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Although preoperative antibiotics are used routinely in ankle fracture surgery, there is considerable variability in postoperative antibiotic dosing regimens amongst surgeons. The aim of this study is to compare the rate of surgical site infection (SSI) in patients receiving one dose of preoperative antibiotics to patients who received more than one dose of antibiotics. A single-center Level I Trauma Center retrospective review of patients with isolated closed ankle fractures who underwent open reduction internal fixation over a 10-year period was performed. Demographics data and risk factors were obtained from the electronic medical record. SSI was detected using a text-mining algorithm on all postoperative clinic notes. Factors associated with the development of SSI or increased antibiotic dosing were evaluated. Eight-hundred and twenty-six patients were included in the analysis. There was no correlation between infection rate and any of the potential risk factors evaluated. Two-hundred and ninety-two patients received only one dose of antibiotics preoperatively and 534 patients received more than one antibiotic dose. The rate of SSI was not significantly different between the single-dose cohort (5.8%) and the multi-dose cohort (3.9%) (p=0.215). Routine use of postoperative antibiotics in open reduction internal fixation of closed ankle fractures did not decrease the rate of SSI, regardless of associated comorbidities. LEVEL OF EVIDENCE: : Level III (therapeutic retrospective cohort study).

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Combined anterior cruciate ligament/medial collateral ligament (ACL/MCL) injuries are relatively common, and multiple factors are involved in surgical decision-making, particularly when it comes to the MCL. Historically, most surgeons treated the MCL conservatively and performed staged MCL reconstruction after MCL reconstruction only if there was persistent medial instability. This was followed by a nonoperative approach for the MCL (when reconstructing the ACL) unless there was evidence of extreme (grade III or >1 cm) valgus instability, valgus malalignment, or mid-substance or tibial-sided injury, avulsion, or Stener lesion. However, the most recent research demonstrates that combined ACL/MCL injuries present a higher risk of ACL reconstruction failure and subsequent revision compared to ACL injuries alone. With growing biomechanical and clinical evidence, more surgeons are repairing or reconstructing the MCL in these combined injuries. Although there is no clear consensus, we recommend surgeons consider surgically treating the MCL to avoid not only excessive force on the ACL graft but also persistent valgus laxity, which can lead to ACL failure. For distal MCL avulsions, repairs have shown excellent midterm outcomes, especially if the tissue quality is pristine. If the tissue quality is not repairable, then we would advocate for repairing whatever tissue is repairable and augmenting with an MCL reconstruction. For mid-substance MCL injuries, if surgical intervention is required, we advocate for MCL reconstruction. For proximal tears, the same criteria used for distal tears apply with management based on tissue quality and joint stability after repair. The ACL is a secondary stabilizer to valgus loads, and MCL deficiency results in tremendous strain on ACL graft reconstructions. If the MCL is even mildly incompetent, we strongly advocate for treating the MCL surgically in this setting.

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STUDY DESIGN: Case series. LEVEL OF EVIDENCE: Level 4C.

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INTRODUCTION: The impact of the COVID-19 pandemic on non-COVID-19 pathologies has been experienced worldwide. While people appropriately avoided social interactions, many also avoided essential medical care for acute and chronic conditions. This delay in seeking care has been associated with increased morbidity and mortality in several conditions, including life-threatening infections such as necrotizing fasciitis. METHODS: We retrospectively reviewed the records of patients that presented to the University of Vermont Medical Center for necrotizing fasciitis during the 1-year period following the declaration of a global pandemic on March 11, 2020. We subsequently compared this data with that of the previous 4 years. RESULTS: During the period of March 12, 2020 to March 12, 2021, there were 17 cases of newly diagnosed necrotizing fasciitis. Compared with an average per year of 8 cases over the previous 4 years, this represents a 113% percent increase in cases of necrotizing fasciitis during the study period (P = .071861). Out of the 17 cases, 4 patients died during their admission, producing a case-fatality rate of 23.5%. This represents a statistically significant increase from previous years (P = .003248), where the average case-fatality rate was 6.3%. CONCLUSION: Our study demonstrates a substantial increase in cases of necrotizing fasciitis following the onset of the coronavirus pandemic. A significant increase in the case-fatality rate was also observed. Given the growing body of literature describing the negative impact of the pandemic on non-COVID-19 morbidity and mortality, our study posits necrotizing fasciitis as one of many affected pathologies. LEVEL OF EVIDENCE: Level IV. Epidemiological.

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BACKGROUND: The femoral intercondylar notch type and the alpha angle (the angle between the femoral notch roof and the long axis of the femur) are easily measured in clinical settings; however, their associations with anterior cruciate ligament (ACL) injury remain unclear. HYPOTHESIS/PURPOSE: The purpose was to determine if the alpha angle and the femoral notch type are associated with noncontact ACL injury univariately and in combination with previously identified knee geometric risk factors. We hypothesized that the alpha angle and the femoral notch type are associated with noncontact ACL injury and that the association differs between men and women. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: The alpha angle and the femoral notch type were measured via 3T magnetic resonance imaging (MRI) acquired from 61 women and 25 men with a first-time noncontact ACL injury. Each injured patient was matched with a control participant based on age, sex, and participation on the same sports team. A conditional logistic regression was used to assess univariate associations with ACL injury as well as multivariate associations using MRI-based risk factors of knee geometry identified in previous analyses: femoral intercondylar notch width at the anterior outlet, femoral intercondylar notch anteromedial ridge thickness, volume of the ACL, tibial plateau lateral compartment subchondral bone slope, lateral compartment middle articular cartilage slope, lateral compartment meniscus-cartilage height, lateral compartment meniscus-bone angle, and medial tibial spine volume. RESULTS: For female athletes, the alpha angle (odds ratio, [OR], 1.82 per 1-degree increase; P = .001), the tibial lateral compartment articular cartilage slope (OR, 1.25 per 1-degree increase in the posterior-inferior directed slope; P = .022), and the femoral notch anteromedial ridge thickness (OR, 3.36 per 1-mm increase; P = .027) were independently associated with ACL disruption. For men, no other variables entered the models after the alpha angle was inputted as the first step (OR, 2.19 per 1-degree increase; P = .010). CONCLUSION: For women, ACL injury was most strongly associated with increased alpha angle, increased tibial plateau slope, and increased femoral notch ridge thickness. For men, increased alpha angle was the most significant factor associated with ACL injury. The mechanism of injury might be associated with a combination of impingement of the ACL against the bone and increased ligament loading.

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Metastatic breast cancer is refractory to conventional therapies and is an end-stage disease. RUNX2 is a transcription factor that becomes oncogenic when aberrantly expressed in multiple tumor types, including breast cancer, supporting tumor progression and metastases. Our previous work demonstrated that the thyroid hormone receptor beta (TRß) inhibits RUNX2 expression and tumorigenic characteristics in thyroid cells. As TRß is a tumor suppressor, we investigated the compelling question whether TRß also regulates RUNX2 in breast cancer. The Cancer Genome Atlas indicates that TRß expression is decreased in the most aggressive basal-like subtype of breast cancer. We established that modulated levels of TRß results in corresponding changes in the high levels of RUNX2 expression in metastatic, basal-like breast cells. The MDA-MB-231 triple-negative breast cancer cell line exhibits low expression of TRß and high levels of RUNX2. Increased expression of TRß decreased RUNX2 levels. The thyroid hormone-mediated suppression of RUNX2 is TRß specific as TRα overexpression failed to alter RUNX2 expression. Consistent with these findings, knockdown of TRß in non-tumor MCF10A mammary epithelial-like cells results in an increase in RUNX2 and RUNX2 target genes. Mechanistically, TRß directly interacts with the proximal promoter of RUNX2 through a thyroid hormone response element to reduce promoter activity. The TRß suppression of the oncogene RUNX2 is a signaling pathway shared by thyroid and breast cancers. Our findings provide a novel mechanism for TRß-mediated tumor suppression in breast cancers. This pathway may be common to many solid tumors and impact treatment for metastatic cancers.

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Dysregulation of the thyroid hormone receptor (TR)ß is common in human cancers. Restoration of functional TRß delays tumor progression in models of thyroid and breast cancers implicating TRß as a tumor suppressor. Conversely, aberrant expression of the runt-related transcription factor 2 (Runx2) is established in the progression and metastasis of thyroid, breast, and other cancers. Silencing of Runx2 diminishes tumor invasive characteristics. With TRß as a tumor suppressor and Runx2 as a tumor promoter, a compelling question is whether there is a functional relationship between these regulatory factors in thyroid tumorigenesis. Here, we demonstrated that these proteins are reciprocally expressed in normal and malignant thyroid cells; TRß is high in normal cells, and Runx2 is high in malignant cells. T3 induced a time- and concentration-dependent decrease in Runx2 expression. Silencing of TRß by small interfering RNA knockdown resulted in a corresponding increase in Runx2 and Runx2-regulated genes, indicating that TRß levels directly impact Runx2 expression and associated epithelial to mesenchymal transition molecules. TRß specifically bound to 3 putative thyroid hormone-response element motifs within the Runx2-P1 promoter ((-)105/(+)133) as detected by EMSA and chromatin immunoprecipitation. TRß suppressed Runx2 transcriptional activities, thus confirming TRß regulation of Runx2 at functional thyroid hormone-response elements. Significantly, these findings indicate that a ratio of the tumor-suppressor TRß and tumor-promoting Runx2 may reflect tumor aggression and serve as biomarkers in biopsy tissues. The discovery of this TRß-Runx2 signaling supports the emerging role of TRß as a tumor suppressor and reveals a novel pathway for intervention.

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Using a retrospective chart review, we compared the use of chest radiography (CXR) and arterial blood gas testing (ABG) before (pre-P) and after (post-P) initiation of specific ordering guidelines for the use of these studies for patients presenting to the ED with acute asthma exacerbation. We noted the number of tests performed, the indication for the test, and the results when performed. There was a 55% reduction in the number of chest radiographs (85 of 213 patients pre-P had CXR as compared with 40 of 222 patients post-P, P <.001). Of the patients who did not have a chest x-ray in the ED, none had an abnormal chest x-ray obtained after admission or if they returned to the ED within 72 hours. There was a 57% reduction in the number of arterial blood gases post-P (9 of 222 patients) as compared with pre-P (20 of 213 patients, P <.001). Although patients with abnormal ABGs had a discernible indication for testing, all of the ABGs for which no indication could be found were normal. A protocol containing criteria for obtaining chest x-rays and arterial blood gas testing can reduce the use of diagnostic testing, thereby improving ED efficiency without adversely impacting patient care.

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We report a rare case of tricep compartment syndrome caused by a hematoma which resulted from noninvasive blood pressure monitoring (NIBPM) during thrombolytic therapy. Clinicians administering thrombolytic agents should be aware of the risk of bleeding and compartment syndrome at the site of NIBPM. Appropriate preventative measures should be instituted when using automated pneumatic cuffs. An understanding of the pathophysiology and clinical presentation of an arm compartment syndrome will allow for prompt diagnosis and surgical treatment.

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