The anatomy of the anterior inferior tibiofibular ligament and its relationship with the Wagstaffe fracture

BackgroundOur aim in this study was to identify the fibular footprint of the Anterior Inferior Tibiofibular Ligament (AITFL) and its relation to Wagstaffe fracture fragment size.MethodsWe examined 25 cadaveric lower limbs which were carefully dissected to identify the lateral ankle ligaments. The AITFL anatomy was compared to 40 Wagstaffe fractures identified from our ankle fracture database.ResultsThe AITFL origin was from the anterior fibular tubercle with an average length of 21.61 mm (95% CI 20.22, 22.99). The average distance of the distal aspect of the AITFL footprint to the distal fibula margin was 11.60 mm (95% CI 10.49, 12.71). In the ankle fractures analyzed, the average length of the Wagstaffe fragment was 17.88 mm (95% CI 16.21, 19.54). The average distance from the distal tip of the fibula to the Wagstaffe fracture fragment was 21.40 mm (95% CI 19.78, 23.01).In total there were 22 syndesmosis injuries. There was no statistical difference in Wagstaffe fragment size between stable and unstable groups.ConclusionThe AITFL fibular origin was both larger and more distal than the Wagstaffe fracture fragments seen in our institution. Therefore, this suggests that a ligamentous failure will also have to occur to result in syndesmotic instability. The size of fracture fragment also did not confer to syndesmotic instability on testing.Level of Evidence - 3     

Remote intervention engagement and outcomes in the Clinical Trials in Organ Transplantation in Children consortium multisite trial

Remote interventions are increasingly used in transplant medicine but have rarely been rigorously evaluated. We investigated a remote intervention targeting immunosuppressant management in pediatric lung transplant recipients. Patients were recruited from a larger multisite trial if they had a Medication Level Variability Index (MLVI) ≥2.0, indicating worrisome tacrolimus level fluctuation. The manualized intervention included three weekly phone calls and regular follow-up calls. A comparison group included patients who met enrollment criteria after the subprotocol ended. Outcomes were defined before the intent-to-treat analysis. Feasibility was defined as ≥50% of participants completing the weekly calls. MLVI was compared pre- and 180 days postenrollment and between intervention and comparison groups. Of 18 eligible patients, 15 enrolled. Seven additional patients served as the comparison. Seventy-five percent of participants completed ≥3 weekly calls; average time on protocol was 257.7 days. Average intervention group MLVI was significantly lower (indicating improved blood level stability) at 180 days postenrollment (2.9 ± 1.29) compared with pre-enrollment (4.6 ± 2.10), p = .02. At 180 days, MLVI decreased by 1.6 points in the intervention group but increased by 0.6 in the comparison group (p = .054). Participants successfully engaged in a long-term remote intervention, and their medication blood levels stabilized. NCT02266888.     

COVID-19 in pediatric kidney transplantation: The Improving Renal Outcomes Collaborative

There are limited data on the impact of COVID-19 in children with a kidney transplant (KT). We conducted a prospective cohort study through the Improving Renal Outcomes Collaborative (IROC) to collect clinical outcome data about COVID-19 in pediatric KT patients. Twenty-two IROC centers that care for 2732 patients submitted testing and outcomes data for 281 patients tested for SARS-CoV-2 by PCR. Testing indications included symptoms and/or potential exposures to COVID-19 (N = 134, 47.7%) and/or testing per hospital policy (N = 154, 54.8%). Overall, 24 (8.5%) patients tested positive, of which 15 (63%) were symptomatic. Of the COVID-19-positive patients, 16 were managed as outpatients, six received non-ICU inpatient care and two were admitted to the ICU. There were no episodes of respiratory failure, allograft loss, or death associated with COVID-19. To estimate incidence, subanalysis was performed for 13 centers that care for 1686 patients that submitted all negative and positive COVID-19 results. Of the 229 tested patients at these 13 centers, 10 (5 asymptomatic) patients tested positive, yielding an overall incidence of 0.6% and an incidence among tested patients of 4.4%. Pediatric KT patients in the United States had a low estimated incidence of COVID-19 disease and excellent short-term outcomes.     

Cranial epidural empyema with osteomyelitis caused by actinomyces, CT, and MRI appearance

Actinomycosis is an uncommon cause of intracranial infection. Epidural empyema represents about 6% of CNS actinomycotic lesions. A case of an epidural empyema with parietal bone osteomyelitis caused by Actinomyces israelii is presented. Relevant neuroimaging features were bone erosions and a multiloculated collection with annular contrast enhancing on CT. Postoperative MRI revealed extensive involvement of the neighbor dura, falx, and subdural space. MRI was crucial to follow-up the response to antibiotic treatment.     

Factors influencing contralateral lymph node metastasis from oral carcinoma

BACKGROUND: An ipsilateral neck dissection is mandatory during initial treatment stages II-IV oral carcinomas. However, no consensus exists whether or not to perform an elective contralateral neck dissection. METHODS: Five hundred thirteen consecutive cases of squamous cell carcinoma (269 tongue, 135 floor of the mouth, 44 inferior gingiva, 65 retromolar trigone) were reviewed. Tumor stages were: 69 T1, 227 T2, 217 T3-T4, 263 N0, 250 N1-N3. A total of 563 neck dissections were performed in 448 patients. Univariate and multivariate analysis of risk factors were performed using logistic regression. RESULTS: Two hundred twenty-three patients (49.8%) had positive nodes in the specimen (182 ipsilateral, 36 bilateral, 5 contralateral). Contralateral neck recurrences occurred in 38 cases (33 not submitted to a contralateral neck dissection initially). Multivariate logistic regression analysis demonstrated that clinical stage (p = .0001), tumor crossing midline (p = .0011), and floor of the mouth involvement (p = .0236) were the most important predictors of contralateral metastasis. CONCLUSION: The contralateral side of the neck is a common and potentially preventable site of recurrence in tumors of the oral cavity. The multivariate model obtained discriminates patients with low and high risk (more than 20%) of contralateral metastasis. The application of this mathematical model can be useful for the indication of contralateral neck dissections, because not all tumors crossing midline are associated to a high risk (stages I and II tumors not involving the floor of the mouth) and not all tumors not crossing midline are at low risk (stages III and IV tumors involving the floor of the mouth).