Concomitant Injuries Research Articles

Serum Glutamate dehydrogenase activity enables sensitive and specific diagnosis of hepatocellular injury in humans.

Serum activities of alanine- and aspartate- aminotransferases (ALT and AST) are considered the "gold standard" biomarkers of hepatocyte injury in clinical practice and drug development. However, due to expression of ALT and AST in myocytes, the diagnosis of hepatocellular injury in patients with underlying muscle diseases, including drug-induced muscle injury, is severely limited. Thus, we proposed glutamate dehydrogenase (GLDH) as a liver-specific alternative to serum ALT and AST. In fact, our exploratory studies showed that GLDH has comparable performance to ALT for detecting hepatocyte injury without interference from concomitant muscle injury. Here, we report the results of studies confirming the reference intervals in a healthy human population and sensitivity and specificity of GLDH for detection of hepatocyte injury in human subjects. In human subjects, we could not perform liver biopsies due to ethical reasons, we also confirmed the relationship of GLDH and histopathologic lesions using 32 model toxicants in rats. Furthermore, we have shown that injury to tissues that are known to express appreciable levels of GLDH does not affect serum GLDH measurements, indicating excellent liver specificity of serum GLDH. Finally, we observed faster elimination of GLDH than ALT in humans, indicating that decreasing GLDH values could be considered an early sign of recovery. This study provides comprehensive evidence of excellent sensitivity and liver specificity of GLDH for diagnosis of hepatocellular injury, including evaluation of reference intervals that is essential for interpretation of serum GLDH in human subjects.

Influence of Injury to the Kaplan Fibers and Anterolateral Ligament on Pivot-Shift Phenomenon in Adult and Adolescent Patients With Anterior Cruciate Ligament Injury: A Retrospective Cohort Study

Background: Studies have shown that Kaplan fibers (KFs) play a role in controlling anterolateral rotatory knee laxity in anterior cruciate ligament (ACL) injury. However, recent clinical studies have suggested that KF injuries are not associated with a higher-grade pivot shift in knees with acute ACL injuries. Purpose: To compare the effect of KF and anterolateral ligament injury on anterolateral rotatory laxity as measured by the pivot-shift test in both adult and adolescent patients with acute ACL injury. Study Design: Cross-sectional study; Level of evidence, 3. Methods: This study consisted of patients who experienced primary acute ACL tears between January 2019 and December 2021. The magnetic resonance imaging examinations and pivot-shift tests for these individuals were conducted within 14 days after injury. Variables associated with concomitant injury were included in a binary logistic regression model to evaluate risk factors of a high-grade pivot shift and a KF injury. Results: The study included 540 patients with acute ACL tears (64 adolescent patients and 476 adults). The main risk factor for a high-grade pivot shift after acute ACL injury in adults was partial or total disruption of anterolateral ligament continuity (odds ratio [OR], 2.271; 95% CI, 1.499-3.442). In adolescent patients, the main risk factor was KF injury (OR, 19.98; 95% CI, 2.367-168.669), including edema and disruption of continuity. Conclusion: The main risk factor for a high-grade pivot shift after acute ACL injury differs between adolescent patients and adults: the KF injury sign in adolescent patients indicates a higher-grade pivot shift.

A Retrospective Study of Ballistic Pelvic Fractures With Focus on Short-Term Clinical Outcomes.

To evaluate the orthopaedic management, associated injuries, and outcomes in patients treated for low-velocity ballistic pelvic fractures. Retrospective chart review. Single, urban, Level I trauma center. Patients 15 years or older treated for low-velocity ballistic pelvic (OTA/AO 61 and 62) fractures from May 2018 to August 2021. Primary study measures included pelvic fracture location, concomitant associated injuries, surgical interventions, and antibiotic treatment. Postinjury sequelae evaluated include infection, neurologic deficit, and need for orthopaedic removal of foreign body. Risk factors of postinjury sequelae were investigated. A total of 156 patients with ballistic pelvic fractures were included. The cohort consisted of 135 (86.5%) male patients with a mean age of 29.8 years. One hundred ten (70.5%) patients sustained 2 or more gunshot wounds. Ninety-eight (62.8%) patients underwent an exploratory laparotomy with 79 (50.6%) having a confirmed concomitant intestinal injury. Additional associated injuries included nerve injury (13.5%), vascular injury requiring repair or embolization (10.9%), and bladder injury (10.3%). Nine (5.7%) patients underwent orthopaedic operative management-five (3.2%) patients for operative fixation and 4 (2.5%) patients for removal of intra-articular foreign bodies. Diabetes (odds ratio [OR]: 33.1, P = 0.025), neurologic deficit on presentation (OR: 525.2, P < 0.001), vascular injury requiring repair or embolization (OR: 8.7, P = 0.033), and orthopaedic pelvic fixation (OR: 163.5, P = 0.004) were positively associated with the defined postinjury sequelae at 30 and 90 days of follow-up. There was not a statistically significant association between infection and retained foreign body (OR: 3.95 [95% CI 0.3-58.7, P = 0.318]) or bowel contamination (OR: 6.91 [95% CI 0.4-58.7, P = 0.178]). Ballistic fractures of the pelvis and acetabulum rarely required operative fixation (3.2%) or irrigation and debridement. Neither retained foreign body nor presumed bowel contamination of pelvic fractures had a statistically significant association with infection, which further supports conservative management of these injuries. Patients with diabetes, neurologic deficit on presentation, vascular injury necessitating intervention, and orthopaedic fixation of pelvic fracture are associated with increased risk of postinjury sequelae. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Surgical Intervention Results in Better Patient-Reported Outcomes Than Delayed Treatment in Patients Undergoing Anterior Cruciate Ligament Reconstruction in the Presence of Concomitant Medial Collateral Ligament Injury

Early Surgical Intervention Results in Better Patient-Reported Outcomes Than Delayed Treatment in Patients Undergoing Anterior Cruciate Ligament Reconstruction in the Presence of Concomitant Medial Collateral Ligament Injury

Traumatic Abdominal Wall Hernia, often missed diagnosis in blunt trauma and delayed elective repair: A Case Report

Background: Traumatic Abdominal Wall Hernia (TAWH) is a rare type of hernia following blunt abdominal trauma that can easily missed. Always have high clinical suspicion following blunt trauma. Ultrasound scans and CT scans are particularly useful investigation to diagnose TAWH and associated abdominal injuries. Surgical repair is the definitive management of TAWH. Case description: This report presents a case of a 57-year-old male who presented abdominal wall hernia following blunt trauma to the abdomen and the diagnosis and management of TAWH. Conclusion: The timing of surgery depends on the concomitant injury. Delayed elective repair may be safe and cause less postoperative complications in stable patients. Delayed repair carries the risk of bowel incarceration and strangulation.

MiR-103–3p attenuates liver injury with severe acute pancreatitis by inhibiting pyroptosis through miR-103–3p/NLRP1 axis

BackgroundSevere acute pancreatitis (SAP) is a common digestive system disorder in clinical practice, and it is often associated with liver damage in patients with severe acute pancreatitis. Several studies have indicated that pyroptosis plays a role in liver damage following severe acute pancreatitis (SAP). However, the precise mechanisms remain unclear. This study aims to elucidate the association and specific mechanisms between liver injury following SAP and pyroptosis, providing theoretical support for research on SAP-induced liver injury. MethodsA rat model of SAP with concomitant liver injury was successfully established. The expression levels of miR-103–3p across different liver tissue groups were quantified using quantitative reverse transcriptase polymerase chain reaction (qRT-PCR). Bioinformatic analyses and dual-luciferase reporter assays confirmed that NLRP1 is a direct target of miR-103–3p. In vivo assessments of miR-103–3p levels were performed, and the extent of cell pyroptosis during liver injury post-SAP was evaluated through western blotting, qRT-PCR, scanning electron microscopy, histopathology, immunofluorescence, and immunohistochemistry. The role of miR-103–3p in regulating NLRP1-mediated pyroptosis and its impact on SAP-induced liver injury were validated. ResultsThis study reports that following SAP-induced liver injury, the expression of miR-103–3p in liver tissue was significantly decreased, and cell pyroptosis was involved in the process of liver injury. Experimental validation indicated that NLRP1 was a downstream target of miR-103–3p. Overexpression of miR-103–3p in vitro significantly alleviated the severity of liver injury following SAP, while simultaneously inhibiting cell pyroptosis. ConclusionThese findings indicate that pyroptosis may be linked to SAP-induced liver injury and that miR-103–3p mitigates hepatocyte pyroptosis by reducing liver injury through the suppression of NLRP1 expression.

Beyond the imaging evaluation of fractures of the lateral process of the talus: Let's not forget concomitant injuries.

Fractures of the lateral process of the talus (FLPT) are uncommon fractures that represent a clinical challenge. Traditional radiological classification systems rely predominantly on radiographic findings. However, due to the high rate of FLPT misdiagnosis and the limited accuracy in evaluating concomitant talar injuries through plain radiographs, novel imaging classification systems have been developed that aim to enhance the diagnosis of concomitant talar injuries, thereby optimizing patient management and reducing the incidence of long-term complications.

Knee joint dislocations-Current epidemiology and treatment in Germany.

Knee joint dislocations, though rare, present significant challenges due to potential complications like vascular and nerve damage, and are known to be often linked to sports injuries, accidents and obesity. This study aims to analyse the epidemiology, incidence and treatment approaches for knee dislocations in Germany from 2019 to 2022. This retrospective cohort study utilized data from the German Institute for the Hospital Remuneration System to examine knee dislocation cases across German medical institutions. Patient data coded under International Statistical Classification of Diseases and Related Health Problems 10 for 'knee dislocation' enabled detailed analysis by age, sex and surgical procedures categorized by operation and procedure codes. The Patient Clinical Complexity Level (PCCL) assessed complication severity. Analysis of 1643 knee dislocation cases revealed an incidence rate of 0.44-0.54 per 100,000 inhabitants annually. During the years 2020 and 2021, there were fewer cases of knee dislocations. Male patients comprised 50%-56% of cases, with an average hospital stay of 11 days. Most cases were PCCL 0 (62%-72%) and predominantly affected patients aged 18-29 years. Anterior tibial dislocations were common among classified cases. Injuries included ligament ruptures, meniscus lesions and grade I soft-tissue injuries. Patients with pre-existing knee prostheses constituted 0%-16% annually. Treatment involved closed reduction, external fixation and surgeries like capsuloligamentous reconstructions and arthroscopic procedures. Revision knee arthroplasty was required in 2%-9% of cases, with obesity rates up to 7%. This study provides valuable insights into the epidemiology, incidence and treatment of knee dislocations in Germany, with a focus on demographic risk factors, treatment complexities and the impact of obesity and knee prostheses. The findings emphasize the importance of specialized care in larger hospitals, comprehensive management of concomitant injuries and the need for improved coding accuracy. Future research should aim to refine treatment protocols. Level III.

Physiologic Preoperative Knee Hyperextension Is Not Associated With Postoperative Laxity, Subjective Knee Function, or Revision Surgery After ACL Reconstruction With Hamstring Tendon Autografts.

There is concern that physiologic knee hyperextension may be associated with inferior outcomes after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon (HT) autografts. To assess whether there is an association between contralateral passive preoperative knee hyperextension (≤-5°) and postoperative anterior knee laxity, subjective knee function, or revision surgery after ACLR using HT autografts. Cohort study; Level of evidence, 3. Patients without concomitant ligament injuries who underwent primary ACLR using an HT autograft at Capio Artro Clinic, Stockholm, Sweden, between January 1, 2005, and December 31, 2018, were identified. The cohort was dichotomized into the hyperextension group (≤-5°) and the no hyperextension group (>-5°) depending on preoperative contralateral passive knee extension degree. Anterior knee laxity (KT-1000 arthrometer; 134 N) was assessed preoperatively and at 6 months postoperatively. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1, 2, and 5 years postoperatively. Patients who underwent revision ACLR at any institution in Sweden within 5 years of the primary surgery were identified in the Swedish National Knee Ligament Registry. A total of 6104 patients (53.5% male) for whom knee range of motion measurements were available were identified (hyperextension group [≤-5°]: 2350 [38.5%]; mean extension, -6.1°± 2.3° [range, -20° to -5°]; no hyperextension group [>-5°]: 3754 [61.5%]; mean extension, 0°± 1.4° [range, -4° to 15°]). There were no intergroup differences in anterior knee laxity preoperatively (hyperextension group, 3.6 ± 2.8 mm; no hyperextension group, 3.7 ± 2.7 mm; P = .24) or postoperatively (hyperextension group, 1.8 ± 2.3 mm; no hyperextension group, 1.8 ± 2.2 mm; P = .41). The only significant but nonclinically relevant intergroup differences were seen in the KOOS Symptoms subscale at the 1-year follow-up (hyperextension group, 81.4 ± 16.0; no hyperextension group, 80.3 ± 16.5; P = .03) and in the Sport and Recreation subscale at the 5-year follow-up (hyperextension group, 73.0 ± 25.6; no hyperextension group, 75.7 ± 24.3; P = .02). No other significant intergroup differences were noted preoperatively or at 1, 2, or 5 years postoperatively in any of the KOOS subscales. The overall revision ACLR rate at ≤5 years after the primary surgery was 4.9% (302 of 6104 patients). The hazard for revision ACLR in the no hyperextension group (4.5%; 170 of 3754 patients) was not significantly different from that in the hyperextension group (5.6%; 132 of 2350 patients) (hazard ratio, 0.89; 95% CI, 0.71 to -1.12; P = .34). A subsequent subanalysis showed that the hazard of revision ACLR in patients with no hyperextension was not significantly different from that of patients with ≤-10° of extension (5.8%; 27 of 467 patients) (hazard ratio, 0.91; 95% CI, 0.61 to 1.36; P = .65). Preoperative passive contralateral knee hyperextension (≤-5°) was not associated with postoperative anterior knee laxity, subjective knee function, or revision surgery ≤5 years after ACLR using HT autografts. Therefore, the presence of knee hyperextension alone should not be considered a contraindication per se for the use of HT autografts in ACLR.

Effect of Graft Choice for ACL Reconstruction on Clinical Outcomes in Combined ACL and MCL Injuries: Comparison Between Bone-Patellar Tendon-Bone and Hamstring Autografts

Background/Objectives: The optimal graft, particularly in combined anterior cruciate ligament (ACL) and medial collateral ligament (MCL) injuries, remains controversial. We evaluated the influence of graft choice between bone-patellar tendon-bone (BPTB) and hamstring autografts on clinical outcomes in combined ACL and MCL injuries. Methods: This retrospective analysis included patients with concurrent ACL and MCL injuries who underwent single-bundle ACL reconstruction with BPTB (group B) or hamstring (group H) grafts, between 2010 and 2019, with a ≥2-year follow-up. Patients were classified based on the MCL injury grade (I, II, or III). Clinical outcomes were assessed through knee stability evaluations using valgus stress radiographs and the KT-2000 arthrometer, patient-reported outcomes using the International Knee Documentation Committee (IKDC) subjective score and Lysholm score, and radiologic outcomes using the IKDC radiographic grade. Results: The study included 169 patients (group B, 92; group H, 77). No significant between-group differences in knee stability or functional outcomes were found after follow-up. Within the same MCL injury grade, particularly in high-grade MCL injuries, BPTB grafts resulted in significantly better medial stability (side-to-side difference in medial joint opening on valgus stress radiographs: grade II, p = 0.006; grade III, p = 0.039) and functional outcomes (IKDC subjective score: grade II, p = 0.045; grade III, p = 0.038) than hamstring grafts. In the hamstring group, higher-grade MCL injuries were associated with worse outcomes (Lysholm knee score, p = 0.009; IKDC subjective score, p = 0.015). Conclusions: Graft choice in ACL reconstruction with concomitant MCL injuries may affect clinical outcomes, particularly in high-grade MCL injuries. Although both graft types performed similarly overall, BPTB grafts provided superior medial stability and functional results in higher-grade MCL injuries. However, caution is needed when interpreting these results due to limitations such as the small sample size and the lack of randomization in graft selection.

Recovery after neurologic injury in operative acetabular and pelvic fractures: Defining the natural history of foot drop

IntroductionDorsiflexion weakness, or footdrop, is a well-described sequela of high-energy acetabular and pelvic trauma, but little data exists describing the factors related to neurologic recovery and the timeline therein. An improved understanding of these factors would facilitate prognostication, patient education, and treatment decision-making. The aim of this study was to compare neurologic recovery between acetabular and pelvic fractures, delineate factors associated with recovery, and determine the expected timeline of recovery. MethodsA retrospective chart review was conducted at a level 1 tertiary referral center from 2000 to 2021 using CPT codes and keyword search functions to identify adult patients with neurologic injury in the setting of operative acetabular and/or pelvic ring trauma. Patients were included if they had documented, graded weakness not clearly explained by a concomitant injury (extremity or spine) following a pelvic/acetabular injury. Patients were followed to a minimum of 6 months follow-up or to neurologic recovery. Primary outcomes were the presence of motor recovery and time to initial and maximum recovery. The contributions of injury type and initial neurologic status were analyzed using logistic regression for impact on neurologic recovery. ResultsWe identified 121 patients with neurologic injury and resultant footdrop in the setting of an operative pelvic ring or acetabular fracture. From this cohort, 58 patients (47.9 %) demonstrated some degree of neurologic recovery in follow-up. There was no difference in recovery when comparing injury type (pelvis vs. acetabulum). Any motor function (including flicker) at time of initial evaluation was predictive of recovery (OR 6.18, [2.00 – 19.14]; p = 0.002). Initial neurologic function also correlated with more rapid recovery in comparison to patients with initial absent neurologic function both in time to initial recovery (56 days vs 107 days; p = 0.016) and time to maximum recovery (153 days vs 241 days; p = 0.027). ConclusionsThese results highlight the relatively poor prognosis for neurologic recovery in operative pelvic and acetabular injuries. Any initial neurologic function is predictive of likelihood of neurologic recovery and correlates with a more expedient neurologic recovery. Ultimately, this enables providers to better educate patients and facilitates decisions regarding further intervention.

Anterior Cruciate Ligament Tear: Individualized Indications for Non-Operative Management.

Anterior cruciate ligament (ACL) rupture represents a common sports injury that is mostly managed operatively. However, non-operative treatment can also play a role, despite the limited high-quality published data on ACL tear management. Both methods have shown favorable outcomes, but clear guidelines based on high-quality research are lacking. Several factors should be considered and discussed with the patient before deciding on the best treatment method. These include patient characteristics and expectations, concomitant injuries, and clinical evaluation, with laxity or/and instability being one of the most essential parameters examined. This should eventually lead to an individualized approach for each patient to ensure the best possible outcome. This review aims to delve into all parameters that are related to ACL rupture and guide physicians in choosing the most appropriate treatment method for each patient.

Perioperative Management of Tibial Spine Fractures in Pediatric Patients: A Delphi Study to Identify Principles of Treatment.

The Delphi technique is a structured, iterative group survey method utilized to reach a consensus among experts in a field regarding topics with evidence-based equipoise. Currently, there are few studies at the highest levels of evidence published on the perioperative tibial spine management, making it an ideal subject to utilize expert opinion to reach consensus decision. The purpose of this study was to utilize a Delphi-method survey to achieve consensus statements regarding the perioperative management of tibial spine fractures. Before study initiation, 3 rounds of surveys were agreed upon, maintaining the traditional Delphi principles. Consensus was defined as 75% agreement or disagreement on a Likert scale. An anonymous survey consisting of 50 statements describing the management of tibial spine fractures preoperative and postoperative in varying scenarios was distributed to a group of 44 pediatric sports medicine orthopaedic surgeons utilizing an electronic survey software system. Of 44 surgeons invited to participate, 24 responded to round 1, 28 responded to round 2, and 25 responded to round 3. Consensus was achieved for the following: use of x-ray to determine initial treatment; casting for a minimum of 3 weeks for nonoperative management, but <3 weeks if treated with surgical fixation; advanced imaging to avoid missing concomitant injury; the necessity of physical therapy, but not continuous passive motion (CPM); and for arthroscopic surgical intervention. It was also agreed that functional testing is important in return-to-play (RTP) decision-making, though the specific timelines and clearance criteria could not be agreed upon. There were statements that displayed continued disagreement, including the role of aspiration, preoperative range of motion management, and the timing of surgical scheduling. Utilizing a Delphi methodology with experienced surgeons on tibial spine treatment, consensus in the management of tibial spine fracture was achieved for definitive management strategies. Further study will be important to optimize our management of this youthful population with tibial spine fractures.

Computed tomography of acute orbital trauma in children: a retrospective study

INTRODUCTION: Orbital injuries account for 36 to 64% of all blunt trauma to the facial bones. Diagnosis of orbital wall fractures is carried out using conventional radiography in several projections and computed tomography; magnetic resonance imaging is less commonly used. Often, due to the small displacement of orbital bone fragments, X-ray diagnosis is difficult. Multislice CT with reconstruction of sagittal, coronal projections and 3D in the bone window in such cases is the best visualization method. However, there are still no clear indications for the use of each method and there is no complete view of the CT characteristics of orbital damage.OBJECTIVE: To study the diagnostic value of computed tomography of orbital fractures in pediatric patients with acute trauma.MATERIAL AND METHODS: Retro- and prospectively analyzed the results of CT scans of 94 patients with facial fractures from 01/01/2023 to 09/01/2023 to assess combined orbital injuries. Orbital fractures were detected in 63 children (67.0%). There were 44 boys (69.84%), 19 girls (30.15%) aged from 7 months to 17 years 10 months (average age 10.3). Statistics: For statistical analysis, the method of calculating the nominal correlation using the Kramer coefficient (V) using the IBM SPSS Statistics software package was used.RESULTS: Concomitant injury was observed in 30 (47.6%); isolated 33 (52.36%). The number and frequency of fractures observed were as follows: superior wall of the orbit — 39 (61.9%); zygomatic complex — 19 (30.1%); lower wall of the orbit — 43 (68.2%); nasal bone — 17 (26.9%); lower jaw — 6 (9.5%); medial wall of the orbit — 28 (44.4%); upper jaw — 27 (42.8%); alveolar process — 6 (9.5%); isolated zygomatic arch — 14 (22.2%); Le Fort type I — 1 (1.5%); Le Fort type II — 2 (3.1%); and Le Fort type III — 0 (0%). Orbital hematomas were found in 25 patients (39.6%). It was revealed a strong correlation between the presence of contiguous skull fractures and multiple skull fractures (V=0.878, p&lt;0.001), frontal sinus fractures and frontal sinus hemosinus (V=0.69, p&lt;0.001).CONCLUSION: Orbital fractures are a frequent type of facial fracture occurring in children with blunt isolated and combined trauma. In children with blunt trauma, head CT combined with clinical examination is currently the optimal tool for diagnosing clinically significant orbital injuries. There is a strong correlation between orbital hematomas and orbital vault fractures, orbital hematomas and lattice fractures, adjacent skull and orbital vault fractures, and adjacent skull and lattice fractures. CT examination should include multiplanar (in coronal and sagittal planes) and 3D reconstructions, which help to assess the extent of the fracture, the presence of diastasis, the degree of muscle impingement. Based on the data obtained, the clinician determines the need for surgical intervention.

Traumatic injuries in ankylosing spinal diseases

Ankylosing spinal diseases, such as ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), are highly important in spinal traumatology and are therefore specifically considered in the AO Spine Classification of spinal injuries. These diseases make the spine extremely susceptible to injury and also complicate the diagnosis and treatment, leading to an increased mortality. Concomitant neurological injuries are frequent. The treatment of such injuries requires great attention and careful preparation. Early and precise diagnostics using computed tomography (CT) and magnetic resonance imaging (MRI) as well as a surgical intervention are crucial for the survival and the quality of life of patients. The treatment is carried out surgically as conservative treatment often leads to high complication rates. In postoperative care special attention must be paid to cardiopulmonary complications.

Intraoral gunshot injury associated with soot in the deep airways

In suicidal gunshots to the head, the oral cavity ranks among the preferred entrance sites. If the weapon’s muzzle end is located within the mouth, it is to be expected that the cartridge discharge residues are deposited on the buccal and palatal mucosa, the tongue and the pharynx, often in combination with tears of the lips due to the expanding combustion gases. Ensuing from the bullet entrance wound and any concomitant injuries, blood is released into the upper airways and subsequently aspirated into the lung periphery provided that respiration continues for at least a short time. Evidently, this impedes the detection of additional soot deposits in the trachea, bronchi and alveoli. Using the example of an intraoral gunshot with a revolver cal. 357 Magnum, the paper points out that in individual cases it may be possible to prove the presence of gunshot residues in the deep airways.

Revision ACL reconstruction, but not bilateral ACL reconstruction, is associated with clinically relevant inferior subjective knee function compared with primary ACL reconstruction: A comparative analysis of 6831 patients.

To evaluate and compare the subjective knee function in patients undergoing revision and bilateral anterior cruciate ligament (ACL) reconstruction (ACLR) with those undergoing primary ACLR in a large cohort. Patients without concomitant ligament injuries who underwent primary, revision or bilateral ACLR at the Capio Artro Clinic, Stockholm, Sweden, between 2005 and 2018 were identified. The Knee injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1, 2 and 5 years postoperatively from the Swedish National Knee Ligament Registry. Patients who underwent revision and bilateral ACLR were compared with those who underwent primary ACLR (control group) using Student's t test. A total of 6831 patients (6102 with primary ACLRs, 343 with revision ACLRs and 386 with bilateral ACLRs) were included. Preoperatively, there were significant but nonclinically relevant differences in favour of the revision ACLR group for KOOS Symptoms, Pain, Activities of Daily Living (ADL) and Sport/Rec subscale scores compared with the primary ACLR group. Postoperatively, except for the 1-year Symptoms and ADL subscales, the revision ACLR group reported significantly lower scores on all KOOS subscales than the primary ACLR group, with clinically relevant differences (>8-10 points) for the 1-, 2- and 5-year Sport/Rec and Quality of Life (QOL) subscales. The bilateral ACLR group reported significantly, but not clinically relevant, inferior scores on the 1-year Symptoms and QOL subscales and the 5-year Sport/Rec and QOL subscales compared with the primary ACLR group. Revision ACLR, but not bilateral ACLR, was associated with clinically relevant inferior subjective knee function compared with primary ACLR. It is important to counsel patients regarding their future subjective knee function after repeated ACLR. Compared to primary ACLR, inferior subjective results should be expected after revision ACLR, but not after bilateral ACLR. Level III.

Medial sleeve fractures in elite-athletes: A heterogeneous group, anatomical and case-based considerations.

The purpose of this study is to provide a detailed description of the anatomy and radiology of the medial sleeve and present an approach in its management among elite athletes. Five cases of elite athletes who underwent treatment for a medial sleeve injury of which the diagnosis was confirmed through physical examination and additional magnetic resonance imaging scan are described in this study. Two patients presented with isolated medial sleeve injuries, while the other three patients suffered from concomitant ankle injuries. Non-operative treatment consisted of relative rest, soft cast immobilization and mobilization in a walking boot or kinesiotape which was successful in four of the cases with regard to the medial sleeve. One patient underwent surgery due to syndesmotic instability. Another patient presented with combined medial and lateral ankle instability which was treated surgically with an open medial and lateral ligament repair. All patients were able to return to their pre-injury sports and at the time of the last follow-up were still playing in their pre-injury level of competition. Medial sleeve injuries of the ankle in elite athletes should be considered in the differential diagnosis for athletes presenting with medial ankle pain. Inherent knowledge regarding anatomy is essential when guiding the management of these injuries which can be treated successfully with a non-operative approach consisting of relative rest, immobilization, kinesiotape and physical therapy. In case of persistent medial instability or rotational instability, surgical repair is a viable treatment option. Both modalities allow athletes to return to the pre-injury level of competition. However, early diagnosis is crucial to minimize the delay of appropriate treatment and avoid potential residual symptoms. Level IV.

Computed tomographic features of Morel-Lavallée lesions in 3 cats.

To describe the CT features of Morel-Lavallée lesions (MLLs) and their association with trauma in cats. This study aimed to investigate whether MLL fluid in cats accumulates between the dermis and deep fascia near superficial trauma, exhibits a vertical attenuation gradient, and shows no or only mild contrast enhancement on CT images. 3 young cats: a 1-year-old neutered male domestic shorthair cat, a 2-year-old neutered male domestic shorthair cat, and a 3-year-old neutered female British Shorthair cat. The clinical presentation of the 3 cats in the study involved recurrent swelling and fluid accumulation affecting at least 1 pelvic limb following trauma. In all cases, there was a fluid-filled space deep to the skin and superficial subcutaneous layer but superficial to the deep fascial plane overlying the muscular component of the pelvic limbs. The MLL fluid had a vertical attenuation gradient and no or only mild contrast enhancement. Morel-Lavallée lesions are often initially overlooked, likely due to distraction by concomitant significant bone injuries, and can be mistaken for hematomas, seromas, subcutaneous edema, contusions, or cellulitis, leading to less aggressive treatment. If left untreated, MLLs present a significant risk of extensive skin necrosis compared to other types of subcutaneous swelling.

Graft Failure and Contralateral ACL Injuries After Primary ACL Reconstruction: An Analysis of Risk Factors Using Interpretable Machine Learning.

Anterior cruciate ligament (ACL) reconstruction (ACLR) can be successful in restoring knee stability. However, secondary ACL injury, either through graft failure or contralateral injury, is a known complication and can significantly impact the ability of a patient to return successfully to previous activities. To develop and internally validate an interpretable machine learning model to quantify the risk of graft failure and contralateral ACL injury in a longitudinal cohort treated with ACLR. Case-control study; Level of evidence, 3. An established geographic database of >600,000 patients was used to identify patients with a diagnosis of ACL rupture between 1990 and 2016 with a minimum 2-year follow-up. Medical records were reviewed for relevant patient information and 4 candidate machine learning algorithms were evaluated for prediction of graft failure and contralateral ACL injury in patients after ACLR as identified either on magnetic resonance imaging or via arthroscopy. Performance of the algorithms was assessed through discrimination, calibration, and decision curve analysis. Model interpretability was enhanced utilizing global variable importance plots and partial dependence curves. A total of 1497 patients met inclusion criteria. Among them, 140 (9.4%) had graft failure and 128 (8.6%) had a contralateral ACL injury after index surgery at a median follow-up of 140.7 months (interquartile range, 77.2-219.2 months). The best performing models achieved an area under the receiver operating characteristics curve of 0.70 for prediction of graft failure and 0.67 for prediction of contralateral ACL injury, outperforming a logistic regression fitted on the identical feature set. Notable predictors for increased risk of graft failure included younger age at injury, body mass index (BMI) <30, return to sports <13 months, initial time to surgery >75 days, utilization of allograft, femoral/tibial fixation with suspension/expansion devices, concomitant collateral ligament injury, and active or former smoking history. Predictors of contralateral ACL injury included greater preoperative pain, younger age at initial injury, BMI <30, active smoking history, initial time to surgery >75 days, history of contralateral knee arthroscopies, and involvement in contact sports. Less than 18% of all patients who undergo ACLR should be expected to sustain either a graft failure or contralateral ACL injury. Machine learning models outperformed logistic regression and identified greater preoperative pain, younger age, BMI <30, earlier return to higher activity, and time to surgical intervention >75 days as common risk factors for both graft failure as well as contralateral ACL injury after ACLR. Surgeon-modifiable risk factors for graft failure included allograft and femoral/tibial fixation with a suspension/expansion combination.