Medial Aspect Research Articles

The Effect of Hallux Valgus Surgery on the Transverse Plane Hallux Proximal Phalanx Position

The objective of this investigation was to evaluate the apparent movement of the hallux proximal phalanx in the transverse plane relative to the second metatarsal following hallux valgus surgery. Pre- and postoperative radiographs of a consecutive series of 45 feet undergoing hallux valgus surgery were analyzed. Significant improvements were observed in the first intermetatarsal angle (12.4 vs 7.5 degrees; p < .001), hallux valgus angle (24.3 vs 13.4 degrees; p < .001), tibial sesamoid position (4.6 vs 2.7; p < .001), and second metatarsal-hallux proximal phalanx angle (80.1 vs 84.6 degrees; p < .001). No difference was observed in the distance between the second metatarsal bisection and the medial aspect of the tibial sesamoid (31.7 vs 31.5 mm; p = .756) nor between the second metatarsal bisection and medial aspect of the hallux proximal phalanx base (34.6 vs 34.2 mm; p = .592). Significant differences were observed between the second metatarsal bisection and the central aspect of hallux proximal phalanx base (26.5 vs 23.9 mm; p < .001) and between the second metatarsal bisection and the lateral aspect of the hallux proximal phalanx base (19.3 vs 15.4 mm; p < .001). A statistically significant difference was observed in the change of distance between the second metatarsal bisection and the medial, central, and lateral aspects of the hallux proximal phalanx base (-0.4 vs -2.6 vs -3.9 mm; p = .002). These results indicate that the hallux proximal phalanx does not translocate in the transverse plane following hallux valgus surgery, but instead pivots about the medial aspect of the joint.

Physiotherapy Rehabilitation in Operated Case of Patellar Fracture and Medial Malleolus Fracture- A Case Report

Introduction: Road traffic accidents (RTA) are responsible for a considerable amount of global death and morbidity, particularly in developing nations. 'Hidden pandemics,' such as mortality from RTA, often go unnoticed over the world.(1) These days traffic road accidents lead to many fractures included patellar fracture. Patellar fractures account for about 1% of all skeletal fractures and are most common in people between the ages of 20 and 50. 1–3 Men have nearly twice as many cases as women.&#x0D; Clinical Findings: On physical examination respiratory system, cardiovascular system and central nervous system are normal and on local examination of left lower limb demonstrate attitude of limb in hip and knee in extension and foot in external rotation and multiple abrasions are present over the knee and there were abrasion of 10*2cm present over medial aspect of great toe and abrasion of 5*2cm present over the postero-medial aspect of distal 3rd leg, lacerated wound on medial malleolus.In this case patient was on 8 week protocol for physiotherapy management.&#x0D; Discussion: In this case report we are discussing a case of 36 year old male with fracture of patella and medial malleolus managed with tension band wiring and nailing respectively. The primary goal of physiotherapy management was to prevent secondary complications and make the patient independent for which rehabilitation protocol was planned which included isometric exercises, dynamic quadriceps bed mobility exercises and ambulation.&#x0D; Conclusion: Physiotherapy plays an important role in rehabilitation of patient with medial malleolus and patella fracture.

Midbrain Dopamine Neurons Defined by TrpV1 Modulate Psychomotor Behavior.

Dopamine (DA) neurons of the ventral tegmental area (VTA) continue to gain attention as far more heterogeneous than previously realized. Within the medial aspect of the VTA, the unexpected presence of TrpV1 mRNA has been identified. TrpV1 encodes the Transient Receptor Potential cation channel subfamily V member 1, TRPV1, also known as the capsaicin receptor, well recognized for its role in heat and pain processing by peripheral neurons. In contrast, the brain distribution of TrpV1 has been debated. Here, we hypothesized that the TrpV1+ identity defines a distinct subpopulation of VTA DA neurons. To explore these brain TrpV1+ neurons, histological analyses and Cre-driven mouse genetics were employed. TrpV1 mRNA was most strongly detected at the perinatal stage forming a band of scattered neurons throughout the medial VTA, reaching into the posterior hypothalamus. Within the VTA, the majority of TrpV1 co-localized with both Tyrosine hydroxylase (Th) and Vesicular monoamine transporter 2 (Vmat2), confirming a DA phenotype. However, TrpV1 also co-localized substantially with Vesicular glutamate transporter 2 (Vglut2), representing the capacity for glutamate (GLU) release. These TrpV1+/Th+/Vglut2+/Vmat2+ neurons thus constitute a molecularly and anatomically distinct subpopulation of DA-GLU co-releasing neurons. To assess behavioral impact, a TrpV1Cre-driven strategy targeting the Vmat2 gene in mice was implemented. This manipulation was sufficient to alter psychomotor behavior induced by amphetamine. The acute effect of the drug was accentuated above control levels, suggesting super-sensitivity in the drug-na ve state resembling a “pre-sensitized” phenotype. However, no progressive increase with repeated injections was observed. This study identifies a distinct TrpV1+ VTA subpopulation as a critical modulatory component in responsiveness to amphetamine. Moreover, expression of the gene encoding TRPV1 in selected VTA neurons opens up for new possibilities in pharmacological intervention of this heterogeneous, but clinically important, brain area.

Superior capsule reconstruction: anatomy, biomechanics, indications, and graft treatment.

Superior capsule reconstruction: anatomy, biomechanics, indications, and graft treatment.

The Great Stent Graft Escape

A 72 year old male presented with a six week history of two purulent wounds on the medial aspect of his right transfemoral amputation stump (performed in 2015), and a chronic sinus distally. A computed tomography scan showed a kinked right superficial femoral artery (arrow) with an uncovered stent and Gore Viabahn endoprosthesis (WL Gore & Associates, Flagstaff, AZ, USA) inserted in 2015 for chronic limb threatening ischaemia and dissection during angioplasty. Despite initial conservative antibiotic management, the wounds deteriorated so the endoprostheses were explanted. Staphylococcus aureus was cultured and a two week course of intravenous flucloxacillin was given.Image 1

Soft tissue filler augmentation of the orbicularis retaining ligament to improve the lid-cheek junction.

The orientation of facial ligaments changes with increasing age due to the loss of bony support. Soft tissue filler injections placed in close proximity to facial ligaments can alter their orientation to help achieve an improved and younger aesthetic appearance. To assess the anatomic and aesthetic effects of a standardized injection with soft tissue filler placed directly inferior to the orbicularis retaining ligament in the infraorbital region. A total of 163 patients with signs of infraorbital aging were treated with a standardized soft tissue filler injection into and in close proximity to the orbicularis retaining ligament (ORL). 2D frontal images of the infraorbital region were rated by eleven blinded and independent raters with regards to the aesthetic appearance of the infraorbital region before and after the standardized injection treatment. The aesthetic appearance of the entire infraorbital region (lid-cheek junction) was rated before and after the treatment. The severity of the tear trough (medial aspect of the infraorbital region) as well as the hollowing of the lateral aspect of the infraorbital region also was rated before and after the treatment. Aesthetic improvement was statistically significant when evaluated by the blinded raters, the treating physician, and the patients. All the results were "very much improved" compared to baseline. The effectiveness of this injection technique is thought to be due to the strategic placement of soft tissue filler that helps to reposition facial ligaments that have changed their orientation during the aging process.

A Rare Anatomical Variation of the Spinal Accessory: Case Report

Anatomical variation in the location of the spinal accessory nerve as it relates to the internal jugular vein has been reported in the literature and anatomy texts. Knowledge of the landmarks of the spinal accessory nerve and its relationship to the internal jugular vein is extremely helpful in its identification during neck surgery for precluding neurovascular complications. The nerve mostly passes laterally (anterior) or medially (posterior) to the internal jugular vein at the level of the medial aspect of the posterior belly of the digastric muscle. However, there is a rare anatomical and surgical variant. In our case report, we describe an unusual relationship of the spinal accessory nerve to the internal jugular vein. In our case study, the nerve pierces the internal jugular vein.

MTHFR promoter methylation might mitigate the effect of smoking at the level of LINE-1 in cleft lip tissues: A preliminary study.

The medial and maxillary aspects of the upper lip originate at separate embryonic stages and therefore may experience different maternal exposure patterns which may affect methylation. Based on this hypothesis, we investigated the level of methylation of the methylene tetrahydrofolate reductase promoter gene (mMTHFR) in tissues from cleft lip, and mMTHFR levels by MTHFR c.677C > T genotype. We further investigated whether mMTHFR mitigates the effect of smoking on long interspersed nuclear element (LINE-1) methylation in these tissues. DNA extracted from medial and lateral tissues of 26 infants with nonsyndromic cleft lip with or without cleft palate (nsCL/P) was bisulfite converted and mMTHFR was measured on a pyrosequenser. LINE-1 methylation and MTHFR c.677C > T genotype data were obtained in our previous study. There was no substantial difference in mMTHFR (p=.733) and LINE-1 (p=.148) between the two tissues. mMTHFR was not influenced by MTHFR c.677C > T genotype, but there was suggestive evidence that the difference was larger among infants exposed to maternal smoking compared to nonexposed. LINE-1 methylation differences were significant (p=.025) in infants born to nonsmoking mothers, but this was not apparent (p=.872) in infants born to mothers who smoked. Our Pearson's correlation analysis suggested a weak inverse association between mMTHFR and LINE-1 (r=-.179, p=.381). Our preliminary observation of differences in patterns of mMTHFR levels in lip tissue suggests the interplay of gene and environment in the establishment of methylation in tissues at both sides of cleft lip. This requires investigation in a larger cohort, integrated with metabolic assessment.

Application of ultrasound in the closed reduction and percutaneous pinning in supracondylar humeral fractures

BackgroundUltrasound examination can be applied to the diagnosis of pediatric elbow fracture. This study aims to analyze the application value of ultrasound in the surgical treatment of supracondylar humeral fractures.Methods64 children with supracondylar humeral fractures were treated with ultrasound-guided closed reduction and percutaneous pinning (CRPP), 31 patients were treated with CRPP under radiography guidence. The reduction effect of supracondylar humeral fractures was determined through the perioperative ultrasound images of the lateral, medial and posterior aspects of the elbow. Percutaneous pinning was performed after supracondylar humeral fractures were well reduced. A follow-up examination was performed and all the patients were evaluated according to Flynn’s criteria.ResultsThe mean duration of surgery was 58.3 min (42–108 min) in the ultrasound group and 41.5 min (24-63 min) in the radiography group (P < 0.05). The mean carrying angle was 8.2° (0°–15°) in the ultrasound group and 9.4°(3°–16°) in the radiography group; The mean Baumann’s angle was 75.5°(60°–85°) in the ultrasound group and 73.4°(62°–82°) in the radiography group; The mean lateral humerocapitellar angle was 38.4° (26°–54°) in the ultrasound group and 41.6°(29°–52°) in the radiography group; No significant differences were observed between the two groups. According to the Flynn’s criteria, 49 (76.6%) patients had excellent, 10 (15.6%) patients achieved good, 3 (4.7%) patients showed fair results and 2 (3.1%) patients achieved poor results in the ultrasound group; 22 (70.9%) patients had excellent, 6 (19.4%) patients achieved good, 2 (6.5%) patients showed fair results and 1 (3.2%) patients achieved poor results in the radiography group; No statistically significant difference was noted between the results of these two groups (P > 0.05). After surgery, three patients had pin tract infection. One patient had ulnar nerve neurapraxia in the radiography group. No cases with Volkmann’s contracture were reported.ConclusionUltrasound-guided CRPP is a safe and reliable surgical treatment of pediatric supracondylar humeral fractures.Trial registration Retrospectively registered.

The Incidence and Anatomic Variation of Os Naviculare in a Multiethinic Asian Population

The incidence of asymptomatic os naviculare ranges from 4% to 21%, varying between different ethnicities, with majority of studies performed in Caucasians. The aim of this study was to document the incidence of asymptomatic os naviculare in an Asian population stratified by ethnicity, and to characterize the features of each type. The records of all patients who underwent dorsoplantar and oblique foot radiographs between July and December 2017 were reviewed. We excluded patients with medial-sided foot pain. The radiographs of the remaining patients were reviewed and the incidence and type of os naviculare according to Coughlin's classification were recorded. About 439 patients were included. The overall incidence of asymptomatic os naviculare was 46.0%, of which 76.7% were bilateral. The prevalence of type Ia, Ib, and Ic os was 7.5%, 6.2%, and 5.9%, respectively. The prevalence of type IIAa, IIAb, IIAc, IIBa, IIBb, and IIBc was 2.7%, 0.7%, 0.2%, 16.6%, 5.9%, and 2.1%, respectively. The prevalence of type IIIa, IIIb, and IIIc was 1.1%, 8.4%, and 0.2%. Type IIBa had the highest prevalence of 16.6% out of 439 patients. The highest incidence of os naviculare was in the Chinese population (n=145, p=.034) at 50.2%. There was no significant gender difference in the incidence of asymptomatic os naviculare. The incidence of asymptomatic os naviculare in a multiethnic Asian population is higher than that reported in other populations, and particularly in the Chinese. Type IIBa was the most prevalent type, which differs from previous reports. When treating patients of Chinse ethnicity who present with pain over the medial aspect of the foot, the diagnosis of a symptomatic os naviculare should be considered.

1064 Extra-Articular Tibial Deformity Management in Total Knee Replacement

Abstract Aim In knee replacements, restoration of mechanical alignment is essential. Patients with extra-articular deformities (EAD) pose challenges in planning knee replacements. We present a method, based on our experience and review of literature on planning knee replacement surgery, in the presence of extra-articular coronal plane deformity of the tibia. Method Retrospective analysis was made of six patients with EAD of the tibia who underwent knee replacement at our centre. Mechanical axis of the tibia is considered and positioning of the tibia component is planned perpendicular to the mechanical axis of the tibia. The integrity of the collaterals determines the need for correction. Tibial resection &amp;gt;15mm from medial or lateral aspect of the tibia is an indication for corrective osteotomy prior to replacement surgery. The hip knee ankle angle (HKA) was noted. Pre-operative, post-operative clinical score, degree of constraints and post-operative complications were recorded. A post-operative long leg alignment radiograph was obtained. Result All patients had total knee replacement without correction of deformity. Adequate alignment of the limb and restoration of mechanical axis was achieved in all six patients without the need for correction of tibial deformity. All patients had improvement in their HKA angle and Oxford knee score. No re-operations were required, and no complications recorded. Conclusions Our study will help provide guidance on operative planning and decisions making for patients with extra-articular coronal plane tibial deformities.

Hibernoma of Thigh: A Case Report of 39-Year-Old Male

Introduction:Hibernoma is an uncommon benign lipomatous tumor that originates from residual brown fat. It commonly affects adult patients aged between 30 and 40 with a slight predominance in male more than female and usually seen in the thigh, shoulder, back, chest, axilla, and neck. The present report aimed to highlight on a viable differential diagnosis of thigh mass including liposarcoma and atypical lipoma.Case Presentation:This is the case report with detailed history, examination of 39-year-old male patient with hibernoma over medial aspect of thigh. Marginal surgical resection was carried and sent to histopathology to confirm the diagnosis of hibernoma.Conclusion:Hibernoma is a rare benign lipomatous soft tissue tumor with no known risk for malignant transformation or metastasis. Based on imaging examination, it can mimic malignant tumors such as, liposarcoma, in which we believe that biopsy is required in order to reach the diagnosis in most of the cases.

Combined Exoscopic and Endoscopic Technique for Craniofacial Resection.

We determined the feasibility of the combined exoscopic-endoscopic technique (CEE) as an alternative to the microscope in craniofacial resection (CFR). This retrospective study was conducted at a single institution and included eight consecutive patients with head and neck tumors who underwent CFR between September 2019 and July 2021. During the transcranial approach, microsurgery was performed using an exoscope in the same manner as in traditional microscopic surgery, and an endoscope was used at the blind spot of the exoscope. The exoscope provided images of sufficient quality to perform microsurgery, while the sphenoid sinus lumen was the blind spot of the exoscope during anterior (n = 3) and anterolateral CFR (n = 2), and the medial aspect of the temporal bone was the blind spot of the exoscope during temporal bone resection (n = 2). These blind spots were visualized by the endoscope to facilitate accurate transection of the skull base. The advantages of the exoscope and endoscope include compact size, ergonomics, surgical field accessibility, and equal visual experience for neurosurgeons and head and neck surgeons, which enabled simultaneous transcranial and transfacial surgical procedures. All the surgeries were successful without any relevant complications. CEE is effective in transcranial skull base surgery, especially CFR involving simultaneous surgical procedures.

Rotating Hinge Revision Total Knee Arthroplasty for Severe Arthrofibrosis.

First, remove all soft-tissue and osseous sources of stiffness and adequately expose the knee, then remove all previous components. Create a stable and balanced extension gap, and, conversely, a relatively loose flexion gap, which allows for a substantial increase in range of motion. Then, in order to prevent instability in flexion, a rotating hinge prosthesis is utilized, which allows for appropriate kinematic motion despite gap imbalance. Additional steps to regain flexion include medial and lateral distal femoral partial condylectomies, as well as patellar component revision. The first line of treatment for stiffness following total knee arthroplasty is nonoperative and is mainly focused on physical therapy3. Manipulation under anesthesia can also be performed within the first 12 weeks postoperatively3. Surgical treatments can include arthroscopic debridement as well as open debridement with possible polyethylene liner exchange. If there is a mechanical cause for stiffness, then this should also be addressed surgically. For cases of arthrofibrosis without a clear mechanical etiology or for cases in which the above treatment has failed, complete revision of the femoral and tibial components should be considered3. An alternative option to the technique proposed here is to utilize a varus-valgus constrained implant. Revision with a hinged implant allows for a more aggressive approach to regaining motion, as compared with all other surgical alternatives. By revising all components, the surgeon is able to remove all sources of stiffness and reconstruct the knee until as much range of motion as possible is achieved. Unfortunately, even with balanced extension and flexion gaps, refractory stiffness is common. A solution for this residual stiffness is to unbalance the gaps and create a loose flexion gap. By doing so, the surgeon is advised to switch to a hinged implant to create a kinematically balanced knee. Any other revision implant, such as a varus-valgus constrained implant, would risk flexion instability. Several studies have examined the use of revision total knee arthroplasty with a hinged implant for arthrofibrosis and have showed substantial improvements in knee range of motion. Bingham et al. showed that the rotating hinge group had a 20° improvement in range of motion (p = 0.048)1. Hermans et al. found a 35.8° flexion gain in the hinge group compared with a 14.2° flexion gain in the varus-valgus constrained group (p = 0.0002)4. van Rensch et al. found a median gain of 45° of range of motion5. Patients should be aware that this procedure involving the use of a hinged implant has similar risks to other revision total knee arthroplasty procedures; specifically, there is a risk of recurrent arthrofibrosis as well as mechanical complications1,5. Achieve adequate exposure with a quadriceps snip.Perform a thorough synovectomy and debridement.Create a balanced extension gap with a relatively loose flexion gap.Distalize the joint line by resecting additional proximal tibia in cases of patella baja.Beware of refractory stiffness as a result of a scarred extensor mechanism.Consider revising the patellar component.Consider performing a partial condylectomy at the medial and lateral distal aspects of the femur. TKA = total knee arthroplastyAP = anteroposteriorCT = computed tomographyMRI = magnetic resonance imagingRHK = rotating hinge kneeNSAIDs = nonsteroidal anti-inflammatory drugs.

S3090 A Rare Case of Gastric Small Cell Carcinoma

Introduction: Small cell primary gastric cancer is rare and most commonly occurs in the Asian population. These malignancies account for 0.1 to 1% of gastric malignancies. When small cell is found in the gastrointestinal (GI) tract, the stomach is the least common site of presentation. If symptoms are present, it is usually epigastric pain or dysphagia. Herein, is a case of this rare carcinoma. Case Description/Methods: The patient is a 55-year-old male with no reported medical history who developed abdominal pain early in 2020 but did not seek treatment due to the ongoing Covid pandemic. He continued to have symptoms and eventually went to an outside hospital where he was admitted for his newly diagnosed anemia. A computed topography (CT) scan showed fluid within a non-distended stomach and gastric wall thickening. He underwent an initial EGD which showed an ulcerated mass (Figure 1A, 1C);biopsies were unremarkable. Due to high suspicion for malignancy, he underwent a repeat EGD with biopsies that showed malignancy favoring lymphoma. Positron emission topography (PET) scan revealed disease in the medial and posterior aspects of the upper stomach. Ultimately, he underwent a third EGD to obtain additional diagnostic material for ancillary testing. Pathology showed small cell neuroendocrine tumor (Figures 1B and 1D). He was referred for surgical evaluation and had extensive surgical resection including the left lobe of liver, small bowel and stomach followed by chemotherapy. He is currently doing well. Discussion: Small cell carcinoma is a rare carcinoma, specifically with the primary site in the stomach. When it is found, it is often misdiagnosed until the time of surgical resection. In this case, initially pathology favored lymphoma. It was not until the third EGD, that the correct diagnosis was made. This patient delayed seeking care due to the Covid pandemic, which delayed his diagnosis and subsequent treatment by several months..

S3024 Case of a Young Adult With Small Intestine Predominant Henoch Schonlein Purpura

Introduction: Henoch Schonlein Purpura (HSP) is the most common systemic vasculitis in young children, but is less commonly seen in adults. Diagnosis is based on the presence of palpable purpura without thrombocytopenia and with at least one other disease manifestation (arthritis, renal involvement, and/or abdominal pain). Gastrointestinal (GI) manifestations rarely precede the classic rash. Here we describe a young adult who initially presented with solely GI involvement of HSP. Case Description/Methods: A 25-year-old healthy male presented with two weeks of nausea, persistent sharp peri-umbilical abdominal pain of variable severity, and melena. Labs were notable for WBC 10.9 K/uL with neutrophilic predominance, CRP 66 mg/L, ESR 4 mm/hr, creatinine 0.88 mg/dL. Abdominal X-ray with mildly dilated gas-filled small bowel loops in central abdomen. CT abdomen/pelvis was unrevealing. EGD revealed antral-predominant nodular erythematous mucosal lesions in the stomach but otherwise normal appearing gastric mucosa (Fig 1a), histologically with surface hemorrhage. In the duodenum, diffuse erythematous mucosa with spontaneous hemorrhage was seen (Fig 1b), pathology consistent with duodenitis and erosions/ulcerations. Colonoscopy revealed right-sided erythema and granularity with biopsies showing non-specific inflammation. Interestingly, the day after endoscopic evaluation the patient developed bilateral lower extremity petechial rash (Fig 1c). Punch biopsies were diagnostic of IgA-mediated leukocytoclastic vasculitis. The overall presentation was consistent with HSP without renal involvement. Further work-up showed low C3 (consistent with HSP), negative ANA screen and ANCA, normal gastrin level, negative cryoglobulins, and unremarkable infectious work up. Discussion: HSP in adults is rare, especially if it presents with isolated GI disease. However, clinicians should maintain a high index of suspicion in adults with manifestations of small bowel inflammation. HSP mainly affects the small intestine, because the villi contain end-capillaries that get obstructed by immune complexes and cause necrosis. The rest of the GI tract is generally not involved by medium-vessel vasculitis due to its redundant circulation. The skin and epiphyseal plate have similar capillaries and are therefore frequently affected by HSP. Treatment with corticosteroids is controversial as most patients improve with supportive care. In this case, decision was made to treat with corticosteroids as patient returned with worsening disease activity.Figure 1.: a) Endoscopic view of gastric antrum/pylorus with multiple small nodular erythematous mucosal lesions; b) Endoscopic view of second portion of the duodenum showing diffuse erythematous mucosa with many erosive purple-hued mucosal lesions in a diffuse distribution with associated spontaneous bleeding; c) Classic purpuric rash on medial aspect of right foot.

S1644 A Curious Case of Duodenal Mass Causing Malignant Biliary Obstruction and White Bile

Introduction: We describe a case of a duodenal mass causing malignant biliary obstruction and the use of LAMS cholecystoduodenostomy for gallbladder drainage revealing white bile. Case Description/Methods: An 83 year-old male developed orange colored urine and stool for 3 weeks. CA 19-9 was 8,381 U/mL and direct bilirubin was 43.7 mg/dL. CT Abdomen and Pelvis with contrast showed a dilated common bile duct to 1.6cm with narrowing at the ampulla, dilated intrahepatic ducts, and a duodenal mass. ERCP demonstrated a large duodenal ulcerated mass from D1 to D3 and replaced the medial aspect of the duodenal wall. Despite probing the mass with guidewire, bile duct access was unsuccessful. Biopsies showed poorly differentiated adenocarcinoma with mucinous and signet ring cell features (Figure 1A). EUS showed a 4x6cm obstructing polypoid mass in the duodenum (star) with invasion into the distal common bile duct (arrow) resulting in a dilated common bile duct (circle) (Figure 1B). Subsequent LAMS cholecystoduodenostomy was performed for drainage (arrow) (Figure 1C). White bile (clear bile) was noted upon deployment into the gallbladder (star) (Figure 1D). Discussion: White bile in malignant biliary obstruction occurs because the biliary epithelium secretes mucus into bile despite the obstruction, resulting in colorless fluid. White bile has been associated with worse survival in these patients.Figure 1.: (a) duodenal adenocarcinoma with mucinous and signet ring cell features (b) duodenal adenocarcinoma (star) invading the distal common bile duct (arrow) resulting in a dilated common bile duct (circle) (c) LAMS deployment (arrow) within the dilated gallbladder while creating the cholecystoduodenostomy (d) White bile (star) draining through the LAMS.

NECROTIZING SOFT TISSUE INFECTION BY SERRATIA MARCESCENS: AN EARLY DIAGNOSIS WITH THE UTILIZATION OF LABORATORY RISK INDICATOR FOR NECROTIZING FASCIITIS (LRINEC) SCORE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Necrotizing soft tissue infections (NSTIs) include a vast array of necrotizing forms that affect the deeper layers of tissues including fasciitis and myositis. Though rare, with approximately 500 to 1500 estimated cases per year, many providers find the diagnosis difficult due to unaffected appearance of overlying tissue on initial presentation. This case showcases complexities of a Type II-Monomicrobial NSTI-Serratia Marcescens, and the benefit of utilizing the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, for early identification of NSTIs. CASE PRESENTATION: A 66-year-old-male with history of DM with complaint of left lower extremity edema. He reported an insidious onset of swelling that started five days prior to arrival with no precipitating or consequential factors. He was hemodynamically stable with 3+ pitting edema extending beyond the left thigh, erythema below the left knee with blisters on the medial aspects of the left leg. Serum studies showed a D-Dimer 12.6, CRP 1.9, and ESR 29. Venous doppler was consistent with extensive left deep vein thrombosis with CT imaging negative for abscess or subcutaneous air. He was treated with IV Clindamycin and therapeutic anticoagulation. Days later, the cellulitis had progressed nearly three times the original size with a worsening leukocytosis, ESR 111, and CRP 17.5. A surgical debridement showed multiple cavitary abscesses. Pathology showed necrotizing soft tissue infection with Serratia M. He was started on a prolonged course of IV Pip-Tazo and Vancomycin, with eventual preservation of extremity function. DISCUSSION: NSTI has a rapid clinical course and is associated with a high mortality, ranging 14-39%. Early signs of NSTI are dubious and mimic simple soft tissue infections which evolve in a course of days. Serratia M., is extremely rare and atypical with only 17 reported cases. It is an opturnitistic infection affecting the immunocompromised, it thrives in higher concentrations activating cascades of hyperreactive cellular responses. Inflammatory mediators upregulate factors VII and VIIa and reduce anti-coagulation proteins precipitating a pro-thrombotic event. Initially, it was unclear if the patient had NSTI with a LRINEC score of 2/12. The second encounter, his score was 7/12, suggestive of NSTI. The final LRINEC score indicated a positive predictive value of 92%. A study by Wong et. al. performed a prospective study utilizing the LRINEC score resulting with positive predictive value of 92% and negative predictive value 96% suggesting to be a beneficial tool. CONCLUSIONS: The LRINEC score is beneficial in identifying NSTI early. Early diagnosis is crucial, it is estimated that between 85-100% of NSTI are initially missed and often confused for myositis, DVT, cellulitis, or deep tissue abscess. A high index of suspicion is imperative in lieu of absent cutaneous findings early in the course of the disease process. REFERENCE #1: Goldstein, Ellie J. C., et al. "Necrotizing Soft-Tissue Infection: Diagnosis and Management." OUP Academic, Oxford University Press, 1 Mar. 2007, academic.oup.com/cid/article/44/5/705/348724. REFERENCE #2: www.samsonconsulting.co.uk. Misdiagnosing Necrotising Fasciitis, www.glynns.co.uk/necrotising-fasciitis/misdiagnosing-necrotising-fasciitis.php. REFERENCE #3: Guberman, Ronald. "Case Study: Treating Necrotizing Fasciitis Caused By Serratia Marcescens." Podiatry Today, 24 Aug. 2011, www.podiatrytoday.com/treating-necrotizing-fasciitis-caused-iserratia-marcescensi. DISCLOSURES: No relevant relationships by Swetha Paduri, source=Web Response No relevant relationships by Nehal Patel, source=Web Response No relevant relationships by Charmi Patel, source=Web Response No relevant relationships by Paul Roach, source=Web Response

Anatomy, Morphology and Function of the Tensor of Vastus Intermedius: A Systematic Review.

The tensor of vastus intermedius is a newly discovered muscle that is located at the anterior compartment of the thigh. The aim of the present study is to report, assess and synthetize the existing evidence on the anatomy, variation and morphological characteristics of the TVI as well as to examine its clinical importance. A systematic review was performed evaluating both anatomical and medical imaging studies which provided information about TVI anatomy, prevalence, variations and morphological characteristics. The search strategy was conducted in major electronic databases. Two reviewers worked independently to screen all possible references via a title/abstract examination. Methodological quality was examined with the Anatomical Quality Assurance checklist. A total of 295 cadaveric knees were included in the nine studies where in 244 (82.7%) cases the TVI was identified. Based on this evidence, it appears that the TVI is located between the vastus lateralis and vastus intermedius. The muscle belly is located proximally, and it is combined with a broad and flat aponeurosis before forming a tendinous structure that is attached at the medial aspect of the patella. The TVI presented some morphological variations and complex muscle architecture that varied along its length. There is insufficient good quality evidence as more than half of the included studies were ranked as having a “High” risk of bias with various methodological issues. Higher quality studies are recommended to evaluate the TVI morphology to better understand its functional and clinical importance.

Unilateral Obturator Hernia in Elderly Male: A Case Presentation

OBTURATOR HERNIA is a rare condition of pelvic hernia in which abdominal contents protrude through the obturator canal. This condition can lead to bowel obstruction with relatively high mortality and morbidity due to bowel ischemia/gangrene. Most commonly presents in elderly thin females. It is primarily asymptomatic unless there is compression of the obturator nerve. Therefore, obturator hernia in the differential diagnosis of intestinal obstruction of unknown origin. Computed tomography is the modality of choice for preoperative diagnosis as obturator hernia. Sometimes mistakenly diagnosed as femoral or inguinal hernia on Ultrasonography. Its early diagnosis is challenging since the signs and symptoms are non-specific make a preoperative diagnosis difficult. We present a case of obturator hernia in an 81-year-old male with a known prostate carcinoma who presented with a painless soft swelling in the medial aspect of the right upper thigh and a negative Howship-Romberg sign.