Lupine Publishers | Outcome of Arthroscopic Bankart’s Repair Using Trans- Glenoid Suture Technique in Recurrent Post-Traumatic Anterior Shoulder Dislocation Without Bony Defect

 Lupine Publishers |  Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

Background: Recurrent dislocation of the shoulder is the leading complication of traumatic anterior glenohumeral dislocation. It occurs commonly in young adult males. The most common pathology encountered in the early phase is Bankart’s lesion. Arthroscopic trans glenoid suture capsulorrhaphy is an effective alternative for Correcting the pathology of anterior and anteroinferior shoulder instability.

Objective: To present the outcome of arthroscopic Bankart’s repair using Caspari’s technique.

Methodology: It is a prospective cohort study conducted on 54 patients that undergone arthroscopic Bankart’s repair for recurrent shoulder dislocation at National Orthopedic Hospital, Dala and Habeeby Orthopedic Clinic, Kabuga, Kano from March 2015 to February 2021. Cases were recruited through the surgical outpatient department, SOPD. Instability was assessed pre- and postoperatively using the Rowe Score. The instability shoulder index score (ISIS) was used as predictive tool for arthroscopic treatment while the Western Ontario Shoulder Instability Index (WOSI) and the Walch-Duplay scores were used as functional outcome measures. Data were captured using Microsoft excel worksheet and analyzed using SPSS version 20.0 for windows.

Results: Fifty-four patients were studied with an average age of 25.0 +/- 5.4 years and M: F of 8: 1. All were posttraumatic with a mean frequency of dislocation of 5.2 +/- 3.0 per week before surgery. All the patients had positive apprehension test. The average duration of hospital stay was 5 +/- 2days. The average pre-operative instability shoulder index score (ISIS) was 2.1 +/- 1.5. The Rowe scores showed statistical improvement after operation with P <0.001. The average pre-operative Western Ontario Shoulder Instability Index (WOSI) Score and Walch-Duplay scores equally improved to with P < 0.001 at 2 years of follow up. There was no recurrence after 2 years of follow up. Caspari’s technique is cost effective as two strands of polyester 5 sutures cost 1.4% of the price of two anchor sutures.

Conclusion: Caspari’s Technique gives good to excellent functional outcome in recurrent shoulder dislocations without bony defect and it is cost effective.

Introduction

Glenohumeral dislocation is a common entity and represents more than 50% of all joint dislocations with anterior dislocation being most common with overall incidence of 2% [1]. Dislocation of shoulder involves a tear of the inferior capsuloligamentous complex and labrum from the anterior inferior glenoid most of the times (97%) [2]. Recurrent instability was defined as at least one episode of recurrent dislocation or subluxation [2]. Recurrent dislocation of shoulder (RDS) is a common injury in high demand professionals, like athletes and military personnel [3]. Recurrent dislocation of the shoulder is the leading complication of anterior glenohumeral dislocation, and it accounts for an average of 70-90% recurrence rate in patients aged 20 to 40 years [1]. Bankart lesion is found in over 80% of shoulders with recurrent shoulder instability [1]. The open Bankart repair was the gold standard for years, however arthroscopic Bankart repair has gained popularity [5]. Recurrent instability rates with this type of procedure averaged as low as 7%. Despite these excellent results, there has been growing interest in the arthroscopic management of anterior glenohumeral instability because of the advantages like less morbidity, shorter time of surgery, improved range of motion, improved cosmesis and less post-operative pain [1]. The main concern in managing traumatic shoulder dislocations is the high rate of recurrence and the functional disability or additional injuries to structures within the glenohumeral joint that may follow [5]. Patient factors including age, activity level, sport and number of instability events must be considered along with examination and imaging findings [6]. The role of arthroscopic procedures in the management of glenohumeral stability continues to evolve [7]. The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability [8]. Arthroscopic Bankart repair resulted in a 7-fold lower recurrence rate and a higher rate of return to play than conservative management [9]. Arthroscopic Bankart repair is an effective, cosmetic and safe surgical procedure with good clinical outcomes and excellent post-operative shoulder range of motion [4]. Arthroscopic transglenoid suture capsulorrhaphy, is an effective alternative for correcting the pathology of anterior and anteroinferior shoulder instability [7]. Arthroscopic Bankart’s repair in recurrent shoulder dislocation with suture anchors is a reliable procedure with respect to shoulder function, recurrence rate and range of movement [1]. It is best indicated for traumatic anterior dislocators with a Bankart’s lesion and good quality glenohumeral ligaments [7]. We study the outcome of Caspari’s technique in patients with traumatic recurrent anterior shoulder dislocation without bony defect.

Methodology

It is a prospective cohort study conducted on 54 patients who underwent arthroscopic Bankart’s repair for recurrent shoulder dislocation at National Orthopedic Hospital, Dala and Habeeby Orthopedic Clinic, Kabuga, Kano from March 2015 to February, 2021. All patients aged 18 to 50 years with recurrent posttraumatic anterior shoulder dislocation were recruited through the surgical outpatient department, SOPD. Patients with multidirectional, posterior and fracture dislocation, and those with associated bone defects were excluded from the study. Plain radiographs (true anteroposterior, Rockwood and axillary views, Figure 1ac) were obtained for all the patients to assess bone and articular congruency, rule out bone defects and other degenerative changes. The instability shoulder index score (ISIS) was used as predictive tool for deciding on arthroscopic treatment. Rowe scoring was done to assess instability before surgery as well as WOSI and Walch- Duplay scores. The procedure was done under general anesthesia with curved endotracheal tube intubation. patients were positioned in the lateral decubitus position with locally improvised weight over a drip-stand [Figure 2a]. Surgeries were performed by the same surgeon assisted by senior registrars. The standard posterior portal is the portal of entry while the working (anterior) portal is created using an inside-out technique [Figure 2b].

Results

Fifty-four patients were studied with an average age of 25.0 +/- 5.4 years and M: F of 8: 1 [Figure 4]. The right shoulder was 9 times more affected than the left. All were posttraumatic with a mean frequency of dislocation of 5.2 +/- 3.0 per week before surgery [Figure 2]. All the patients had had traditional bone setters’ manipulation. All the patients had positive apprehension test. The average duration of surgery from skin incision to closure is 55 +/- 15.5 minutes. All the patients were found to have Bankart’s lesion with variable degenerative changes. There was significant shoulder swelling extending to the neck region in the immediate postoperative period, but not enough to warrant ICU admission in any of the patients. The swelling subsided in an average of 5.5 +/- 1.5 hours in all the patients. The average duration of hospital stay was 5 +/- 2days. The average pre-operative instability shoulder index score (ISIS) was 2.1 +/- 1.5. The Rowe scores showed statistically significant improvement after operation with P <0.001 at 2 years of follow up [Figure 5]. The average pre-operative WOSI and Walch-Duplay scores were 1444.7 +/-271.3 (68.8 +/- 12.9 %) and 27.1 +/- 9.8 respectively. The postoperative scores improved to an average of 217.5 +/- 116.5 (10.4 +/- 5.6 %) and 90.6 +/- 5.2 respectively with P < 0.001 at 2 years of follow up [Figure 5]. All the patients were followed up for a minimum of 2 years. There was no recurrence of dislocation nor revision after minimum of 2 years of follow up. The cost of 2 strands of polyester 5 sutures needed is 1.4 % of the cost of 2 anchor sutures.

Discussion

Optimal clinical results after arthroscopic Bankart suture repair are mostly dependent on proper patient selection and attention to technical details at the time of surgery [10]. The majority of patients were males (M: F ratio of 8: 1) with an average age of 25.0 +/- 5.4 years which is similar to the findings of Murphy A, et al. where male patients were 75.5% with average age was 28.0 years (range, 15-73 years) [11] recorded an average age of 21 (16-30) years which suggests more adolescent’s involvement than in this study [12]. The average hospital stay was 5 +/- 2days which was more than the 1.2 days (1-5 days) recorded by [12]. This may not be unrelated to the peculiarity of our environments in which there is a wide gap between the tertiary institutions and the primary health care facilities. So patients are kept longer in the tertiary centres than necessary Arthroscopic Bankart repair for anterior shoulder instability has been shown to result in excellent longterm functional outcomes despite a relatively high rate of recurrent instability necessitating revision surgery [11]. Some studies were compared arthroscopic repair to the open Later jet procedure, it was found out that the Later jet procedure had less recurrence [10- 14]. arthroscopic treatment of patients with recurrent traumatic anterior instability yields results comparable to open procedures, including athletes involved in high-level contact and collision sports. They believed that addressing capsular laxity surgically is critical, particularly when dealing with chronic instability [15]. Our outcome in two years have shown better recurrence rate than the Laterjet procedure at least in the years under review as no recurrence so far. The review by Rossi LA, et al. showed an overall recurrence rate of 11.3% for arthroscopic Bankart repair based on suture anchors [16]. Arthroscopic Bankart repair with the use of suture anchors is a reliable treatment method, with good clinical outcomes, excellent post-operative shoulder motion and low recurrence rates [8]. Redis location rate tended to be higher if there had been more than 1 dislocation preoperatively (P =.098) [17]. This is however contrary to the findings in this study as mean frequency of dislocation of stood at 5.2 +/- 3.0 per week before surgery, but there was no single recurrence at a minimum of 2 years of follow-up. Stabilization after the first-time dislocation achieves better clinical and radiological outcomes than after multiple dislocations [17]. There was no patient who presented with one episode of dislocation. Patients were evaluated before the intervention and at the mean follow-up of approximately two years using Rowe, WOSI and Walch-Duplay scores. Ghai, et al. also used a minimum of 2 years, but used Rowe, Oxford shoulder score and Tegner activity scale [3].

The mean time to return to sports in the study by Rossi LA was 5.3 months [16]. This is similar to return to full duty in 6 months by the patients studied in this study. The demand may not be as enormous as in those involved in collision sports though. The Rowe and ASOSS scores showed statistical improvement after operation (P <0.001). The ASOSS score varied significantly between sports (P < 0.001) [16]. there is great variability in the rate of return to sport at the same level, in shoulder performance after returning to competition, and in the postoperative recurrence rates [16]. This is similar to our findings where the Rowe scores showed statistical improvement after operation with P <0.001. The average preoperative WOSI and Walch-Duplay scores equally improved to with P < 0.001 at 2 years of follow up. Figure 5 showed good correlation between Rowes and Walch-Duplay graphically. All the patients studied were very satisfied with the treatment. This conforms but somewhat better than the findings of Aboalata M, et al. who found out that the patient satisfaction rate was 92.3% and return to the preinjury sport level was possible in 49.5% [17-19]. Arthroscopic Bankart repair for anterior shoulder instability provides good to excellent functional outcome, improved range of motions and low recurrence rate [8]. Five patients complained of suture-knot irritation in the study by Kim SJ, Jahng JS, Lee JW [9]. Four patients made a similar complain in this study. They were counselled on the temporary nature of such feelings and they all improved clinically. Immediate arthroscopic Bankart repair with an accelerated rehabilitation program is an effective and safe technique for treating young active patients with first-time traumatic anterior shoulder dislocations [10], but it could not be applied here as all the patients presented with more than one episode of dislocation.

Conclusion

Caspari’s Technique gives good to excellent functional outcome in recurrent shoulder dislocations without bony defect and it is cost effective.

 

Lupine Publishers | Using Biceps Autograft in Reconstruction of Labral Defect in Recurrent Shoulder Dislocation

Lupine Publishers |  Orthopedics and Sports Medicine Open Access Journal (OSMOAJ) 

Abstract

Background: Recurrent anterior shoulder dislocation is a very common problem that face the orthopedic surgeon, which affects young people in their life, especially the professional workers or athletes and military persons. They may need either arthroscopic or open procedure to obtain a stable shoulder. Arthroscopic Bankart repair is the most popular technique used, but there is a high recurrence rate in patients either with labral tear or glenoid bone loss more than 25%. Bankart repair depends on the presence of a capsule stretching and /or attenuation which is reported in patients with a chronic recurrent shoulder dislocation. The purpose of this study is to explain the technique that we used to reconstruct the labral defect in recurrent shoulder dislocation by using Biceps Brachii tendon as auto graft.

Methods: Four patients with history of recurrent shoulder dislocation underwent shoulder arthroscopy using the long head of Biceps as autograft in our department with average follow up 21 months (range,18 - 26 months) after the operation. All the patients had history of recurrent shoulder dislocation. We evaluated them according to clinical examinations and radiological investigations including X-ray and MRI. In this paper we explain our arthroscopic technique using long head of Biceps Brachii as a graft to cover anterior glenoid in cases of unreconstructedly labrum.

Results: The patients 

who underwent arthroscopic surgery using this technique had a significant improvement, pain free range of motion were normal forward flexion 170˚ - 180˚, abduction 90˚, external rotation with abduction 90˚, with normal flexion of elbow, normal supination and pronation. Apprehension test post-operative was negative, and improvement DASH score 14.5 to 16.5. The patients return to do their daily activities normally.

Conclusion: Using Biceps tendon as autograft to cover the labral defect will do the same work of the labrum to form a bumper by deepening the socket so the ball will be in its place, for this reason we repair the capsule and the Biceps tendon to restore shoulder instability with less side effects when comparing with conjoined tendon transfer and it is a simple procedure.

Keywords: Recurrent Shoulder Instability; Bankart Repair; Biceps Brachii Autograft; Latarjet Procedure

Introduction

Discussion

Recurrent anterior shoulder dislocation is a common pathology in active young patients, most of the cases treated surgically either by arthroscopy or open. Arthroscopy when there is detachment of the capsule -labral injury. Latarjet is a procedure for restore shoulder stability by the sling effect of conjoined tendon [8], in cases of significant bone loss of the anterior glenoid rim. Recurrence rate for the Bankart procedure alone range up to 37.5% among patients with poor labrum tissue or glenoid rim erosion or in high-impact athletes [9,10]. Many studies show that there are several factors which considered as a reason for high rate of failure as professional players who need forceful external rotation and abduction, younger age and those with soft tissue and bone defects [11,20]. A soft tissue procedure is also better tolerated when in contact with humeral head and avoid most of the complications of the coracoid bone attached to the glenoid like nonunion [12], graft resorption [13,14] and graft migration12. One of the disadvantages of Latarjet procedure is destroyed the coracoacromial arch which may result superior instability [6,7]. Repairing the labrum and restoration of capsular tension should be done in same session to get more anatomic procedure and to reduce the recurrence rate [15,16].

The patients who underwent arthroscopic surgery using this technique have a significant improvement, pain free range of motion are normal forward flexion is 170˚-180˚, abduction 90˚, external rotation with abduction is 90˚, with formal flexion of elbow, normal supination and pronation. Apprehension test post-operative is negative, and improvement DASH score 14.5 to 16.5. The patients return to do their daily activities normally. This study describes a new technique that can be used in patients with unrepairable labrum and with small bone loss from the glenoid, which may help the patients to avoid other operations as Latrajet procedure. Repair of labrum and restoration of capsular tension should be done together so as to perform a more anatomic procedure and reduce the recurrence rate [21,22]. In our technique we use the biceps tendon to replace the labrum and restore of capsular tension to reduce the recurrence rate. The number of patients is low because of the situation of covid-19 and we closed the operation theater in our department for many times.

Conclusion

Using Biceps tendon as autograft to cover the labral defect will do the same work of the labrum to form a bumper by deepening the socket so the ball will be in its place, for this reason we repair the capsule and the Biceps tendon to restore shoulder instability with less side effects when comparing with conjoined tendon transfer and it is a simple procedure. We believe that the contraindication of this technique is rupture of the Biceps tendon

Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

 Independence Day 2021 in United States

Lupine Publishers | Implementation of A Screening Checklist to Improve the Diagnosis of Chronic Kidney Disease in A Safety Net Clinic

  Lupine Publishers | Lupine Online Journal of Nursing & Health care (LOJNHC)

Abstract

Objective: To determine the risk for developing type 2 diabetes among population of Rawalpindi city.

Subjects & Methods: A cross-sectional descriptive study was conducted among 90 healthy attendants of the patients admitted in wards of Holy Family Hospital, Rawalpindi to assess their risk for developing type 2 diabetes. Data was gathered through consecutive sampling. All study participants knew they did not have any type of diabetes and they were not receiving anti-diabetic drugs. The data was collected during 2 weeks in July 2018 by means of structured questionnaire. The data was analyzed by using SPSS version 25.0

Results: Of the total 90 study subjects, 57 were females. Mean age of respondents was 44.6±5.78 years. About 10% respondents had Body Mass Index (BMI) greater than 35kg/m2 and had very high risk of developing type 2 diabetes within next 10 years. Daily consumption of fruits and vegetables seemed to have statistically insignificant relationship (P>0.20) with reduction in risk for type 2 diabetes. Only 01 respondent out of those physically active at work was at high risk for type 2 diabetes. About 27.8% respondents had positive family history. Risk of developing type 2 diabetes was insignificantly associated with gender (P>0.94). Overall, only 6 respondents predominantly females 55-64 years old had high to very high risk of developing type 2 diabetes.

Conclusion: Majority of the study participants had low to slightly elevated risk of developing type 2 diabetes. This risk can better be eliminated by lifestyle modification.

Keywords: Type 2 Diabetes; Risk Assessment; Body Mass Index; Family History

Introduction

Type 2 Diabetes is a chronic metabolic disorder showing enormously raised prevalence worldwide. Number of people affected by this epidemic is expected to double in next decade [1]. This disease is incurable. However, various treatment modalities endorsed are lifestyle modifications, reducing obesity, intake of oral hypoglycemic drugs and insulin sensitizers [1]. Type 2 Diabetes is among the greatest public health threats associated with drastic escalation of its incidence globally [2]. Type 2 Diabetes ought to investigate in overweight adults of any age with history of one or more risk factors [3]. This disease is attributed to amalgamation of numerous environmental and genetic risk factors [3]. However, investigation of type 2 diabetes should commence at age of 45 among people not having relevant risk factors [4].

Type 2 diabetes is found to be prevalent in certain races like African Americans, Hispanics and Native Americans who are more susceptible to diabetes than Caucasians [5] Even victims are unaware of their disease due to mildness of associated symptoms [5]. WHO has regarded population of developing countries as more prone to develop type 2 diabetes [6]? According to International Diabetes Federation Report 2015, 415 million people are suffering from this disease globally and about 642 million people are expected to be victimized by 20406. Proportion of diabetics is likely to double in near future primarily due to increased life expectancy and urbanization irrespective of the prevalence of obesity [7]. However, there is likelihood to arrest this increase by lifestyle modifications [8]. A systematic analytical study carried out among Pakistani population in 2015 showed 11.8% people with type 2 diabetes and situation was expected to be grave with passage of time [9]. The present study is intended to assess the risk factors for type 2 diabetes among Pakistani population specifically of Rawalpindi city to identify the risk factors for this disease. This research will provide useful information to our policy makers for strategic planning in this concern.

Subjects and Methods

A cross-sectional descriptive study was carried out among healthy attendants of the patients admitted in wards of Holy Family Hospital, Rawalpindi to determine their risk of developing type 2 diabetes. Information was gathered from 90 attendants not suffering from type 2 diabetes through consecutive sampling during two weeks in July 2018. Confirmed diagnosed cases of type-II diabetes were excluded from this study. The information was collected from study participants by using Type 2 diabetes risk assessment form designed by Prof. Jaakko, Department of Public Health, University of Helsinki. Data was collected from study participants pertinent to their demographic profile, BMI, waist circumference, physical activity, dietary habits, family history and relevant health profile. Waist circumference was measured by means of inch tape and weight was measured by weight machine. Data was analyzed by using SPSS version 25.0. Frequency and percentage were calculated for all variables. Gender based risk of type 2 diabetes was statistically confirmed by applying Fisher’s Exact test. Statistical association of type 2 diabetes risk with regular consumption of fruits and vegetables was verified by chi-square test. P-value≤0.05 was taken as significant.

Results

Majority of study participants (63.33%) were females. Mean age of respondents was 44.6±5.78 years. Most of the males (48.5%) were observed to have waist circumference less than 94cm while majority of female respondents (43.9%) had 80-88cm waist circumference. About 75.6% study subjects were under 45 years of age and only 2.2% respondents were above 64 years old. Age based gender distribution of the study subjects is shown in Figure 1. Fruits, vegetables, and berries were consumed every day by 44.4% of study subjects. Moreover, daily consumption of fruits and vegetables revealed statistically non-significant relationship (P>0.20) with reduction in risk of type 2 diabetes. Most of the females in comparison with males had BMI greater than 35kg/ m2 as depicted below in Figure 2. Out of 9 respondents with BMI>35kg/m2 only 3 were determined to be at high to very high risk (Risk score 15-20) of developing type 2 diabetes. Out of 90 study participants, 31.6% females had waist circumference more than 88cm while only 18.2% males had waist circumference more than 102cm. About 42% of females and 67% of males were found to have 30 minutes of daily physical activity at work. Only 1 study subject out of those engaged in daily physical activity at work was found to be at high risk of developing type 2 diabetes within 10 years as depicted below in Table 1. Only 16.7% respondents were taking medication for hypertension regularly while only 12.2% participants gave history of hyperglycemia during their lifetime out of which 54.5% were males. According to type 2 diabetes risk assessment scale designed by Prof. Jaakko, risk of developing type 2 diabetes within next 10 years among study subjects is illustrated below in Figure 3. However, risk of developing type 2 diabetes was found to be insignificantly associated with gender as depicted below in Table 2. 27.8% respondents had their immediate family members suffering from type 2 diabetes while 37.8% subjects had no relevant family history.

Discussion

The prevalence of diabetes mellitus is estimated to rise from 2.8% in 2000 to 4.4% in 2030. This means that about 366 million world population will be diabetic by the end of next 10 years [10]. This prevalence is more likely to grow exponentially in third world countries [11]. In response to the current scenario, implementation of primordial preventive measures to control this modern epidemic is the need of time. In present study, low risk of developing type 2 diabetes within next 10 years was found among 36 (40%) study subjects whereas high to very high risk was found among only 6 (7%) respondents out of which 5 were females. Another Asian study carried out in 2016 on 150 urban slum developers using Finnish Diabetes risk score showed 11.3% people at high to very high risk of developing type 2 diabetes within next 10 years [12]. The reason for low risk in current study might be inadequate sample size (90). Real picture could better be achieved by conduction of research on more individuals. The current study showed high risk (1%) of developing type 2 diabetes among 5% of study subjects found to be physically inactive and were taking medication for high blood pressure. Similarly, an Indian study showed about 11% risk of developing type 2 diabetes among 53.3% study subjects found to be physically inactive [12]. Both research showed proportionate relationship of lack of physical activity/exercise with risk of developing type 2 diabetes. Although social and print media is playing marvelous role in getting our people aware of diverse physical activities in accordance with their circumstances and workplace but apart from physical fitness people should also be sensitized specifically for their wellbeing. This study concluded high to very high risk of developing type 2 diabetes among 7% respondents with their positive family history, while a study by [13] among population of Bangladesh revealed 47.7% of participants with positive family history [13]. A similar Brazilian research carried out in 2013 reflected that 47% of respondents had positive family history of type 2 diabetes [14]. Contrary to international research, current study is depicting raised percentage of positive family history among Pakistani population. This factor can better be scrutinized by conduction of research on large number of individuals.

About 14% female study subjects in current study had BMI>35kg/m2. Another research revealed higher risk of type 2 diabetes among females due to greater tendency of putting weight among them. This feature is significantly attributed to variations in sex hormones in addition to genetics, familial tendency, and lifestyle [15]. There is need to do rigorous research on this aspect across countries by eliminating confounders to determine scientific association of obesity with hormones. According to our study, 5 females out of 6 were determined to be at high to very high risk of developing diabetes. Contrary to these results, an international study concluded the high risk for type 2 diabetes among males [16]. The reason for this variation might be the racial difference and social set up. However, these factors need in depth insight to reach the accurate conclusion. The present study revealed that consumption of fruits and vegetables is insignificantly associated with protection from risk of developing type 2 diabetes (P>0.20). Likewise, a study by [17] portrayed insignificant association (P>0.20) in this regard [17]. This aspect entails detailed elaboration of associated factors like intake of fatty foods and protein diet apart from consumption of fruits and vegetables. Our results showed that only 15 respondents were regularly taking medication for high blood pressure out of which 5 subjects were at high risk of developing type 2 diabetes within next 10 years. On the other hand, a prospective study carried out among hospitalized patients of Bulgaria revealed higher risk for developing type 2 diabetes among hypertensive patients [18]. As current study is cross-sectional descriptive and carried out among non-diabetics, this might be the reason for less individuals at high risk for developing type 2 diabetes within next 10 years.

Conclusion and Recommendation

High risk of developing type 2 diabetes was found among females 55-64 years of age with very high BMI, no physical activity and specifically with diabetic history of immediate family members. Considering study results, risk of developing type 2 diabetes in the community can be minimized by increased physical activity and weight reduction However, these study subjects should regularly be followed up for development of type 2 diabetes.

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Lupine Publishers | Locked Bridge Plating is a Suitable Option for Forearm Fractures Secondary to Civilian Low Velocity Gunshot Injuries

 Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

Go to

Introduction: The purpose of this retrospective study is to compare the outcomes of low velocity gunshot fractures of the forearm treated with minimal debridement and locked bridge plating to patients treated with formal debridement and conventional plating.

Materials and Methods: A 10 year IRB approved retrospective review of our national trauma database was conducted. Initial treatment consisted of wound care and sterile dressing. Forearm radiographs were acquired to determine bony involvement. All patients received intravenous antibiotics upon presentation to the emergency department and for a minimum of forty-eight hours after admission or operative intervention. Patients were placed into two categories of operative or nonoperative treatment. Those placed into operative treatment were further divided into the subcategories of formal debridement and plating or minimal debridement and plating.

Results: 94 patients were included in the study. 29 were treated nonoperatively and 65 were treated operatively. Of those 65, 30 underwent minimal debridement and bridge plating and 35 were treated with formal debridement and bridge plating. All patient radiographs displayed fracture healing at latest follow-up with no evidence of infection or osteomyelitis. Nerve injuries were found among 15 patients and vascular injuries were present in 7.

Conclusions: Both methods of irrigation and debridement resulted in reliable osseous union with no instances of osteomyelitis. These results suggest that immediate locked bridge plating with minimal debridement is a suitable option for the treatment of forearm fractures following low velocity gunshot injuries.

Keywords: Irrigation; Debridement; Forearm; Gunshot; Fracture; Minimal

Introduction

There are 300,000 injuries and 30,000 hospitalizations from gunshot wounds annually in the United States [1-3] primarily from low-velocity handguns. These weapons produce less soft-tissue injury than high-velocity rifles or shotguns attributed to lower mass, velocity and energy transfer of the projectiles to surrounding tissues [4, 5]. Gunshot wounds of the forearm have been reported in several small series in the literature; however, no treatment guidelines backed by adequate scientific evidence exist. Prior studies with limited numbers have recommended debridement irrigation, antibiotics and compression plating for displaced fractures of one or both bones, and immobilization for undisplaced simple fractures of single bones. We feel that aggressive debridement and conventional compression plating may not be practical for these injuries which often have boney comminution but minimal soft tissue injury. A potential alternative is limited debridement and bridge plating. The purpose of this study is to compare the outcomes of low velocity gunshot fractures of the forearm treated with minimal debridement and locked bridge plating to patients treated with formal debridement and conventional plating.

Materials and Methods

An IRB approved 10-year retrospective review of our hospital trauma database revealed one-hundred and one patient admitted to the hospital with forearm fractures following gunshot wound (2000-2010). Seven patients were excluded from the study as their injuries were the result of a high-velocity firearm, leaving ninety-four patients treated for gunshot wounds of the forearm with hospitalization. Patients who were discharged from the emergency room with gunshot wounds with or without fractures and patients who left the hospital against medical advice prior to treatment were not captured in this database. There were eightythree males and eleven females. The average age was 27.7 years with a range of 16-52 years. The average duration of follow-up of all patients was 27.3 months with a range of 9 to 105 months. Treatment was initiated with wound care by applying a sterile dressing in the emergency department. Forearm radiographs were acquired to determine bony involvement. Clinical suspicion of limb ischemia by physical exam was an indication for angiography. All patients received intravenous antibiotics upon presentation to the emergency department and for a minimum of forty-eight hours after admission or operative intervention. The initial antibiotic selected was cefazolin with or without gentamicin, and some patients with concomitant thoracic or abdominal injuries received additional antibiotics for greater time periods. Patients with non-displaced or minimally displaced fractures were treated non-operatively with local wound care, antibiotics, and casting. Displaced fractures were divided into 2 groups.

During the first 5 years 35 patients underwent aggressive debridement and irrigation of wounds, fracture stabilization using compression plating techniques when feasible and bridge plating when there was bone loss. Antibiotic cement spacers were placed where there was bone loss followed by delayed grafting using iliac crest bone. Eight were stabilized with initial external fixation followed by plating and 27 had immediate plate fixation. The second 5 years included 30 patients treated with open reduction and internal fixation (ORIF) with a bridge plating technique, limited irrigation and debridement of entry and exit wounds locally at the level of skin and subcutaneous tissue without debridement of bone. This was intended to minimize soft tissue stripping around the fracture site. Bullet fragments were not disturbed unless they were superficial and easily removed without further damaging the surrounding soft tissues. Entrance and exit wounds were not closed primarily. Patients with non-displaced or minimally displaced fractures (29) were treated non-operatively with local wound care, antibiotics and casting. These were often admitted for concomitant injuries and thus were picked up in our database. We reviewed all radiographic images obtained at presentation and during treatment. Fractures were classified as radius, ulna or both (Figure 1). The fracture location was noted whether they were proximal, midshaft or distal and if they were non-displaced or minimally displaced versus comminuted and displaced. Radiographic data were used to determine the status of fracture healing or hardware failure. Patients were examined in the clinic (Figure 2) to assess for fracture healing, infection, presence of deformity, sensory or motor deficits, and range of motion. Range of motion was classified as good (<10 degrees flexion extension loss and <25 degree pronation/ supination loss), satisfactory (<30 degree flexion extension loss and <50 degree pronation/supination loss) or poor (>30 degree flexion extension loss or >50 degree pronation/supination loss)

Results

Operative Treatment

Sixty-five patients were treated operatively. Thirty patients underwent bridge plating and minimal debridement of the gunshot wounds without excision of only frankly necrotic tissue and minimal to no bone debridement and no bone grafting (Figure 3). Thirtyfive patients were treated with formal irrigation and debridement of the wounds and stabilization (Figure 4). Of the thirty patients with bridge plating and limited debridement twenty-nine patients displayed fracture healing at their latest follow up and one patient required revision surgery for delayed union. There were no signs of infection or osteomyelitis at final follow up. Of the thirty-five patients treated with more aggressive irrigation and debridement with fracture stabilization, seven patients were determined to have more extensive soft tissue injury requiring multiple surgeries and more aggressive debridement and eventual soft tissue coverage. Five of these seven required early bone grafting after original damage control surgery and prior to soft tissue reconstruction. All patients displayed radiologic evidence of healing at their latest follow up with no patient showing signs of infection or osteomyelitis.

Non-Operative Treatment

Twenty nine patients were treated non-operatively with local wound care and casting for forearm fractures. All patients had a single bone non-displaced or minimally displaced fracture. All patients displayed radiographic evidence of fracture healing at their latest follow up with no patient showing signs of infection or osteomyelitis. Range of motion in this subset was determined to be satisfactory or good at final follow up.

Nerve Injuries

There were fifteen patients with an associated nerve injury. The ulnar and median nerve were the most common nerves injured (six patients each) followed by the radial nerve in four patients and the palmar cutaneous nerve and anterior interosseous nerves in one patient each. Three patients had multiple nerve injuries. In seven patients the nerve injury resolved completely and in five patients a partial nerve deficit was observed. Three patients showed no recovery with one patient displaying a classical ulnar claw hand deformity.

Vascular Injury

Seven patients presented with signs of associated vascular injury of the forearm. There were four radial artery injuries and four ulnar artery injuries. One patient had both arteries injured and repaired. All patients had a viable limb on follow up. Three patients had nerve injury associated with vascular injury. One patient developed a compartment syndrome requiring fasciotomy.

Discussion

Early stabilization of forearm fractures is important after a gunshot injury and the management of the open wound and soft tissue injury is always an important consideration for surgical planning. In this study, we showed that minimal irrigation and debridement of the entrance and exit wounds is adequate for low velocity gunshot injuries to the forearm with minor visible soft tissue injury, and that bridge plating with minimal surgical dissection through the zone of injury is sufficient to achieve reliable union of these fractures. Dicpinigaitis, et al. showed that most non-displaced fractures of the radius or ulna can be effectively managed with casting al in their review of the literature addressing gunshot wounds to the extremities, but displaced fractures should be treated operatively with compression plating [4]. reported superior results in patients treated with delayed primary ORIF with displaced forearm fractures secondary to gunshot wounds [12]. In the same study, no patients treated by delayed ORIF went on to melanin or delayed union, but all patients did have decreased range-of-motion, particularly pronation and supination. Rodrigues, et al. recommended a treatment protocol involving early wound care and provisional stabilization followed by definitive treatment with internal fixation within one week [18-20]. In our review, thirty five patients were successfully treated with a more extensive soft tissue debridement with fracture stabilization, and thirty patients with comminuted and displaced fractures were effectively treated with local wound care followed by internal fixation with bridge plating.

Several studies have also examined the effectiveness of nonsurgical treatment in non-displaced or minimally displaced forearm fractures resulting from low-velocity firearms. Elstrom, et al. reported on fourteen patients that were treated with casting [12]. In eight non-displaced single bone fractures, seven had good outcomes. In six displaced fractures, closed reduction and casting lead to poor outcomes in four patients. Lenihan ,et al. reported on thirty-seven patients with civilian gunshot wounds to the radius and ulna [13]. Twenty-three patients with non-displaced fractures were treated by closed means with twenty-one showing good outcomes. However, in the fourteen patients with displaced fractures, the outcomes of the eight patients who had closed reduction were worse than the six patients treated surgically. Dickson, et al. prospectively evaluated patients with non-displaced fractures treated as outpatients with closed reduction and casting [3]. Only one patient in their study went on to delayed union [3]. also reported excellent results in patients of non-displaced fractures treated with closed reduction in a long arm cast, with seven of eight patients showing evidence of fracture healing and good functional outcome. The same study reported that four out of six patients with comminuted and displaced fractures treated with casting went on to malunion or delayed union resulting in a poor functional outcome. The authors concluded that closed reduction has satisfactory results in non-displaced fractures while displaced fractures require internal fixation to achieve superior outcomes. In our retrospective review we found similar results and agree that patients with minimally displaced or non-displaced extra-articular fractures can be adequately treated with closed reduction and casting without surgical debridement. We add to these findings that extensive surgical debridement can also be withheld with low risk of infection or nonunion after bridge plating for fracture stabilization.

Past studies have shown that bullets are not sterilized during discharge of the weapon and may act as a vector introducing pathogenic bacteria into the wound4. Controversy exists, however, as to the necessity of administering prophylactic antibiotics to this patient population. Patzakis, et al. demonstrated an infection rate of 13.9% in patients with open fractures resulting from gunshot wounds not treated with antibiotics and an infection rate of 2.3% in patients treated with cephalothin [7]. The study also showed no statistically significant difference in infection rate between the control group (13.9%) and a group treated with penicillin and streptomycin (9.7%) [7]. Conversely investigated the efficacy of antibiotics in a similar patient population and showed no significant difference in infection rate between the control group and the experimental group treated with at least twenty-four hours of intravenous cefazolin [2]. concluded in a prospective study that short-term intravenous antibiotics did not decrease the risk of infection [9]. recommended the use of prophylactic antibiotics in high-velocity and intra-articular injuries but did not support the use of prophylactic antibiotics for low-velocity injuries [10]. Howland and Ritchey in a retrospective analysis concluded that prophylactic antibiotics were unnecessary in the treatment of lowvelocity gunshot fractures [11-20]. In our study, all patients were treated with intravenous first generation cephalosporin antibiotics, and in some cases additional antibiotics to treat other concurrent injuries. As no patient in our review developed osteomyelitis even with a large subset undergoing limited debridement, we support the use of a first-generation cephalosporin for 48 hours in patients reporting with open forearm fractures secondary to low-velocity gunshot wounds.

We recognize the following limitations of our study. First, it is retrospective in nature and carries all the associated risks of bias. It is additionally possibly biased towards more severe injuries since all included patients were admitted for at least 48 hours. Patients with minor gunshot forearm injuries and treated as outpatients had variable antibiotic regimens or no antibiotics and were not captured in this database. Thirdly, the patient population of this study is small, although it is larger than previously published studies. Furthermore, we had difficulty in contacting patients in our study for longer term follow up.

Conclusion

Forearm fractures caused by low velocity gunshot wounds in a civilian setting are often comminuted single bone injuries with minor soft tissue injury. Both the aggressive and limited debridement regimens resulted in reliable osseous union and no instances of osteomyelitis. These results suggest that immediate locked bridge plating with minimal debridement is a suitable option for the treatment of forearm fractures following low velocity gunshot injuries.

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Lupine Publishers | Is There a Role for Platelet-Rich Plasma Injection in Pediatrics? a Narrative Review

 Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)

Abstract

This review identifies some of the relevant literature regarding the application of platelet-rich plasma (PRP) and the corresponding evidence of its use in the pediatric population. Because of its potential in various regenerative processes, there is a building interest in its utilization. However, very few high-quality studies investigating the therapeutic use of PRP exist for many reasons. The concentration of plasma constituents, response to PRP in different tissues, and its preparation are some of the issues that have been overlooked or not standardized when investigating its efficacy. With this lack of evidence, PRP’s utilization in the general population, and consequently in pediatrics, has been under-investigated and relegated mostly to animal models. We postulate that PRP may have some of its best utility in the young athlete with musculoskeletal derangements. In addition, further investigations need to be conducted in pediatric patients to determine whether PRP will be beneficial.

Keywords:Orthobiologics; Platelet rich plasma (PRP); Pediatrics, Sports injuries; Sports medicine; Orthopedic surgery

Abbreviations:(PRP): Platelet rich plasma; (ACL): Anterior cruciate ligament; (UCL): Ulnar collateral ligament; (MCL): Medial collateral ligament; (MPFL): Medial patellofemoral ligament; (RICE): Rest ice compression and elevation; (DASH): Disabilities of the Arm Shoulder and Hand; (KJOC): Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow

Introduction

Over the last three decades, there has been increasing interest in biological treatments for musculoskeletal pathology. Advances in plasma and stem cell research have led to the study and utilization of our own biologic machinery’s regenerative or reparative potential. Uses of these therapies have their roots in plastic surgery starting in the 1990s, and since that time, there has been an increased focus on their use in sports medicine [1] The theory behind platelet-rich plasma (PRP) is the sequestration of blood plasma, which contains many of the healing factors responsible for tissue repair, to the area in question. This article aims to review PRP as a treatment modality and identify the most common uses of PRP in the pediatric population. We will also bring attention to its current limitations and future potential. There is a wealth of studies on its use in several sports-related pathologies, but studies on pediatric use and indications are still lacking [2]

What is PRP

Traditionally, PRP has been defined depending on its most abundant constituent, and fibrin density once activated.3 The four major types are Pure Platelet-Rich Plasma (P-PRP) (or Leukocyte- Poor Platelet-Rich Plasma (LP-PRP)), Leukocyte-and Platelet-Rich Plasma (LR-PRP), Pure Platelet-Rich Fibrin (P-PRF) (or Leukocyte- Poor Platelet-Rich Fibrin, and Leukocyte-and Platelet-Rich Fibrin (L-PRF)) [3] Each of these preparations has its specific composition, which has indications depending on the pathology in question. Each formulation induces specific effects on cartilage depending on the concentration of different factors. However, one of the significant difficulties with the administration of PRP products is utilizing the correct concentration or ratio of plasma factors that will induce the appropriate response [4]. For instance, in a 2015 study by Zhou, both L-PRP and P-PRP demonstrated different responses to the differentiation of trophoblast stem cells to tenocytes. L-PRP was detrimental to these tenocytes by activating catabolic effects on tendons. On the other hand, P-PRP was anabolic to tenocytes, leading to healing via scar tissue formation [5].

Current literature has recognized some evidence for the use of PRP depending on the pathology in question. In a review by Le, there is support for the use of LR-PRP for lateral epicondylitis, osteoarthritis in the knee, patella tendonitis, plantar fasciitis, and as an adjunct for pain following bone-patellar tendon-bone ACL reconstruction. Alternatively, PRP is also shown to be ineffective in Achilles tendinitis, injured muscle, fracture non-unions, and ACL or Achilles tendon repair. Furthermore, there is incomplete evidence for PRP in rotator cuff tears, osteoarthritis of the hip, and ankle sprains [6]. Some of the criticism from lack of evidence or utility for PRP is due to the varying methodology of PRP preparation and formulation across studies. There is little to no clear literature on the active components responsible for the bulk of the biologic response that PRP theoretically induces. We are aware of these molecules and the responses they impart. However, the concentration and heterogeneity between samples obtained from different patients vary. This diversity between formulations of PRP can potentially produce varying results from case to case [7].

Uses for PRP

Regardless of the heterogeneity with PRP’s formulations, it can be appreciated that cytokines and PRP factors may be responsible for its regenerative properties. There is evidence that these factors may very well expedite healing, especially in chronic tendinopathies, where the tendon in question lacks the nutrient environment to repair itself [6] A systematic review and metaanalysis by Miller concluded that PRP was effective in treating and expediting the healing in these aforementioned chronic conditions [8] Other indications for PRP’s use in the literature review include but are not limited to rotator cuff repair, Achilles tendon repair, and ACL surgery. Sprains and muscle injuries have also been a subject of interest. Moreover, PRP has been studied for use in other non-soft tissue-related pathologies, including osteoarthritis of hip and knee and fracture management and nonunions. [6] It must be mentioned that the majority of randomized controlled trials testing the efficacy of PRP are not high quality. Furthermore, to achieve better studies and obtain reproducible results, Chahla, et al. published the importance of standardizing PRP harvesting preparations and PRP compositions to make comparisons between studies.

Further emphasizing the issue of timing and formulation of a PRP injection, Laprade, et al. investigated whether or not the use of a single dose of varying concentrations of PRP accelerates ligament healing and improves the histological characteristics and biomechanical properties with a comparison to standard saline injections on the contralateral limb [9] The study was conducted by inducing a grade 3 MCL sprain on New Zealand White rabbits, and then an injection of either saline or varying concentrations of PRP was delivered immediately post-operatively. The study concluded that low dose concentrations of PRP injections into injured ligaments did not improve the healing of injured MCLs, and higher doses seemed to decrease the quality of the ligament healing. The study further emphasized that additional in vivo studies are needed to standardize the timing of injection and the concentration of PRP injection in the treatment of ligament injuries [9].

Use in pediatrics

With the advent of PRP use in adults, there is gaining interest in its use for pediatric sports injuries. The following points call attention for further investigation when considering PRP in the young athlete: increasingly promising data with more randomized controlled trials, a better understanding of the healing factors found in plasma, improved protocols for obtaining specific formulations, and reducing heterogeneity among said formulations. Furthermore, we should note the potentially increased efficacy among the younger population due to genetic factors, the negative immunogenicity with autologous PRP, and the non-invasive nature of these treatments. With the increasing number of sports injuries in the younger population, research in biological treatment is imperative. Schroeder et al. investigated overuse injuries from 2006 to 2012 and found these injuries occurred in 1.50 per 10,000 athletic exposures within the interest population. Females had a greater risk of overuse versus males, with the most significant risk being in track and field. 7.7% of all injuries in this population were overuse injuries. The most frequent site was in the lower leg. Injuries most frequently resulted in less than a week of time off, with 7.6% of the patients reporting time loss greater than three weeks [10].

Similarly, there is an increased amount of ligamentous injuries necessitating reconstruction in the young population. According to some studies, ACL injuries requiring reconstruction alone have increased 924% from 1994 to 2006 [11] This study identified prolonged sports participation, increased amount of athletes participating, and a focus on a single sport as risk factors for the increased incidence. Other common sports injuries in the pediatric population include the medial patellofemoral ligament (MPFL) and the ulnar collateral ligament (UCL) [2] There are currently no studies examining PRP’s use as an augment for MPFL injury or repair. Other indications presented by Bray, et al. that warrant further study include PRP for tendon injuries, cartilage defects, and fractures, although even less data is available for these situations. The majority of studies investigating PRP’s potential in these instances continue to be limited in number, contradictory in results, and limited to adult subjects.

Potential Benefits of PRP in pediatrics

With increasing sports participation and focus on specialization in a single sport with minimal rest in training, overuse injuries in adolescent athletes are increasing. These injuries vary in morbidity from requiring rest for a few days and subsequently missing a few games or practices to season-ending injuries. While rest, ice, compression, elevation (RICE therapy) with or without accompanying physical therapy are often chosen as treatment regimens, there is a lack of level I evidence to support their efficacy.12 While not performed in pediatric patients but rather patients >/= 18 years of age with a median age of 21 years old, a randomized controlled trial by Hamid, et al. in 2014 investigated the effect of a single PRP injection and a standardized rehab protocol versus a rehabilitation program alone on grade 2 hamstring injuries. The primary outcome of return to play was found to be statistically significant (p=.02), and substantially sooner with the PRP injection with an average return to play of 26.7 days +/- 7.0 days versus 42.5 +/- 20.6 days in the control group [13]

A systematic review by Figueroa et al. compared ACL reconstruction with PRP as an adjunct versus ACL reconstruction alone. In total, eleven studies were reviewed. Six of those demonstrated statistical significance in regards to “graft maturation” with PRP. One study showed improved tunnel healing and another showed better clinical outcomes. Five studies showed no added benefit when PRP was added to ACL reconstruction [14] Podesta, et al. conducted a case series in 2013 on 34 athletes with partialthickness UCL tears as evidenced by clinical examination and confirmed on MRI, who failed at least two months of nonoperative care. The patients were treated with a single leukocyte rich PRP injection. The average age of these players was 18 years, with a range from 14 to 34 years. The study resulted in 30 out of 34 patients returning to the same level of play without issues at an average of 12 weeks post-treatment. The average Disabilities of the Arm, Shoulder and Hand (DASH) score improved from 21 to 1, and the average Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow (KJOC) score improved from 46 to 93-both of which were statistically significant. The study concluded that PRP was effective in treating partial UCL tears of the elbow in young athletes [15]

On the contrary, Chauhan, et al. conducted a retrospective study on PRP injections in 133 MLB pitchers versus no PRP in 411 MLB pitchers in the nonoperative treatment of UCL injuries. The PRP group resulted in a significantly longer return to throwing and a significantly longer return to play. However, PRP’s formulation was non-standardized, with some patients receiving leukocyte rich PRP and others receiving leukocyte poor injections. Additionally, the time from injury to injection was not standardized. Notably, the average age of the non-PRP group was 22.6 years old versus 24.3 years old for the PRP group. [16] However, as evidenced by Podesta, et al. PRP’s efficacy was seen in young athletes with PRP. While the two studies’ results differ in their outcomes, both suggest younger patients can do well with the nonoperative case of UCL injuries. The two studies differed on major criteria such as time from injury to injection and type of PRP injections. Therefore, further investigation needs to be conducted on the type of injection and the time from injury to injection, both of which need to be standardized for further conclusions, which seems to be one of the underlying problems with PRP studies. Additionally, since younger patients have a greater healing capacity, an appropriately timed PRP injection of the correct formulation may further enhance their recovery and return to sport.

Tendinopathies are another indication for the potential benefit of PRP administration. Sanchez, et al. injected PRP during Achilles tendon repair in a case-control study from 2007. In the participants treated with PRP, return to base function was faster than in the non-PRP group [17] Kon, et al. found significant improvement in all functional scores used in their study when PRP was used to treat jumper’s knee (patellar tendinitis) [18]. One of the most common injuries to young athletes is chondral damage. Chondral injury is another area of interest as it is a common injury with the potential for arthritis development. Many treatments have been developed to treat cartilage lesions, including microfracture, which is a similar concept to PRP. By surrounding the defective cartilage with a nutrient-rich environment, microfracture and PRP theoretically lead to chondral repair via similar mechanisms. Again, Bray et al. suggest future investigation into PRP as a therapeutic for these injuries; however, at this time, these injuries are mostly treated with microfracture, osteochondral autograft, osteochondral allografts, and autologous chondrocyte implantation. Good results have been documented in the pediatric population. One of the reasons why PRP use in this group is possibly incomplete is the more urgent nature of treating these injuries, which can accelerate towards arthritis.

Finally, fracture management is another area where PRP administration has piqued some interest. One study demonstrated reduced clinical and radiographic healing time of femoral neck fractures with PRP in addition to cannulated screw fixation compared to just cannulated screw fixation [19, 20] However, a subsequent paper demonstrated the opposite effect. Singh reports that although PRP may provide an artificial hematoma effect in the initial healing phase, it does not affect femoral shaft fracture healing when used with intramedullary nailing.

Conclusion

Young athletes often participate in year-round sports. These athletes are also focusing on single sports at a younger age, and therefore participation in multiple sports and appropriate crosstraining is often lacking. Without consistent rest periods or cross training, an increasing number of athletes will continue to sustain overuse and sports-related injuries. Since younger patients have a greater healing capacity, adding PRP to the treatment regimen, in theory, may enhance their ability to return to their sport sooner. While PRP’s potential applications in sports medicine are still being studied extensively, no trials are specifically studying pediatric patients. Since cytokines found in PRP are involved in the signaling pathways that occur during healing stages of inflammation, cellular proliferation, and subsequent tissue remodeling, investigations into the appropriate timing, makeup (Pure PRP, Leukocyte and PRP, Pure PRF, Leukocyte and PRF), and concentration of PRP need to be further investigated. In place of the increasingly promising data in adult patients, further investigations need to be conducted in pediatric patients to determine whether PRP will have any considerable benefit.

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Lupine Publishers | Case Report of Multiple Myeloma Presenting with Unique Skin Manifestation with Literature Review

 

Lupine Publishers | Open Access Journal of Oncology and Medicine (OAJOM)

Introduction

Multiple myeloma (MM) accounts for approximately 2% of all malignancies and 13% of hematological malignancies worldwide [1]. MM is the second most common hematologic malignancy [1] and it is a neoplasm of clonal plasma cells which originate from the B-cell lineage and develop after lineage commitment in the bone marrow of progenitor cells [9]. Cutaneous involvement in patients with multiple myeloma is rare and it usually represents of a poor prognosis. Cutaneous involvement indicates an increased tumor burden. The most common cause of cutaneous involvement is due to direct extension from underlying bone lesions of MM or solitary plasmacytoma of bone [2]. It is very rare to have primary cutaneous plasmacytoma [3].

Case Presentation

We present the case of a friendly Caucasian American 70-yearold female with no significant PMH who initially presented to Ruby Memorial Emergency Department in November 2015 with persistent back and left side pain. At that time, she began to notice weakness and some numbness in lower extremities and along with the increasing low back pain decided to seek medical attention and presented to the hospital. On admission, CT thoracic spine (11/16/15) revealed a T5 wedge compression deformity. CT lumbar spine revealed degenerative changes with diffuse osteoporosis. MRI thoracic spine (11/17/15) revealed a T5 burst fracture with retropulsion, focal kyphotic deformity, severe central canal stenosis, possible pathologic fracture deformity, And possible cord contusion at T5. CBC on admission revealed WBC 5.1 with normal differential, Hgb 11.5 with MCV 105.3 and platelet count 170,000. BMP normal, creatinine 0.75, corrected calcium 10.2. Subsequently, she underwent a posterior spinal fusion T3-T8, left costotransversectomy with left pedulectomy and subtotal corpectomy (excision of tumor) via transpedicular approach with placement of anterior cage, T5 laminectomy, and T6-7 partial laminectomy. Pathology revealed a tumor composed of sheets of atypical plasmacytoid cells positive with immunostain for CD138 and negative for pancytokeratin, CD20, and CD3. Insufficient tissue remained for kappa and lambda ISH. The finding was consistent with plasma cell neoplasm. SPEP revealed an M spike seen in the gamma, consistent with monoclonal gammopathy. Random UPEP/ IFE revealed a monoclonal lambda protein without detectable associated IgG, IgA or IgM heavy chain. In December, SPEP/IFE revealed an IgG Lambda monoclonal protein (5.95 g/dL). Free light chain ratio 0.013 (Kappa 0.80 mg/dL, Lambda 60.50 mg/dL). Quantitative IgG 5950 g/dL. Hgb 9.4 with MCV 98.5. Creatinine 0.62. Corrected serum calcium 11.2. Albumin 2.0. Beta 2 microglobulin 4.25. Skeletal survey reveals diffuse osteolytic process with multiple calvarial, vertebral body and rib lesions identified. T3-T8 posterior spinal fusion for pathological T5 compression fracture noted.

She had a bone marrow biopsy/aspirate which revealed 47% lambda restricted plasma cells, with marked atypia including a plasmablastic morphology. Preliminary FISH results indicate multiple trisomies, 1q21 gain, del (13q14) and a non-standard IGH rearrangement-t(8;14). Hyperdiploidy detected. She was diagnosed with IgG Lambda Multiple Myeloma. ISS Stage II, DS IIIA. Soon thereafter, she was started on a bortezomib-based triplet regimen - bortezomib, cyclophosphamide, dexamethasone (CyBorD). She completed 4 cycles. In April 2016, SPEP/IFE revealed an IgG Lambda monoclonal protein - not quantified. Quantitative immunoglobulins: IgG 1013 mg/dL. Free light chain assay revealed a ratio of 1.169 (kappa 2.98 mg/dL, Lambda 2.55 mg/ dL). CBC normal. Hgb 13.2. Serum creatinine 0.59. Serum calcium 9.7 (corrected). Serum albumin 3.0 g/dL. Beta 2 microglobulin 2.65 mcg/mL. Skeletal survey demonstrated new evidence of L5 pathological compression fracture. A repeat bone marrow biopsy revealed a variably cellular marrow (10-50%). Maturing trilineage hematopoiesis noted. No atypical plasma cell infiltrate (<5% by CD138 ICH). Cytogenetics normal. Unable to run FISH. At the end of the month, her regimen switched to Lenalidimide/Dexamethasone and she completed 4 cycles. In August, she began maintenance therapy with Lenalidomide at 10 mg daily. She then presented with multiple skin papule skin lesions (Figure 1) mostly on her gluteal region. In January 2017, she had a left gluteal skin biopsy consistent with plasma cell neoplasm with high grade features (plasmablastic differentation) In February 2017, SPEP/IFE revealed a IgG Kappa monoclonal protein (not quantified). IgG level 2303 mg/dL. Free light chain assay reveals a ratio of 1.31 (Kappa 12.63 mg/dL, Lambda 9.62 mg/dL). She completed radiation therapy to left gluteal skin - received 30 Gy/15 fractions. SPEP/IFE revealed a IgG Kappa monoclonal protein (not quantified). IgG level 2357 mg/dL. Free light chain assay reveals a ratio of 1.47 (Kappa 12.20 mg/dL, Lambda 8.32 mg/dL). In March 2017, she was started on Pomalidomide/ Dex. Unfortuatnely she was found to have progression of her disease noted. She was then started on Daratumumab which she could not tolerate and was then started on Carfilzomib/Dex. She has received multiple radiation therapy to her left gluteal region, mid back and left upper lip with significant resolution in all areas. In February 2017, she was admitted to Ruby with worsening pain and lesions located in her lower extremities and edema (Figure 1). Peripheral duplex was obtained and blood cultures to rules out a venous clot and infection respectively. A biopsy was obtained (Figure 2) which showed cutaneous involvement of her multiple myeloma. Radiation Oncology was consulted, and she was started on palliative radiation for 5days which initially improved her pain and swelling. Unfortunately, her lesions continue to arise with intermittent, short lived responses to systemic therapy. Her lesions now too widespread for continued radiation therapy. She noticed lesion in her scalp. She continues to follow up in clinic where she was started on single agent Doxil 40 mg/m2 every 4 weeks. Sadly, she continues have progressive cutaneous disease around the flank, abdomen, and bilateral thighs.

Discussion

We present an interesting case of cutaneous involvement of multiple myeloma where although the patient has been on multiple therapies continues to progress in her disease. Her case is interesting from other presentations in that they don’t usually do not describe the course of regimen used in treatment. The standard of care of cutaneous involvement revolves controlling the origin of the disease. One specific treatment that we tried was localized radiation. There is not much data or past literature discussing the use of radiation or its efficacy. Unfortunately for our case, the treatment only helped briefly. Most common involvement for MM is soft tissue involvement of the upper airway and oral cavity. They usually consist of firm, erythematous, nontender nodules involving the neck, ears, shoulders, axillae, chest, abdomen, and dorsum of the hands [11]. The first reported case of skin involvement in a person with MM was presented by Bruno Block in 1910. He described a patient who had small reddish macules that evolved into brown reddish papules and nodules with scale crusts. Histologically these lesions showed epidermal necrosis. He eventually had disease in pleura, stomach, and heart and passed away two years later [3]. A review of literature reveals that there are over 100 described cases. The age ranges from 36 to 81 with a median of 60 years old. Numeric date was available for 87 cases and 63 of them were male and 24 were female [4]. Cutaneous involvement of MM may appear in area of the skin, but it has been reported most commonly on the trunk and abdomen. Skin lesions is commonly described as papules or nodules that measure 1-5 cm in diameter with firm consistency, smooth surface, and a red or violaceous color [5]. Some authors reported that cutaneous involvement of MM only occurs when the tumor mas burden is over 2-3 kg [6]. Cutaneous involvement in patient with MM and extramedullary plasmacytoma generally appears late during the disease. On average, death occurred within 12 months after the diagnosis. Autopsy of these patients reveal extensive plasmacytic infiltration of multiple organs [7].

A review of the cases of MM involving the skin revealed that 40 cases were IgG, 21 cases were IgA, and 9 cases were IgD. The risk of cutaneous involvement by MM is not associated with a particular class of myeloma immunoglobins. Histopathologically, the lesions of MM involving the skin show 2 patterns: nodular and diffuse interstitial [6]. (Figure 2, 3). The worldwide incidence of myeloma is 86,000 cases annually. Mortality rate in MM is high with a median survival of 50-55 months and 63,000 deaths being reported worldwide each year [8]. Significant advances have been made in understanding multiple myeloma (MM) and its precursor diseases. These advances include the gain in knowledge in the underlying pathophysiology, Food and Drug Administration (FDA) approvals of novel therapies with meaningful efficacy and the science in underlying disparities in patients with MM [9].

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