the tibial tubercle as a bone marker and a skin pointer was attached. Rotational forces of 3, 6 and 9 nm applied at 0°, 30°, 45°, 60° and 90° of knee flexion were analysed using the Pearson correlation coefficient and paired t-test. RESULTS : Total rotation recorded with the skin pointer significantly correlated with the bone marker at 3 nm at 0° (skin pointer 23.9 ± 26.0° vs bone marker 16.3 ± 17.3°, r = 0.92; P = 0.0), 30° (41.7 ± 15.5° vs 33.1 ± 14.7°, r = 0.63; P = 0.037), 45° (49.0 ± 17.0° vs 40.3 ± 11.2°, r = 0.81; P = 0.002), 60° (45.7 ± 17.5° vs 34.7 ± 9.5°, r = 0.86; P = 0.001) and 90° (29.2 ± 10.9° vs 21.2 ± 6.8°, r = 0.69; P = 0.019) of knee flexion and 6 nm at 0° (51.1 ± 37.7° vs 38.6 ± 30.1°, r = 0.90; P = 0.0), 30° (64.6 ± 21.6° vs 54.3 ± 15.1°, r = 0.73; P = 0.011), 45° (67.7 ± 20.6° vs 55.5 ± 9.5°, r = 0.65; P = 0.029), 60° (62.9 ± 22.4° vs 45.8 ± 13.1°, r = 0.65; P = 0.031) and 90° (43.6 ± 17.6° vs 31.0 ± 6.3°, r = 0.62; P = 0.043) of knee flexion and at 9 nm at 0° (69.7 ± 40.0° vs 55.6 ± 30.6°, r = 0.86; P = 0.001) and 60° (74.5 ± 27.6° vs 57.1 ± 11.5°, r = 0.77; P = 0.006). No statistically significant correlation with 9 nm at 30° (79.2 ± 25.1° vs 66.9 ± 15.4°, r = 0.59; P = 0.055), 45° (80.7 ± 24.7° vs 65.5 ± 11.2°, r = 0.51; P = 0.11) and 90° (54.7 ± 21.1° vs 39.4 ± 8.2°, r = 0.55; P = 0.079). We recognize that 9 nm of torque may be not tolerated in vivo due to pain. Knee rotation was at its maximum at 45° of knee flexion and increased with increasing torque. CONCLUSION : The skin pointer and knee rotation jig can be a reliable and simple means of quantifying knee rotational laxity with future clinical application.Published versio

The modified fascial sling technique for ulnar nerve anterior transposition: surgical techniques and results

Background: Approaches to surgical treatment to cubital tunnel syndrome include simple decompression, decompression with medial epicondylectomy, and decompression with anterior transposition of the ulnar nerve. Transposition of the ulnar nerve involves decompression and transposition of the nerve anteriorly to a subcutaneous, intramuscular, or submuscular position. However, transposing the ulnar nerve to subcutaneous plane renders it more susceptible to external trauma. Hence, this technique article introduces the use of a modified fascial sling. Methodology: The modified fascial sling technique for anterior transposition of the ulnar nerve involves careful dissection to identify the ulnar nerve, decompression of the nerve, then transposition of the ulnar nerve anterior to the medial epicondyle. An AlloWrap (Stryker, Kalamazoo, MI, USA) is first wrapped around the ulnar nerve, followed by wrapping a fascial sling fashioned from the flexor carpi ulnaris fascia. A prospective case series for this surgical technique was conducted. Wilcoxon signed-rank test compared preoperative and postoperative qDASH-9 scores, an abbreviated questionnaire to assess functional limitations of the upper limb. Results: Five patients were included in this study, with a mean duration of follow-up of 530.4 days. The mean QuickDASH-9 functional disability score was 36.5 ± 25.1 preoperatively and 20.6 ± 12.8 postoperatively, demonstrating statistically significant improvement (P = .008). Conclusion: The modified fascial sling technique for anterior transposition of the ulnar nerve was developed to address the complications of perineural adhesions after transposition causing tethering of the ulnar nerve. At the same time, the fascial sling prevents posterior subluxation of the ulnar nerve back to its original location, thereby reducing the risk of recurrent symptoms

Septic arthritis of the glenohumeral joint: A case series and review of investigative and treatment strategies

Introduction: Glenohumeral septic arthritis is most caused by hematogenous seeding of the joint by S. Aureus, and also as a result of previous surgery or intra-articular injection. Although rare, septic arthritis of the glenohumeral joint has poor prognosis. In patients who survive the infection, the potential to cause rapid and catastrophic damage to articular cartilage, frequently causes lifelong morbidity. Methods: Four consecutive patients (five shoulders) treated at our institution between December 2019 to September 2020 were identified for the study. Medical records were reviewed, and basic demographics of the patient series included age, sex, race, BMI were collected. Information such as comorbidities, inciting injuries, history of presentation, examination findings, biochemical results, radiological findings, aspiration results and cultures, intra-operative findings, as well as blood cultures were extracted. Results: Four patients (age range of 65–83 years old) underwent a single arthroscopic washout of the glenohumeral joint. All four patients (3 female, 1 male) presented with acute swollen should joint/s with raised inflammatory markers (ESR, CRP and WBC). Staph Aureus was identified in 50% (n ​= ​2) of the cases with Mycobacterium Kansasii and Group B Streptococcus isolated in the other 2 patients. Half of the cases (n ​= ​2) were deemed to be caused by direct spread of pathogens whereas the other half of the cases (n ​= ​2) were deemed to be due to hematogenous spread. All patients exhibit resolution of clinical infection following the treatment. MRI were done for all patients which aided in the diagnosis of a septic shoulder joint. Conclusion: Our case series shown that single arthroscopic washout and debridement provides acceptable to good short-term outcomes for septic arthritis of the glenohumeral joint. In this case series, the authors have found MRI to be a useful radiographic aid to diagnosis. Level of evidence: Case series

The Hazards of Total Knee Arthroplasty: A Case Report in Illustration

Infections and periprosthetic fractures are uncommon but dreaded complications of total knee arthroplasty which carry attendant morbidity and prolonged hospitalization and necessitate repeat surgery. We present a patient with a total knee arthroplasty who had both intra-operative and post-operative periprosthetic fractures who subsequently developed infection of the prosthesis necessitating revision surgery. This was complicated too by positive intra-operative tissue cultures. The clinical course, presentation and management are discussed. Total knee arthroplasty is a frequently performed and successful operation and its complications are challenging to address and require early recognition by the surgeon with appropriate referral to a dedicated arthroplasty surgeon as needed

A Comparison of Clinical Outcomes of Two Methods of Femoral Hamstring Graft Pin Fixation in Anterior Cruciate Ligament Reconstruction

The outcome of anterior cruciate ligament (ACL) reconstruction with hamstring grafts depends on early rehabilitation and secure graft fixation. Various devices available for graft fixation at the femoral tunnel have different biomechanical properties as demonstrated on cadaveric studies. The aim of this study was to compare clinical outcomes in patients using either of two methods of transfemoral pin fixation for hamstring grafts in ACL reconstruction. Twenty-eight patients undergoing primary ACL reconstruction with hamstring autograft with either transfemoral expansion fixation (Rigidfix) or cortical-cancellous suspension (Transfix) by a single surgeon were analysed including subjective knee scores and objective measurements including range of motion and arthrometer-measured anterior translation. Transfix was used in 14 (50.0%) patients and Rigidfix was used in 14 (50.0%) patients. There was no significant difference in pre-injury Tegner activity scores, pre-operative Tegner activity scores, Lysholm scores and age or in Tegner post-operative activity scores, Lysholm scores, range of motion, Lachman and pivot scores absolute anterior translation and anterior translation compared to the non-operated knee at two years. There was a significant improvement in Tegner (2.6 ± 2.4, p <0.00) and Lysholm (25.3 ± 21.2, p <0.00) scores at two years with no significant difference between the two groups. One patient had a broken Transfix cross-pin 13 months after surgery which presented as a subcutaneous swelling which was removed. Although the biomechanical properties of Rigidfix and Transfix differ as demonstrated in cadaveric studies, both devices had similar favourable clinical outcomes in our series

Airway 'Resistotypes' and Clinical Outcomes in Bronchiectasis

INTRODUCTION: Application of whole-genome shotgun metagenomics to the airway microbiome in bronchiectasis highlights a diverse pool of antimicrobial resistance genes: the 'resistome', the clinical significance of which remains unclear.METHODS: Individuals with bronchiectasis were prospectively recruited into cross-sectional and longitudinal cohorts (n=280) including the international multicentre cross-sectional Cohort of Asian and Matched European Bronchiectasis 2 study (CAMEB 2; n=251) and two independent cohorts, one describing patients experiencing acute exacerbation and a further cohort of patients undergoing P. aeruginosa eradication treatment. Sputum was subjected to metagenomic sequencing and the bronchiectasis resistome evaluated in association with clinical outcomes and underlying host microbiomes.RESULTS: The bronchiectasis resistome features a unique resistance gene profile and elevated counts of aminoglycoside, bicyclomycin, phenicol, triclosan and multi-drug resistance genes. Longitudinally, it exhibits within-patient stability over time and during exacerbations despite between-patient heterogeneity. Proportional differences in baseline resistome profiles including increased macrolide and multi-drug resistance genes associate with shorter intervals to next exacerbation, while distinct resistome archetypes associate with frequent exacerbations, poorer lung function, geographic origin, and the host microbiome. Unsupervised analysis of resistome profiles identified two clinically relevant 'resistotypes' RT1 and RT2, the latter characterized by poor clinical outcomes, increased multi-drug resistance and P. aeruginosa. Successful targeted eradication in P. aeruginosa-colonized individuals mediated reversion from RT2 to RT1, a more clinically favourable resistome profile demonstrating reduced resistance gene diversity.CONCLUSION: The bronchiectasis resistome associates with clinical outcomes, geographic origin, and the underlying host microbiome. Bronchiectasis 'resistotypes' link to clinical disease and are modifiable through targeted antimicrobial therapy.</p