Eric Cohen

Acute pediatric leg compartment syndrome in chronic myeloid leukemia.

Acute compartment syndrome is an orthopedic surgical emergency and may result in devastating complications in the setting of delayed or missed diagnosis. Compartment syndrome has a variety of causes, including posttraumatic or postoperative swelling, external compression, burns, bleeding disorders, and ischemia-reperfusion injury. Rare cases of pediatric acute compartment syndrome in the setting of acute myeloid leukemia and, even less commonly, chronic myeloid leukemia have been reported. The authors report the first known case of pediatric acute compartment syndrome in a patient without a previously known diagnosis of chronic myeloid leukemia. On initial examination, an 11-year-old boy presented with a 2-week history of progressive left calf pain and swelling after playing soccer. Magnetic resonance imaging scan showed a hematoma in the left superficial posterior compartment. The patient had unrelenting pain, intermittent lateral foot parethesias, and inability to bear weight. Subsequently, he was diagnosed with acute compartment syndrome and underwent fasciotomy and evacuation of a hematoma. Laboratory results showed an abnormal white blood cell count of 440×10(9)/L (normal, 4.4-11×10(9)) and international normalized ratio of 1.3 (normal, 0.8-1.2). Further testing included the BCR-ABL1 fusion gene located on the Philadelphia chromosome, leading to a diagnosis of chronic myeloid leukemia. Monotherapy with imatinib mesylate (Gleevec) was initiated. This report adds another unique case to the growing literature on compartment syndrome in the pediatric population and reinforces the need to consider compartment syndrome, even in unlikely clinical scenarios.

Nail Dynamization for Delayed Union and Nonunion in Femur and Tibia Fractures

Femoral and tibial shaft fractures are common injuries in the United States. Since their introduction, reamed intramedullary nails have become the treatment of choice for most of these fractures. However, delayed union and nonunion can complicate treatment in up to 10% of patients. Removal of interlocking screws, or dynamization, can promote fracture healing in cases of delayed union or nonunion. The efficacy of nail dynamization has been reported to range from 19% to 82%. This study was conducted to evaluate the efficacy of dynamization, identify the factors associated with its success or failure, and analyze the cost compared with exchange nailing. The authors retrospectively reviewed charts from 2011 to 2014 and searched billing records for Current Procedural Terminology codes 27506 and 27759, for intramedullary nailing of femoral and tibial shaft fractures, and code 20680, for removal of deep hardware. This search identified 34 patients with 35 fractures treated with dynamization for delayed union or nonunion. Dynamization was effective in creating union in 54% of patients. The factor that best correlated with the success of dynamization was the diameter of the fracture callus at the time of dynamization. Direct costs associated with dynamization were nearly

Atypical Fractures of the Femur: Evaluation and Treatment

10,000 less than those associated with exchange nailing. Dynamization can be an effective first-line treatment for delayed union and nonunion of femoral and tibial shaft fractures. The union rate in the current study is similar to previously published rates, and cost data suggest that dynamization is a viable alternative to exchange nailing for some patients with delayed union or nonunion. [Orthopedics. 2016; 39(6):e1117-e1123.].

Increased Mortality in Elderly Patients with Sarcopenia and Acetabular Fractures

Bisphosphonates are widely used as a primary treatment modality for osteoporosis. These agents prevent bone resorption via both the inhibition of osteoclast function and the promotion of osteoclast apoptosis1,2. The Fracture Intervention Trial Research Group investigated the effectiveness of bisphosphonates for the reduction of fragility fractures of the hip, distal part of the radius, and vertebrae3. Their research demonstrated that, compared with calcium supplementation alone, bisphosphonates with calcium supplementation …

Total Hip Arthroplasty for the Treatment of Failed Acetabular Fractures

Background: Sarcopenia is a condition of clinically relevant loss of muscle mass and function. Acetabular fractures in elderly patients are common and difficult to treat. This study aimed to determine if sarcopenia is common in elderly patients with acetabular fractures and correlates with lower-energy mechanisms of injury, higher rates of complications, and higher mortality than patients with normal muscle mass. Methods: The Rhode Island Hospital Trauma Database was queried for patients who were ≥60 years of age from 2005 to 2014 using the International Classification of Diseases, Ninth Revision, code for closed acetabular fracture, 808.0. Charts were retrospectively reviewed for demographic data, operative intervention, mechanism of injury, mortality, comorbidities, and other factors. Computed tomography (CT) was used to determine the muscle cross-sectional area and to calculate the skeletal muscle index. Results: The database revealed 192 patients coded for acetabular fracture; of these, 181 were correctly diagnosed. Ninety-nine patients had recorded body mass index (BMI) and adequate CT scans to measure the skeletal muscle index. Forty-two patients (42.4%) had sarcopenia, and 57 patients (57.6%) did not have sarcopenia. There were no significant differences in demographic characteristics between the groups with the exception of BMI and sex. BMI was higher in patients who did not have sarcopenia (31.7 kg/m2) than it was in patients with sarcopenia (23.6 kg/m2) (p < 0.001). Male sex was significantly greater (p = 0.0104) in patients with sarcopenia at 76.2% (32 of 42 patients) than in patients without sarcopenia at 50.9% (29 of 57 patients). Fractures in patients without sarcopenia were associated with a higher-energy mechanism of injury in 78.9% of cases compared with 52.4% of cases of patients with sarcopenia (p = 0.005). Sarcopenia was significantly associated (p = 0.0419) with increased 1-year mortality (28.6%) compared with the absence of sarcopenia (12.3%). This association was even stronger if in-hospital mortality was excluded (p = 0.00074). Finally, anterior column fractures were more likely (p = 0.017) to be sustained by patients with sarcopenia at 47.6% (20 patients) than by patients who did not have sarcopenia at 24.6% (14 patients). Conclusions: Sarcopenia is common in elderly patients with acetabular fractures and is associated with lower-energy mechanisms, anterior column fractures, and higher risk of 1-year mortality. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Deltoid Compartment Syndrome After Prolonged Lateral Decubitus Positioning

There is an increasing prevalence of older patients with acetabular fractures and high conversion rate of operatively and nonoperatively treated geriatric acetabular fractures to total hip arthroplasty. These cases should be approached as a revision total hip arthroplasty with many similar challenges including previous hardware, scarring, heterotopic ossification, malunion, nonunion, acetabular bone loss, avascular necrosis of the femoral head, and potential occult infection. The patient should undergo a detailed physical examination documenting gait, neurovascular status of the lower extremity, leg-length discrepancy, and previous surgical incisions. Imaging should consist of AP pelvis, AP and lateral of affected hip, Judet radiographs, and CT scan of the pelvis with 3-D reconstruction. Review of preoperative radiographs and CT scan will allow templating and evaluation of the leg-length discrepancy, heterotopic ossification, previous hardware placement, bone stock, and acetabular defects. Prior to surgery it is important to rule out occult infection of previously failed ORIF of acetabular fractures. A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) should be obtained. If a high index of suspicion for infection remains, then a hip aspiration should be obtained and sent for cell count with differential and culture. The decision regarding surgical approach is often dictated by surgeon’s preferred approach, previous surgical approach used, retained hardware, location of heterotopic ossification removal, and acetabular defects that need to be addressed. These cases have unique challenges related to optimal acetabular cup fixation and stability often requiring structural bone graft, antiprotrusio cage, jumbo cup with distraction, or combined ORIF. There is a high risk of complications compared to primary total hip arthroplasty including increased risk of dislocation, infection, and heterotopic ossification and decreased survivorship of implants. As a result, total hip arthroplasty after failed acetabular fracture should be performed in specialized centers with adult reconstruction and orthopedic trauma specialists.

Rapid-Onset Diffuse Skeletal Fluorosis from Inhalant Abuse

Case: A thirty-six-year-old man fell off a ladder and sustained an open fracture of the distal end of the left humerus. He was taken to the operating room for irrigation, debridement, and fixation of the fracture and was placed in the right lateral decubitus position for over seven hours. He subsequently developed right deltoid compartment syndrome, necessitating emergency compartment release. One year later, he had limited function, with a Disabilities of the Arm, Shoulder and Hand score of 81.3 points. Conclusion: Deltoid compartment syndrome can occur from operative positioning, with poor long-term outcomes as a result. Expeditious surgery, additional padding, and repeat checks are necessary for at-risk patients.

Intraoperative Femur Fracture Risk during primary Direct Anterior Approach Cementless Total Hip Arthroplasty with and without a fracture table

Case: A thirty‐year‐old man presented with severely debilitating left hip pain and stiffness. Radiographs demonstrated diffuse osteosclerosis and heterotopic bone formation with near ankylosis of the left hip. The patient underwent successful joint‐preserving surgery to restore hip range of motion. After disclosing a history of inhalant abuse, which was confirmed by elevated serum fluoride levels, he was diagnosed with diffuse skeletal fluorosis. Conclusions: To the best of our knowledge, we present the first reported case of diffuse skeletal fluorosis caused by inhalant abuse of 1,1‐difluoroethane. Skeletal fluorosis is uncommon in the United States but is important to consider in the differential diagnosis when a patient presents with otherwise unexplained joint pain and osteosclerosis.