Mark LaGreca’s research while affiliated with Philadelphia College of Osteopathic Medicine and other places

Introduction This review of case series and case reports explores conservative management strategies for paraspinal compartment syndrome (PCS), a rare clinical condition. Extremity compartment syndrome has been shown to be managed most effectively with emergent surgical release of the fascial compartment. Given the rarity of PCS and the paucity of research in the literature, some authors have suggested the possibility of conservative treatment. There has been no study to date that has specifically investigated the cases of non-operative management of PCS. Materials and Methods There are 16 case reports in the literature with 22 cases of PCS treated conservatively. The authors reviewed these cases, specifically viewing the clinical courses, why the decision was made to manage conservatively, and the reported outcomes. Results The etiology of PCS varied, with weightlifting being the primary cause in 11 out of 22 cases, followed by strenuous sporting events and postsurgical complications. All patients in this review were male, aged between 18 and 61 years old. Acute presentations exhibited severe back pain, rigid paraspinal musculature, and subjective paraspinal paresthesias. Magnetic Resonance Imaging findings of the spine revealed profound bilateral symmetric intramuscular edema. Among the cases, 8 explicitly reported a return to normal function, while 8 continued to experience symptoms related to the initial injury. Nine cases chose conservative measures primarily because of delayed presentation, seven instances reported successful outcomes with conservative measures; one case cited concerns about infection risk. Discussion The probability of underreporting related to PCS may result in a substantial number of cases being omitted from medical literature. Pathologically, PCS is characterized by increased intra-compartmental pressure, triggering rhabdomyolysis due to significant soft tissue damage. Emergent surgical intervention is the treatment of choice for any compartment syndrome; however, conservative management of these cases has shown satisfactory clinical outcomes. Hyperbaric oxygen therapy emerges as a potential adjunctive treatment to enhance tissue viability, though its efficacy and accessibility warrant further investigation in the context of PCS management. Conclusion Early recognition and treatment of PCS are critical in preventing chronic pain and permanent complications. Given the limitations identified in non-operative management, further research is imperative to optimize treatment strategies.

Introduction Cervical nerve palsies, most commonly C5, are relatively common following posterior cervical decompression and fusion (PCDF) for the management of cervical myelopathy. However, phrenic nerve palsy following PCDF is a rare complication documented in only one previous case report. The authors present a case of phrenic nerve palsy following PCDF. Methods and Material The patient is a 51-year-old male who presented with cervical myelopathy and radiculopathy as well as cervicalgia of 1 year’s duration. The patient underwent C3–C6 posterior cervical decompression and fusion (PCDF). On postoperative day 5, he was found to have a right C5 nerve palsy, which improved with steroid use and physical therapy. When he returned at 7 weeks postoperatively, the patient had progressive dyspnea. A fluoroscopic exam by pulmonology revealed a right-sided phrenic nerve palsy was the cause of the dyspnea. Results and Discussion Phrenic nerve palsy causing hemi-diaphragmatic paralysis is a rare complication of cervical spine surgery that requires a high degree of suspicion due to the nonspecific signs and symptoms. Our clinical case suggests that surgeons should bear in mind phrenic nerve palsy as a potential complication in patients with respiratory distress following cervical laminectomy.

Introduction: Neurofibromatosis type I (NF1) is an autosomal dominant disorder that typically results in Café-au-lait macules and peripheral nerve sheath tumors (i. e, neurofibromas). While peripheral neurofibromas are common, intra-articular knee neurofibromas are rarely described in the literature. To date, there only have been two other case reports noting intra-articular knee neurofibromas. The authors present the case of a patient with NF1 who was found to have an intra-articular knee neurofibroma incidentally discovered during the surgical approach to a retrograde femoral nail. Case Report: The patient is a 65-year-old female who presented to the emergency room after a fall from standing height with left distal thigh pain. X-rays were obtained and demonstrated a left supracondylar, extra-articular distal femur fracture. The patient had known NF1 with widespread cutaneous neurofibromas and was noted to have a large palpable soft-tissue mass over the anterior aspect of the knee on pre-operative examination. After an incision was made for a retrograde femoral intramedullary nail, the large soft-tissue mass prevented adequate surgical visualization. The mass was noted to track laterally around the patellar tendon, into the knee joint, communicating with Hoffa’s fat pad. The mass was resected and sent for pathology. The case proceeded uneventfully. The mass sent for pathology was positive for a neurofibroma. Clinical features alongside radiographic, computed tomography, and histopathological findings are presented. Conclusion: Intra-articular knee neurofibromas are rare and there is a paucity of literature on the topic. While found incidentally in our patient, the discovery of an intra-articular neurofibroma underscores the need for further investigation into its potential association with neuropathic arthropathy and other associated joint disorders. Keywords: Neurofibromatosis, intra-articular lesion, distal femur fracture.

Background Compartment syndrome is a well-known phenomenon that is most commonly reported in the extremities. However, paralumbar compartment syndrome is rarely described in available literature. The authors present a case of paralumbar compartment syndrome after high intensity deadlifting. Case presentation 53-year-old male who presented with progressively worsening low back pain and paresthesias one day after high-intensity deadlifting. Laboratory testing found the patient to be in rhabdomyolysis; he was admitted for intravenous fluid resuscitation and pain control. Orthopedics was consulted, and Magnetic Resonance Imaging revealed significant paravertebral edema and loss of muscle striation. Given the patient’s lack of improvement with intravenous and oral pain control, clinical and radiographic findings, there was significant concern for acute paralumbar compartment syndrome. The patient subsequently underwent urgent fasciotomy of bilateral paralumbar musculature with delayed closure. Conclusion Given the paucity of literature on paralumbar compartment syndrome, the authors’ goal is to promote awareness of the diagnosis, as it should be included in the differential diagnosis of intractable back pain after high exertional exercise. The current literature suggests that operative cases of paralumbar compartment syndromes have a higher rate of return to pre-operative function compared to those treated non-operatively. This case report further supports this notion. The authors recommend further study into this phenomenon, given its potential to result in persistent chronic exertional pain and irreversible tissue damage.

Introduction Given the growing emphasis on patient outcomes, including postoperative complications, in total joint arthroplasty (TJA), investigating the rise of outpatient arthroplasty is warranted. Concerns exist over the safety of discharging patients home on the same day due to increased readmission and complication rates. However, psychological benefits and lower costs provide an incentive for outpatient arthroplasty. The influence of social determinants of health disparities on outpatient arthroplasty remains unexplored. One metric that assesses social disparities, including the following individual components: socioeconomic status, household composition, minority status, and housing and transportation, is the Social Vulnerability Index (SVI). As such, we aimed to compare: (1) mean overall SVI and mean SVI for each component and (2) risk factors for total complications between patients undergoing inpatient and outpatient arthroplasty. Methods Patients who underwent TJA between January 1, 2022 and December 31, 2022 were identified. Data were drawn from the Maryland State Inpatient Database (SID). A total of 7817 patients had TJA within this time period. Patients were divided into inpatient arthroplasty (n = 1429) and outpatient arthroplasty (n = 6338). The mean SVI was compared between inpatient and outpatient procedures for each themed score. The SVI identifies communities that may need support cause by external stresses on human health based on four themed scores: socioeconomic status; household composition and disability; minority status and language; and housing and transportation. The SVI uses the United States Census data to rank census tracts for each individual theme, as well as an overall social vulnerability score. The higher the SVI, the more social vulnerability, or resources needed to thrive in that area. Multivariate logistic regression analyses were performed to identify independent risk factors for total complications following TJA after controlling for risk factors and patient comorbidities. Total complications included: infection, aseptic loosening, dislocation, arthrofibrosis, mechanical complication, pain, and periprosthetic fracture. Results Patients who had inpatient arthroplasty had higher overall SVI scores (0.45 vs. 0.42, P < 0.001). The SVI scores were higher for patients who had inpatient arthroplasty for socioeconomic status (0.36 vs. 0.32, P < 0.001), minority status and language (0.76 vs. 0.74, P < 0.001), and housing and transportation (0.53 vs. 0.50, P < 0.001) compared to outpatient arthroplasty, respectively. There was no difference between inpatient and outpatient arthroplasty for household composition and disability (0.41 vs. 0.41, P = 0.99). When controlling for comorbidities, inpatient arthroplasty [Odds Ratio (OR) 1.91, 95% Confidence Interval (CI) 1.23–2.95, P = 0.004], hypertension (OR 2.11, 95% CI 1.23–3.62, P = 0.007), and housing and transportation (OR 2.00, 95% CI 1.17–3.42, P = 0.012) were independent risk factors for total complications. Conclusion Inpatient arthroplasty was associated with increased social disparities across several components of deprivation as well as an independent risk factor total complications following TJA. To the best of our knowledge, this study is the first to examine the negative repercussions of inpatient arthroplasty through the lens of social disparities and can target specific areas for intervention.

Introduction Humeral shaft and distal humerus fractures have several different treatment options, including plate fixation and intramedullary nailing. Each has its own benefits, but typically, they are not used in conjunction. While nail-plate combinations (NPCs) have become more common in the lower extremity, literature on their use in upper extremity fractures remains scarce. Case Report A 74-year-old right-hand dominant male presented after a fall with a closed left transverse midshaft humerus fracture and an associated supracondylar distal humerus fracture with intercondylar extension through a medial column. Due to the segmental nature of his injury, medial column plating was used in conjunction with a retrograde intramedullary nail to obtain anatomic reduction and fixation of the articular injury while stabilizing the midshaft humerus fracture with minimal soft tissue disruption. The patient was recommended non-weight bearing through his left arm for 6 weeks, at which point he returned to weight bearing as tolerated. He was allowed to range his left elbow after 2 weeks. His left elbow range of motion at the 4-month follow-up was 20-135 degrees, and he reported minimal pain. Conclusion The retrograde NPC should be considered in segmental humeral fractures involving the distal articular surface and midshaft humerus fractures as it limits violation of the soft tissue while avoiding iatrogenic disruption of the articular surface at the shoulder or elbow.

Background The most common cause of revision arthroplasty is prosthetic joint infection (PJI). Chronic PJI is commonly treated with two-stage exchange arthroplasty involving the placement of antibiotic-laden cement spacers (ACS) in the first stage, often containing nephrotoxic antibiotics. These patients often have significant comorbidity burdens and have higher rates of acute kidney injury (AKI). This systematic review aims to assess the current literature to identify (1) AKI incidence, (2) associated risk factors, and (3) antibiotic concentration thresholds in ACS that increase AKI risk following first-stage revision arthroplasty. Methods An electronic search was performed of the PubMed database of all studies involving patients undergoing ACS placement for chronic PJI. Studies assessing AKI rates and risk factors were screened by two authors independently. Data synthesis was performed when possible. Significant heterogeneity prevented meta-analysis. Results Eight observational studies consisting of 540 knee PJIs and 943 hip PJIs met inclusion criteria. There were 309 (21%) cases involving AKI. The most commonly reported risk factors included perfusion-related factors (lower preoperative hemoglobin, transfusion requirement, or hypovolemia), older age, increased comorbidity burden, and nonsteroidal anti-inflammatory drug consumption. Only two studies found increased risk with greater ACS antibiotic concentration (> 4 g vancomycin and > 4.8 g tobramycin per spacer in one study, > 3.6 g of vancomycin per batch or > 3.6 g of aminoglycosides per batch in the other); however, these were reported from univariate analyses not accounting for other potential risk factors. Discussion Patients undergoing ACS placement for chronic PJI are at an increased risk for AKI. Understanding the risk factors may lead to better multidisciplinary care and safer outcomes for chronic PJI patients. Level of evidence III.

Purpose To provide an updated analysis of the sports medicine section of the Orthopedic In-Training Examination (OITE). Methods A cross-sectional review of OITE sports medicine questions from 2009 to 2012 and 2017-2020 was performed. Subtopics, taxonomy, references, and use of imaging modalities were recorded and changes between the time periods were analyzed. Results The most tested sports medicine subtopics included ACL (12.6%), rotator cuff (10.5%), and throwing injuries to the shoulder (7.4%) in the early subset, while ACL (10%), rotator cuff (6.25%), shoulder instability (6.25%), and throwing injuries to the elbow (6.25%) were the most common in the later subset. The American Journal of Sports Medicine (28.3%) was the most cited journal referenced from 2009 to 2012, while The Journal of the American Academy of Orthopaedic Surgeons (17.5%) was most referenced in questions from 2017 to 2020. The number of references per question increased from the early to the late subset (P < .001). There was a trend toward an increased taxonomy type one questions (P = .114), while type 2 questions had a decreased trend (P = .263) when comparing the new subset to the early group. Conclusion When comparing sports medicine OITE questions from 2009 to 2012 and 2017 to 2020, there was an increase in the number of references per question. Subtopics, taxonomy, lag time, and use of imaging modalities did not show statistically significant changes. Clinical Relevance This study provides a detailed analysis of the sports medicine section of the OITE, which can be used by residents and program directors to direct their preparation for the annual examination. The results of this study may help examining boards align their examinations and provide a benchmark for future studies.

Purpose Electric scooters (e-scooters) have seen an increase in popularity in cities across the United States as a form of recreation and transportation. The advent of ride-sharing applications allows anyone with a smartphone to easily access these devices, without any investment or experience required. In this study, the authors analyze scooter-related injuries of the hand and upper extremity. Methods The National Electronic Injury Surveillance System (NEISS) was queried to look for injuries related to the use of e-scooters between 2010 and 2019. Data collected included demographic information, the location of the injury, the injury diagnosis, and disposition. National estimates (emergency room visits in the United States) were calculated using the weight variable included in the NEISS database. Miscoded reports were excluded. As a corollary, Google Trends data were utilized to establish a correlation between e-scooter-related injuries and the relative number of e-scooter hits on the Google search engine. Results From 2010 to 2019, there were 730 e-scooter-related injuries reported to the NEISS database. This corresponds to an estimated 26,412 injuries nationally during this time period. The incidence of scooter-related injuries increased by over 230% (2,130 national injuries in 2010; 7,213 national injuries in 2019; relative difference 5,083). Injuries most commonly occurred in patients aged 10 to 18 years (30.3%). The most frequent site of injury was the wrist (41.9%). The most common injury diagnosis was fracture (55.3%). Additionally, there was a correlation between the number of Google Trends e-scooter hits and the number of injuries during this time period. Conclusions The incidence of e-scooter-related upper extremity injuries increased dramatically in the United States between 2010 and 2019. Clinical relevance As novel e-scooter-sharing apps become increasingly popular, it is imperative that users are educated about the risk of injury and that use of proper protective equipment is encouraged.

Background: There is little data on the magnitude and factors for functional leg lengthening after primary total knee arthroplasty (TKA). Questions/Purpose: We sought to determine the incidence of and risk factors for functional leg lengthening after primary TKA. Methods: We retrospectively reviewed consecutive unilateral primary TKAs at a single institution from 2015 to 2018. Of the 782 TKAs included, 430 (55%) were performed in women; the mean age was 66 years, and the mean body mass index was 29 kg/m ² . Preoperatively, 541 (69%) knees were varus deformities and 223 (29%) were valgus deformities. Hip to ankle biplanar radiographs were obtained preoperatively and 6 weeks postoperatively for all patients. Two independent researchers measured leg length, coronal plane deformity, lateral knee flexion angle, and overall mechanical alignment on all preoperative and postoperative radiographs. Results: The mean overall ipsilateral functional leg lengthening was 7.0 mm. Seven hundred knees (90%) were overall functionally lengthened, including 462 (59%) knees lengthened >5 mm and 250 (31%) knees lengthened 10 mm or more. A valgus deformity and coronal plane deformity of 10° or more were significant risk factors for increased functional lengthening. Patients with severe valgus deformities (>10°) had the largest amount of functional lengthening, at a mean of 13.5 mm. Conclusion: After primary TKA, 90% of limbs are functionally lengthened, including roughly one-third over a centimeter. Valgus knee deformities and severe deformities (>10°) were significant risk factors for increased limb lengthening.