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Injection drug use (IDU) is a risk factor for septic arthritis (SA) of native joints. Amid the opioid crisis, IDU rates have increased. This study assessed differences in pre-operative characteristics, microbial characteristics, and postoperative outcomes of 177 cases of SA treated operatively from 2015 to 2019 at 3 US hospitals, by self-reported IDU status. Forty cases (23%) involved patients who reported IDU. Patient characteristics, comorbidities, microbial characteristics, duration of hospital stay, discharge destination, follow-up rates, and rates of persistent/secondary infection were compared by self-reported IDU status. Compared with non–IDU-associated SA (non–IDU-SA), IDU-associated SA (IDU-SA) was associated with female sex ( P =.001), younger age ( P P P P =.04) and was more likely to involve methicillin-resistant Staphylococcus aureus ( P P P =.01). The 2 groups did not differ in terms of American Society of Anesthesiologists classification, joint involved, Gram stain positivity, presence of bacteremia, peripherally inserted central catheter placement, return to hospital within 3 months, or persistent/secondary positive results on culture within 3 months. Patients with IDU-SA were younger, were more likely to be female, had lower body mass index, and had fewer medical comorbidities but were more likely to use tobacco and to have a psychiatric diagnosis compared with patients with non–IDU-SA. Methicillin-resistant S aureus was more common in the IDU-SA group, as was discharge to a skilled nursing facility or against medical advice. Patients with IDU-SA were less likely to return for follow-up than patients with non–IDU-SA. [ Orthopedics . 2021;44(6):e747–e752.]

First utilized in spine surgery in the late 1980s, the Ponte osteotomy is a method of surgically shortening the posterior column in order to obtain greater corrective power in the management of kyphosis or kyphoscoliosis. It is accomplished by removal of bone around the articulation of spinal facet joints, which alters the mechanical axis of rotation and enables greater deformity correction potential. This procedure is performed in the following steps: (1) a posterior midline incision is made in order to expose and clear soft tissues from the desired surgical site; (2) the spinous process and base of the lamina are removed to allow for better visualization and working space; (3) the inferior facet is excised, followed by (4) removal of the superior facet and the (5) ligamentum flavum. If performed correctly, this procedure should allow for appropriate deformity correction and the ability to place desired instrumentation without problems.

Radiographic parameters are commonly used to determine the need for surgical supracondylar humeral (SCH) fracture reduction and the postoperative quality of reduction. We studied whether such parameters are correlated with mid-term patient-reported outcome (PRO) scores in pediatric patients. We retrospectively reviewed data from 213 patients (104 girls) treated surgically for Gartland type-II (n = 84) or type-III (n = 129) SCH fractures from 2008–2016. Mean (± standard deviation) age at surgery was 5.1 ± 2.1 years. Mean time from initial treatment to outcome survey completion was 5.0 ± 2.1 years (range, 2.0–10 years). We evaluated preoperative radiographs for coronal/sagittal fracture displacement, presence of impaction/comminution, Gartland classification, and rotation. Patients, parents were asked via telephone to complete the QuickDASH (Quick Disability of the Arm, Shoulder, and Hand) and PROMIS (Patient-Reported Outcomes Measurement Information System) Strength Impact, Upper Extremity, and Pain Interference questionnaires. Parents were also asked whether the previously fractured arm appeared normal or abnormal. We evaluated postoperative radiographs for coronal/sagittal deformity, Baumann angle, and rotation and classified reductions as near complete/complete or incomplete. Anterior humeral line through the capitellum, Baumann angle in the 7.5th to 92.5th percentile of the sample, or rotation ratio between 0.85 and 1.15 were considered near complete/complete reductions; all others were considered incomplete. Bivariate analysis was used to determine whether radiographic parameters and arm appearance were associated with QuickDASH and PROMIS scores. Patients with Gartland type-III fractures had significantly greater disability on the QuickDASH at follow-up compared with those with Gartland type-II fractures (P

Oculomotor nerve palsy (ONP) is a rare neurological deficit associated with numerous underlying pathologies. Of these, aneurysm of the posterior communicating artery (PCOM) has been described due to the intimate association with the third cranial nerve in the basal cistern. Less described are other vascular abnormalities and their contribution to ONP. We describe a case of ONP thought to result from a PCOM aneurysm, per the associated magnetic resonance imaging (MRI) scan, yet found intraoperatively to be caused by a congenital vascular aberrancy. This is the first case, to our knowledge, of this presentation.

Computed tomography angiography (CTA) has become an effective tool in the evaluation of patients with subarachnoid hemorrhage (SAH), but it still has limitations. Up to 15% of non-traumatic SAH cases are negative on CTA. The benefits of catheter angiography in the evaluation of certain cases of CTA-negative SAH have been previously demonstrated. Here, we present the case of a 48-year-old female who presented with headache and right-sided hemiparesis, who later became apneic and required intubation. A computed tomography (CT) scan of the head demonstrated a diffuse SAH. A CTA of the head and neck showed no vascular abnormality. Catheter angiography diagnosed a conical-shaped aneurysm at the left A1-A2 junction of the anterior communicating artery complex measuring 3.5 mm by 1 mm. The aneurysm was successfully treated with a craniotomy and microvascular clipping using a 4.7 mm curved Yasargil miniclip (Aesculap, Tuttlingen, Germany). This case illustrates the importance and benefit of catheter angiography in CTA-negative cases of SAH.

A significant but less recognized cause of ischemic stroke and transient ischemic attack (TIA) is atherosclerosis of the vertebrobasilar system, which accounts for 20% of ischemic strokes. Pathology of the vertebrobasilar system can present significant challenges in determining the course of treatment. Due to the complexity of the vertebrobasilar system, there is slight disagreement about how to approach patients with atherosclerotic pathology of the posterior circulation. Two such approaches are either stenting of the vertebral or basilar artery or aggressive medical management. Here, we present the case of a 63-year-old male who presented with lightheadedness, diaphoresis, two episodes of loss of consciousness, and the abrupt onset of unilateral right-sided paresis. A computed tomography angiogram (CTA) of the head and neck demonstrated complex posterior circulation vertebrobasilar vascular stenosis and occlusions. There was an unstable clot located at the junction of the vertebral and basilar arteries requiring a carefully nuanced approach. The patient was started on dual antiplatelet therapy and heparin in an effort to resolve the clot. Repeat CTA after five days revealed resolution of the unstable clot; however, the distal intradural right vertebral artery remained occluded and the left vertebral artery remained stenosed. The patient was then treated with a balloon-mounted coronary stent to eliminate the stenosis, which ultimately restored normal posterior fossa flow dynamics. This case serves as a testament to the variability and complexity of vertebrobasilar arteriopathies as well as the benefit of experienced neurointerventionalists in the successful management of these cases.

Spondylolysis, defined as injury to the pars interarticularis, is the most common identifiable cause of back pain in children. Historically, treatment has primarily been nonoperative, including physical therapy, activity modification, and occasionally bracing(1). In instances in which the condition is refractory to nonoperative management, however, surgical treatment may be an efficacious alternative. Persistent pain following nonoperative management is described as occurring in 6% of the general population, but is reported to be as high as 15% to 47% in the pediatric population who participate in sports(2,3). There have been several proposed methods of surgical intervention, such as screws, hooks, wires, and combinations of the aforementioned, none of which have garnered unanimous support as being most effective. The report by Buck(3) served to popularize the use of intralaminar screwing for fixation, and the 93% success rate reported in that study has since been corroborated, with several studies reporting rates from 82% to 100%(1,3,4). This technique offers a low-profile solution that is motion-sparing with demonstrable stability and mechanical advantage compared with other techniques(5) and has been shown to be a more stable method of fixation that can correct relatively large defects, showing efficacy with defects 4 mm and larger(5). This procedure is performed by (1) placing the patient in a prone position with minimization of lordosis on the operating table and use of fluoroscopy to localize the defect. (2) A midline incision (approximately 5 cm) is made just lateral to the corresponding spinous process in order to expose the lamina and the defect. (3) A curet is used to clean the defect. (4) Under fluoroscopy, and alternating between anteroposterior and lateral views, a percutaneous stab is made if needed using a 4.5-mm cannulated screw guidewire, and the wire is drilled through the caudal laminar surface, bisecting the pedicle to the superior cortex of the pedicle. (5) A 3.2-mm cannulated drill is then used to drill over the guidewire. (6) The wire is removed, and a ball-tip probe is used to feel the cortices. The screw length is measured and tapped. (7) The lamina is distally overdrilled if it is large enough. (8) A solid (rather than cannulated) screw of appropriate size (usually 4.5-mm diameter) is inserted with compression as needed. (9) If necessary, autologous posterior iliac crest bone graft is obtained from the same incision, and cancellous graft is placed in the defect. (10) A corticocancellous strip is overlaid from the lamina to the transverse process.

Hashimoto’s encephalitis (HE), also known as steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT), can be a debilitating manifestation of an autoimmune reaction against the thyroid that is often under-diagnosed primarily due to a lack of definitive diagnostic criteria. This is a case of a 52-year-old woman who has been diagnosed with HE after presenting with recurrent and severe psychosis in conjunction with paranoia and a thyroidopathy. Her symptoms are chronic, having first been documented as presenting 15 years prior and showing progressive exacerbation in both frequency and severity. The patient’s paranoia often manifested as delusions involving family members or close friends and consequently introduced an opportunity for harm to herself and others. She showed great conviction with self-diagnoses that were proven incorrect, resulting in occasional non-compliance. Between episodes, the patient did not show evidence of symptoms. This patient struggled with several incorrect diagnoses and treatments for several years before the correct diagnosis of HE was made and displayed extreme improvement upon corticosteroid administration. This case illustrates the importance of increasing awareness of HE as well as including HE in a differential diagnosis when any patient presents with psychosis and concurrent thyroidopathy. Hashimoto’s encephalitis follows putative characteristics of autoimmune diseases, exhibiting a higher incidence in women as compared to men, presenting with increased titers of autoantibodies, and showing dramatic amelioration when treated with corticosteroids.