Despite an increasing rate of civilian low-velocity gunshot injuries, there remains a lack of evidence-based treatment standards.
Most low-velocity gunshot-induced fractures of the extremity can be ...managed similarly to non-gunshot-induced fractures, with the goals of restoring function and minimizing complications.
There are a limited number of high-quality studies to support the use of prophylactic antibiotics for nonoperatively treated gunshot wounds.
Intra-articular retained bullets should be removed, while prophylactic irrigation and debridement for a transarticular bullet is not routinely warranted for infection prevention.
Much of the literature on low-velocity gunshot wounds is Level-III or IV evidence, warranting the need for higher-powered, randomized, prospective investigations.
Purpose
Treatment for tibial plateau fractures continues to evolve but maintains primary objectives of anatomic reduction of the joint line and a rapid recovery course. Arthroscopic-assisted ...percutaneous fixation (AAPF) has been introduced as an alternative to traditional open reduction internal fixation (ORIF). The purpose of the study is to compare clinical and radiographic outcomes in patients with low-energy Schatzker type I–III tibial plateau fractures treated with AAPF versus ORIF.
Methods
A retrospective chart review was performed at a level 1 trauma centre to compare outcomes of 120 patients (57 AAPF, 63 ORIF) with low-energy lateral Schatzker type I–III tibial plateau fractures who underwent tibial plateau fixation between 2009 and 2018. Demographic information, injury characteristics, and surgical treatment were recorded. The main outcome measurements included reduction step-off, joint space narrowing, time to weight bearing, and implant removal.
Results
There was no difference in age, gender distribution, BMI, ASA, Schatzker classification distribution, initial displacement, blood loss, and reduction step-off between the two groups (
p
> 0.05). Shorter tourniquet time (74.1 ± 21.7 vs 100.0 ± 21.0 min;
p
< 0.001), shorter time to full weight bearing (47.8 ± 15.2 vs. 69.1 ± 17.2 days;
p
< 0.001), and lower rate of joint space narrowing (3.5% vs. 28.6% with more than 1 mm,
p
< 0.001) were associated with the AAPF cohort, with no difference in pain, knee range of motion, or implant removal rate between the two cohorts.
Conclusion
AAPF may be a viable alternative to ORIF for the management of low-energy tibial plateau fractures with outcomes not inferior compared to the traditional ORIF method.
Highlights • Topical agents may be efficacious for oral cancer chemoprevention. • Topical agents reduce systemic toxicity and avoid first-pass metabolism. • Retinoids, bleomycin, adenovirus, and PDT ...reduce clinical presence of oral lesions. • Need for future randomized controlled trials with longer follow-up.
ABSTRACT
Background
Currently no research exists assessing lifestyle modifications and emotional state of acute aortic dissection (AAD) survivors. We sought to assess activity, mental health, and ...sexual function in AAD survivors.
Hypothesis
Physical and sexual activity will decrease in AAD survivors compared to pre‐dissection. Incidence of anxiety and depression will be significant after AAD.
Methods
A cross sectional survey was mailed to 197 subjects from a single academic medical center (part of larger IRAD database). Subjects were ≥18 years of age surviving a type A or B AAD between 1996 and 2011. 82 surveys were returned (overall response rate 42%).
Results
Mean age ± SD was 59.5 ± 13.7 years, with 54.9% type A and 43.9% type B patients. Walking remained the most prevalent form of physical activity (49 (60%) pre‐dissection and 47 (57%) post‐dissection). Physical inactivity increased from 14 (17%) before AAD to 20 (24%) after AAD; sexual activity decreased from 31 (38%) to 9 (11%) mostly due to fear. Most patients (66.7%) were not exerting themselves physically or emotionally at AAD onset. Systolic blood pressure (SBP) at 36 months post‐discharge for patients engaging in ≥2 sessions of aerobic activity/week was 126.67 ± 10.30 vs. 141.10 ± 11.87 (p‐value 0.012) in those who did not. Self‐reported new‐onset depression after AAD was 32% and also 32% for new‐onset anxiety.
Conclusions
Alterations in lifestyle and emotional state are frequent in AAD survivors. Clinicians should screen for unfounded fears or beliefs after dissection that may reduce function and/or quality of life for AAD survivors.
Tibial plateau fractures account for approximately 1% to 2% of fractures in adults
. These fractures exhibit a bimodal distribution as high-energy fractures in young patients and low-energy fragility ...fractures in elderly patients. The goal of operative treatment is restoration of joint stability, limb alignment, and articular surface congruity while minimizing complications such as stiffness, infection, and posttraumatic osteoarthritis. Open reduction and internal fixation with direct visualization of the articular reduction or indirect evaluation with fluoroscopy has traditionally been the standard treatment for displaced tibial plateau fractures. However, there has been concern regarding inadequate visualization of the articular surface with open tibial plateau fracture fixation, contributing to a fivefold increase in conversion to total knee arthroplasty
. In addition, the risk of wound complications and infection has been reported to be as high as 12%
. Knee arthroscopy with percutaneous, cannulated screw fixation provides a less invasive procedure with excellent visualization of the articular surface and allows for accurate reduction and fracture fixation compared with traditional open reduction and internal fixation techniques
. Recent studies of arthroscopically assisted percutaneous screw fixation of tibial plateau fractures have reported excellent early clinical and radiographic outcomes and low complication rates
.
This technique involves the use of both arthroscopy and fluoroscopy to facilitate reduction and fixation of the tibial plateau fracture. Through a minimally invasive technique, the depressed articular joint surface is targeted with use of preoperative computed tomography (CT) scans and intraoperative biplanar fluoroscopy. Reduction is then directly visualized with arthroscopy and fixation is performed with use of fluoroscopy. Lastly, restoration of the articular surface is confirmed with use of arthroscopy after definitive fixation. Modifications can be made as needed.
The traditional method for fixation of displaced tibial plateau fractures is open reduction and internal fixation. Articular reduction can be visualized directly with an open submeniscal arthrotomy and an ipsilateral femoral distractor or indirectly with fluoroscopy.
Visualization of the articular surface is essential to achieve anatomic reduction of the joint line. Inspection of the posterior plateau is difficult with an open surgical approach. Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture may allow for improved restoration of articular surfaces through enhanced visualization. Less soft-tissue dissection is associated with lower morbidity and may result in less damage to the blood supply, lower rates of infection and wound complications, faster healing, and better mobility for patients. In our experience, this technique has been successful in patients with severe osteoporosis and comminution of depressed fragments. If total knee arthroplasty is required, we have also observed less damage to the blood supply and fewer surgical scars with use of this surgical technique.
Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture facilitates anatomical reduction through a less invasive approach. Patients undergoing this method of tibial plateau fracture fixation are able to engage earlier in rehabilitation
. Studies have shown early postoperative range of motion, excellent patient-reported outcomes, and minimal complications
.
Arthroscopically assisted fixation can be applied to a variety of tibial plateau fractures; however, the minimally invasive approach is best suited for patients with isolated lateral tibial plateau fractures (Schatzker I to III) and a cortical envelope that can be easily restored. The cortical envelope refers to the outer rim of the tibial plateau. Fracture pattern and ligamentotaxis determine the cortical envelope, which can be evaluated on preoperative CT scans. In our experience, even depressed segments with a high degree of comminution may be treated with use of this technique with satisfactory results.Articular depression should be targeted with use of a preoperative CT scan and intraoperative fluoroscopy and arthroscopy.The surgeon should be careful not to "push up" in 1 small area; rather, a "joker" elevator or bone tamp should be utilized, moving anterior to posterior, which can be frequently assessed with arthroscopy.The intra-articular pressure of the arthroscopy irrigation fluid should be low (≤45 mm Hg or gravity flow), and the operative extremity should be monitored for compartment syndrome throughout the procedure.
ACL = anterior cruciate ligamentK-wires = Kirschner wiresORIF = open reduction and internal fixationAP = anteroposteriorCR = computed radiography.
Intraarticular steroid injections are a common first-line therapy for severe osteoarthritis, which affects an estimated 27 million people in the United States. Although topical, oral, intranasal, and ...inhalational steroids are known to increase intraocular pressure in some patients, the effect of intraarticular steroid injections on intraocular pressure has not been investigated, to the best of our knowledge. If elevated intraocular pressure is sustained for long periods of time or is of sufficient magnitude acutely, permanent loss of the visual field can occur.
How does intraocular pressure change 1 week after an intraarticular knee injection either with triamcinolone acetonide or hyaluronic acid?
A nonrandomized, nonblinded prospective cohort study was conducted at an outpatient, ambulatory orthopaedic clinic. This study compared intraocular pressure elevation before and 1 week after intraarticular knee injection of triamcinolone acetonide versus hyaluronic acid for management of primary osteoarthritis of the knee. Patients self-selected to be injected in their knee with either triamcinolone acetonide or hyaluronic acid before being informed of the study. The primary endpoint was intraocular pressure elevation of ≥ 7 mm Hg 1 week after injection. This cutoff is determined as the minimum significant pressure change in the ophthalmology literature recognized as an intermediate responder to steroids. Intraocular pressure was measured using a handheld Tono-Pen® applanation device. This device is frequently used in intraocular pressure measurement in clinical and research settings; 10 sequential measurements are obtained and averaged with a confidence interval. Only measurements with a 95% confidence interval were used. Over a 6-month period, a total of 96 patients were approached to enroll in the study. Sixty-two patients out of 96 approached (65%) agreed. Thirty-one (50%) were injected with triamcinolone and 31 (50%) were injected with hyaluronic acid. Patients with osteoarthritis of the knee who were suitable candidates for either a steroid injection or hyaluronic acid injection were included in the study. Exclusion criteria included previous glaucoma surgery, previous corneal injury precluding use of a Tono-Pen, current acute or chronic steroid use, and diagnosis of glaucoma other than primary open-angle. Patients with elevated intraocular pressure at the 1-week timepoint were invited to return at 1 month for repeat measurement; however, only five of nine (55.6%) were able to do so. The mean age of the total population was 64.1 ± 11.65 years. There were 46 (74%) women and 16 men. Patient in the hyaluronic acid injection group were younger than the triamcinolone group, 59.5 ± 11.7 versus 68.7 ± 9.7 years of age (p < 0.003).
The mean intraocular pressure increased by 2.79 mm Hg 1 week after treatment with triamcinolone, but it did not change among those patients treated with hyaluronic acid (2.79 ± 9.9 mm Hg versus -0.14 ± 2.96 mm Hg; mean difference 2.93 mm Hg; 95% confidence interval, -0.71 to 6.57 mm Hg; p = 0.12). More patients who received triamcinolone injections developed an increase in intraocular pressure > 7 mm than did those who received hyaluronic acid (29% nine of 29 versus 0% zero of 31; p = 0.002). Of the nine patients who developed elevated intraocular pressure after a triamcinolone injection, five returned for reevaluation 1 month later, and four of them had pressures that remained elevated > 7 mm Hg from baseline.
There appears to be an associated intraocular pressure elevation found in patients who have undergone a triamcinolone injection of the knee. Further larger scale randomized investigations are warranted to determine the longevity of this pressure elevation as well as long-term clinical implications, including optic nerve damage and visual field loss.
Level II, therapeutic study.
Background & objectives: Beta-blockers have been shown to improve survival in both type A and type B acute aortic dissection (AAD) patients. Calcium channel blockers have been shown to selectively ...improve survival only in type B AAD patients. There is a lack of data on medication adherence in AAD survivors. The purpose of this study was to assess medication adherence in patients who survived an AAD.
Methods: This was a cross-sectional survey-based study of individuals from a single medical centre which was part of the larger International Registry of Acute Aortic Dissection (IRAD). Patients with type A or B AAD who survived to discharge were included in this study. Individuals who were deceased based on the results of an online Social Security Death Index were excluded from the study. Data were obtained from both a survey and also from abstraction from the local academic institution's IRAD registry. A survey packet was sent to patients. One section of this survey was dedicated to assessing medication adherence using the 4-item Morisky scale.
Results: Eighty two completed surveys were returned; 74 patients completed the section of the survey pertaining to medication adherence (response rate 38%). Morisky score was ≥1.0 for 27 (36%) patients and 0 for 47 (64%) patients. Thirty three patients reported yes to 'forget to take medications' and eight reported yes to 'careless with medications.' Medication non-adherence (defined as a score of ≥1.0 on Morisky) was associated with increased follow up recurrence of chest pain at one year of follow up. Only two patients stopped their antihypertensive on their own and did not cite a reason for doing this.
Interpretation & conclusions: The medication adherence rate for patients who survived an AAD was 64 per cent at a median (Q1, Q3) of 7.1 yr (5.6, 11.5) after discharge, as per the Morisky scale. The clinicians should educate their patients on the importance of antihypertensive therapy and assess for forgetfulness and carelessness at each clinic visit, as well as understand patients' beliefs about drug therapy, all of which have been shown to increase medication adherence.
Background Studies have shown acute aortic dissection (AAD) pts >=70 years of age have higher in-hospital mortality and less Type A (TA) surgical management (mgmt).
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