Publications by authors named "Brendon Mitchell"

22 Publications

  • Page 1 of 1

Coronal Lateral Collateral Ligament Sign: Response.

Am J Sports Med 2021 08;49(10):NP54-NP55

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http://dx.doi.org/10.1177/03635465211030209DOI Listing
August 2021

Defining risk factors for adding-on in Lenke 1 and 2 AR curves.

Spine Deform 2021 Nov 3;9(6):1569-1579. Epub 2021 Jul 3.

Department of Orthopaedic Surgery, University of California - San Diego, San Diego, CA, USA.

Purpose: To identify curve/correction characteristics associated with adding-on at 2 years after posterior spinal fusion (PSF) in Lenke 1/2 AR curves.

Methods: A prospective multicenter registry was queried to identify patients with adolescent idiopathic scoliosis (AIS), Lenke 1/2 AR curves, who underwent PSF with a minimum of 2-year follow-up. Patient characteristics as well as pre- and post- operative radiographic variables were evaluated using Classification and Regression Tree (CART) analysis to determine which factors contribute to adding-on.

Results: 253 patients treated with PSF were assessed for adding-on, of which 50 met our adding-on criteria. Univariate analysis revealed adding-on was associated several factors including: post-operative thoracic and lumbar curve magnitude (p > 0.001), first erect (FE) end instrumented vertebra (EIV) angulation (p = 0.009) and EIV translation (p = 0.001), younger age (p = 0.027), Risser stage (p = 0.024), and a more proximal lowest instrumented vertebra (LIV) (p < 0.001). Multivariate CART analysis showed the chance of adding-on was more than 2 times greater (42 vs 16%) when the chosen LIV was translated more than 2.7 cm from the CSVL. When the LIV was within 2.7 cm, the post-op risk of adding-on was increased when the LIV was not perfectly leveled (> 0.5°).

Conclusion: In Lenke 1 and 2 AR curves, pre-operative LIV translation appears to be an independent risk factor for adding-on; and in those with < 2.7 cm of LIV translation, FE LIV angulation also seems to increase the risk of adding-on. These factors are relevant in determining appropriate LIV selection and aid in identifying patients at risk for developing adding-on.
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http://dx.doi.org/10.1007/s43390-021-00382-8DOI Listing
November 2021

Association Between Rotator Cuff Tears and Superior Migration of the Humeral Head: An MRI-Based Anatomic Study.

Orthop J Sports Med 2021 Jun 10;9(6):23259671211009846. Epub 2021 Jun 10.

Department of Orthopaedic Surgery, University of California, San Diego, San Diego, California, USA.

Background: Superior humeral migration has been established as a component of rotator cuff disease, as it disrupts normal glenohumeral kinematics. Decreased acromiohumeral interval (AHI) as measured on radiographs has been used to indicate rotator cuff tendinopathy. Currently, the data are mixed regarding the specific rotator cuff pathology that contributes the most to humeral head migration.

Purpose: To determine the relationship between severity of rotator cuff tears (RCTs) and AHI via a large sample of magnetic resonance imaging (MRI) shoulder examinations.

Study Design: Cohort study; Level of evidence, 3.

Methods: A search was performed for 3-T shoulder MRI performed in adults for any indication between January 2010 and June 2019 at a single institution. Three orthopaedic surgeons and 1 musculoskeletal radiologist measured AHI on 2 separate occasions for patients who met the inclusion criteria. Rotator cuff pathologies were recorded from imaging reports made by fellowship-trained musculoskeletal radiologists.

Results: A total of 257 patients (mean age, 52 years) met the inclusion criteria. Of these, 199 (77%) had at least 1 RCT, involving the supraspinatus in 174 (67.7%), infraspinatus in 119 (46.3%), subscapularis in 80 (31.1%), and teres minor in 3 (0.1%). Full-thickness tears of the supraspinatus, infraspinatus, or subscapularis tendon were associated with significantly decreased AHI (7.1, 5.3, and 6.8 mm, respectively) compared with other tear severities ( < .001). Having a larger number of RCTs was also associated with decreased AHI (ρ = -0.157; = .012). Isolated infraspinatus tears had the lowest AHI (7.7 mm), which was significantly lower than isolated supraspinatus tears (8.9 mm; = .047).

Conclusion: Although various types of RCTs have been associated with superior humeral head migration, this study demonstrated a significant correlation between a complete RCT and superior humeral migration. Tears of the infraspinatus tendon seemed to have the greatest effect on maintaining the native position of the humeral head. Further studies are needed to determine whether early repair of these tears can slow the progression of rotator cuff disease.
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http://dx.doi.org/10.1177/23259671211009846DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8202287PMC
June 2021

Intra-articular Morphine and Ropivacaine Injection Provides Efficacious Analgesia As Compared With Femoral Nerve Block in the First 24 Hours After ACL Reconstruction: Results From a Bone-Patellar Tendon-Bone Graft in an Adolescent Population.

Orthop J Sports Med 2021 Mar 5;9(3):2325967120985902. Epub 2021 Mar 5.

Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA.

Background: Opioid consumption and patient satisfaction are influenced by a surgeon's pain-management protocol as well as the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction are femoral nerve blockade and intra-articular injection; however, debate remains regarding the more efficacious methodology.

Hypothesis: We hypothesized that intra-articular injection with ropivacaine and morphine would be found to be as efficacious as a femoral nerve block for postoperative pain management in the first 24 hours after bone-patellar tendon-bone (BTB) ACL reconstruction.

Study Design: Cohort study; Level of evidence, 3.

Methods: Charts were retrospectively reviewed for BTB ACL reconstructions performed by a single pediatric orthopaedic surgeon from 2013 to 2019. Overall, 116 patients were identified: 58 received intra-articular injection, and 58 received single-shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MMEs) consumed were tabulated for each patient.

Results: Opioid use was 24.3 MMEs in patients treated with intra-articular injection versus 28.5 MMEs in those with peripheral block ( = .108). Consumption of MMEs was greater in the intra-articular group in the 0- to 4-hour period (7.1 vs 4.6 MMEs; = .008). There was significantly less MME consumption in patients receiving intra-articular injection versus peripheral block at 16 to 20 hours (3.2 vs 5.6 MMEs; = .01) and 20 to 24 hours (3.8 vs 6.5 MMEs; < .001). Mean pain scores were not significantly different over the 24-hour period (peripheral block, 2.7; intra-articular injection, 3.0; = .19).

Conclusion: Within the limitations of this study, we could identify no significant difference in MME consumption between the single-shot femoral nerve block group and intra-articular injection group in the first 24 hours postoperatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require fewer opioids 16 to 24 hours postoperatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in adolescent patients undergoing BTB ACL reconstruction.
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http://dx.doi.org/10.1177/2325967120985902DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940747PMC
March 2021

Clinical Outcomes, Survivorship, and Return to Sport After Arthroscopic Capsular Repair With Suture Anchors for Adolescent Multidirectional Shoulder Instability: Results at 6-Year Follow-up.

Orthop J Sports Med 2021 Feb 22;9(2):2325967121993879. Epub 2021 Feb 22.

Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA.

Background: Multidirectional shoulder instability (MDI) refractory to rehabilitation can be treated with arthroscopic capsulolabral reconstruction with suture anchors. To the best of our knowledge, no studies have reported on outcomes or examined the risk factors that contribute to poor outcomes in adolescent athletes.

Purpose: To identify risk factors for surgical failure by comparing anatomic, clinical, and demographic variables in adolescents who underwent intervention for MDI.

Study Design: Case series; Level of evidence, 4.

Methods: All patients 20 years or younger who underwent arthroscopic shoulder surgery at a single institution between January 2009 and April 2017 were evaluated. MDI was defined by positive drive-through sign on arthroscopy plus positive sulcus sign and/or multidirectional laxity on anterior and posterior drawer tests while under anesthesia. A 2-year minimum follow-up was required, but those whose treatment failed earlier were also included. Demographic characteristics and intraoperative findings were recorded, as were scores on the Single Assessment Numeric Evaluation (SANE), Pediatric and Adolescent Shoulder Survey (PASS), and short version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH).

Results: Overall, 42 adolescents (50 shoulders; 31 female, 19 male) were identified as having undergone surgical treatment for MDI with minimum 2-year follow-up or failure. The mean follow-up period was 6.3 years (range, 2.8-10.2 years). Surgical failure, defined as recurrence of subluxation and instability, was noted in 13 (26.0%) shoulders; all underwent reoperation at a mean of 1.9 years (range, 0.8-3.2 years). None of the anatomic, clinical, or demographic variables tested, or the presence of generalized ligamentous laxity, was associated with subjective outcomes or reoperation. Number of anchors used was not different between shoulders that failed and those that did not fail. Patients reported a mean SANE score of 83.3, PASS score of 85.0, and QuickDASH score of 6.8. Return to prior level of sport occurred in 56% of patients.

Conclusion: Adolescent MDI refractory to nonsurgical management appeared to have long-term outcomes after surgical intervention that were comparable with outcomes of adolescent patients with unidirectional instability. In patients who experienced failure of capsulorrhaphy, results showed that failure most likely occurred within 3 years of the index surgical treatment.
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http://dx.doi.org/10.1177/2325967121993879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903833PMC
February 2021

Classifying Ischial Tuberosity Avulsion Fractures by Ossification Stage and Tendon Attachment.

J Bone Joint Surg Am 2021 Jun;103(12):1083-1092

Division of Orthopaedic Surgery, Rady Children's Hospital-San Diego, San Diego, California.

Background: We propose a new classification system for ischial tuberosity fractures in adolescents that is based on the ossification pattern of the apophysis.

Methods: We performed a retrospective review of patients who were diagnosed with ischial tuberosity avulsion fractures at a single institution from 2008 to 2018. Skeletal maturity and fracture location, size, and displacement were recorded based on initial injury radiographs. The fractures were classified by location as being lateral (type 1) or complete (type 2). Pelvic computed tomography (CT) review demonstrated 5 stages of ossification. We then reviewed pelvic CT and magnetic resonance imaging scans to assess the tendinous insertions at the ischial tuberosity apophysis. Reliability analysis was performed.

Results: We identified 45 ischial tuberosity fractures. The mean patient age was 14.4 years (range, 10.3 to 18.0 years). Boys accounted for 82% of the cohort. Forty-seven percent of the fractures were classified as type 1, and 53% were classified as type 2. Type-1 fractures were associated with younger age (p = 0.001), lower Risser score (p = 0.002), lower modified Oxford score (p = 0.002), less displacement (p = 0.001), and smaller size (p < 0.001) when compared with type-2 fractures. Of the 45 patients, 18 had follow-up of >6 months, with 56% going on to nonunion. Nonunion was associated with greater displacement (p = 0.016) and size (p = 0.027). When comparing union rates by fracture type, 33% of type-1 fractures progressed to nonunion, while 78% percent of type-2 fractures progressed to nonunion; however, this difference was not significant (p = 0.153). A review of the advanced imaging indicated that type-1 fractures involved the semimembranosus and conjoined tendons, whereas type-2 fractures also involved the adductor magnus tendon.

Conclusions: We propose a new classification system based on the ossification pattern of the ischial tuberosity apophysis that reflects the skeletal maturity of the patient, the size and location of the fracture, and the amount of displacement, and likely predicts the probability of subsequent nonunion. The ischial tuberosity ossifies in a pattern similar to the iliac crest as described by Risser, and this pattern of ossification dictates the size of the ischial tuberosity avulsion fracture fragments and the involved tendons.
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http://dx.doi.org/10.2106/JBJS.20.01318DOI Listing
June 2021

Coronal Lateral Collateral Ligament Sign: A Novel Magnetic Resonance Imaging Sign for Identifying Anterior Cruciate Ligament-Deficient Knees in Adolescents and Summarizing the Extent of Anterior Tibial Translation and Femorotibial Internal Rotation.

Am J Sports Med 2021 03 22;49(4):928-934. Epub 2021 Feb 22.

Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA.

Background: Incompetence of the anterior cruciate ligament (ACL) confers knee laxity in the sagittal and axial planes that is measurable with clinical examination and diagnostic imaging.

Hypothesis: An ACL-deficient knee will produce a more vertical orientation of the lateral collateral ligament (LCL), allowing for the entire length of the LCL to be visualized on a single coronal slice (coronal LCL sign) on magnetic resonance imaging.

Study Design: Cohort study (diagnosis); Level of evidence, 3.

Methods: Charts were retrospectively reviewed from April 2009 to December 2017 for all patients treated with ACL reconstruction (constituting the ACL-deficient cohort). A control cohort was separately identified consisting of patients with a normal ACL and no pathology involving the collateral ligaments or posterior cruciate ligament. Patients were excluded for follow-up <2 years, incomplete imaging, and age >19 years. Tibial translation and femorotibial rotation were measured on magnetic resonance images, and posterior tibial slope was measured on a lateral radiograph of the knee. Imaging was reviewed for the presence of the coronal LCL sign.

Results: The 153 patients included in the ACL-deficient cohort had significantly greater displacement than the 70 control patients regarding anterior translation (5.8 vs 0.3 mm, respectively; < .001) and internal rotation (5.2° vs -2.4°, < .001). Posterior tibial slope was not significantly different. The coronal LCL sign was present in a greater percentage of ACL-deficient knees than intact ACL controls (68.6% vs 18.6%, < .001). The presence of the coronal LCL sign was associated with greater anterior tibial translation (7.2 vs 0.2 mm, < .001) and internal tibial rotation (7.5° vs -2.4°, = .074) but not posterior tibial slope (7.9° vs 7.9°, = .973) as compared with its absence. Multivariate analysis revealed that the coronal LCL sign was significantly associated with an ACL tear (odds ratio, 12.8; < .001).

Conclusion: Our study provides further evidence that there is significantly more anterior translation and internal rotation of the tibia in the ACL-deficient knee and proves our hypothesis that the coronal LCL sign correlates with the presence of an ACL tear. This coronal LCL sign may be of utility for identifying ACL tears and anticipating the extent of axial and sagittal deformity.
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http://dx.doi.org/10.1177/0363546521988938DOI Listing
March 2021

Predictive Value of the Magnetic Resonance Imaging-Based Coronal Lateral Collateral Ligament Sign on Adolescent Anterior Cruciate Ligament Reconstruction Graft Failure.

Am J Sports Med 2021 03 22;49(4):935-940. Epub 2021 Feb 22.

Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA.

Background: The coronal lateral collateral ligament (LCL) sign is the presence of the full length of the LCL visualized on a single coronal magnetic resonance imaging (MRI) slice at the posterolateral corner of the knee. The coronal LCL sign has been shown to be associated with elevated measures of anterior tibial translation and internal rotation in the setting of anterior cruciate ligament (ACL) tear.

Hypothesis: The coronal LCL sign (with greater anterior translation, internal rotation, and posterior slope of the tibia) will indicate a greater risk for graft failure after ACL reconstructive surgery.

Study Design: Cohort study; Level of evidence, 3.

Methods: Retrospective review was performed of adolescent patients with ACL reconstruction: a cohort without graft failure and a cohort with graft failure. MRI was utilized to measure tibial translation and femorotibial rotation and to identify the coronal LCL sign. The posterior tibial slope was measured on lateral radiographs. Patient-reported outcomes were collected.

Results: We identified 114 patients with no graft failure and 39 patients with graft failure who met all criteria, with a mean follow-up time of 3.5 years (range, 2-9.4 years). Anterior tibial translation was associated with anterolateral complex injury ( < .001) but not graft failure ( = .06). Internal tibial rotation was associated with anterolateral complex injury ( < .001) and graft failure ( = .042). Posterior tibial slope was associated with graft failure ( = .044). The coronal LCL sign was associated with anterolateral complex injury ( < .001) and graft failure ( = .013), with an odds ratio of 4.3 for graft failure (95% CI, 1.6-11.6; = .003). Subjective patient-reported outcomes and return to previous level of sport were not associated with failure. Comparison of MRI before and after ACL reconstruction in the graft failure cohort demonstrated a reduced value in internal rotation ( = .003) but no change in coronal LCL sign ( = .922).

Conclusion: Our study demonstrates that tibial internal rotation and posterior slope are independent predictors of ACL graft failure in adolescents. Although the value of internal rotation could be improved with ACL reconstruction, the presence of the coronal LCL sign persisted over time and was predictive of graft rupture (without the need to make measurements or memorize values of significant risk). Together, these factors indicate that greater initial knee deformity after initial ACL tear predicts greater risk for future graft failure.
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http://dx.doi.org/10.1177/0363546521988939DOI Listing
March 2021

Financial impact of electric scooters: a review of injuries over 27 months at an urban level 1 trauma center (cost of e-scooter injuries at an urban level 1 trauma center).

Trauma Surg Acute Care Open 2021 22;6(1):e000634. Epub 2021 Jan 22.

Department of Orthopaedic Surgery, University of California San Diego, La Jolla, California, USA.

Background: Electric scooters (e-scooters) have become a widespread method of transportation due to convenience and affordability. However, the financial impact of medical care for sustained injuries is currently unknown. The purpose of this study is to characterize total billing charges associated with medical care of e-scooter injuries.

Methods: A retrospective review of patients with e-scooter injuries presenting to the trauma bay, emergency department or outpatient clinics at an urban level 1 trauma center was conducted from November 2017 to March 2020. Demographic and clinical data were collected. Primary outcomes of interest were total billing charges and billing to insurance (hospital and professional). Multivariable models were used to identify preventable risk factors associated with higher total billing charges.

Results: A total of 63 patients were identified consisting of 42 (66.7%) males, average age 40.19 (SD 13.29) years and 3.2% rate of helmet use. Patients sustained orthopedic (29%, n=18), facial (48%, n=30) and cranial (23%, n=15) injuries. The average total billing charges for e-scooter clinical encounters was $95 710 (SD $138 215). Average billing to insurance was $86 376 (SD $125 438) for hospital charges and $9 334 (SD $14 711) for professional charges. There were no significant differences in charges between injury categories. On multivariable regression, modifiable risk factors independently associated with higher total billing charges included any intoxication prior to injury ($231 377 increase, p=0.02), intracranial bleeds ($75 528, p=0.04) and TBI ($360 898, p=0.006).

Discussion: Many patients sustain high-energy injuries during e-scooter accidents with significant medical and financial consequences. Further studies may continue expanding the financial impact of e-scooter injuries on both patients and the healthcare system.

Level Of Evidence: III.
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http://dx.doi.org/10.1136/tsaco-2020-000634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831709PMC
January 2021

Male With Leg Pain.

Ann Emerg Med 2021 02;77(2):e75-e76

Department of Pediatrics, University of California, San Diego, La Jolla, CA; Department of Pediatrics, Division of Orthopedic Surgery, University of California, San Diego School of Medicine, La Jolla, CA.

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http://dx.doi.org/10.1016/j.annemergmed.2020.07.016DOI Listing
February 2021

Identifying the axillary nerve during shoulder surgery: an anatomic study using advanced imaging.

JSES Int 2020 Dec 25;4(4):987-991. Epub 2020 Jul 25.

Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA.

Background: The axillary nerve (AXN) is one of the more commonly injured nerves during shoulder surgery. Prior anatomic studies of the AXN in adults were performed using cadaveric specimens with small sample sizes. Our research observes a larger cohort of magnetic resonance imaging (MRI) studies in order to gain a more representative sample of the course of the AXN and aid surgeons intraoperatively.

Methods: High-resolution 3T MRI studies performed at our institution from January 2010 to June 2019 were reviewed. Four blinded reviewers with musculoskeletal radiology or orthopedic surgery training measured the distance of the AXN to the surgical neck of the humerus (SNH), the lateral tip of the acromion (LTA), and the inferior glenoid rim (IGR). Intraclass correlation coefficient was calculated to assess reliability between reviewers. The nerve location was assessed relative to rotator cuff tear status.

Results: A total of 257 shoulder MRIs were included. Intraclass correlation coefficient was excellent at 0.80 for the SNH, 0.90 for the LTA, and 0.94 for the IGR. All intraobserver reliabilities were above 0.80. The mean distance from the AXN to SNH was 1.7 cm (range, 0.7-3.1 cm; interquartile range, 1.38-2.00) and that from the AXN to IGR was 1.6 cm (range, 0.6-2.6 cm; interquartile range, 1.33-1.88). The mean AXN to LTA distance was 7.1 cm, with a range of 5.2-9.0 cm across patient heights; there was a large effect size related to the LTA to AXN distance and patient height with a correlation of = 0.603 ( < .001). Rotator cuff pathology appears to affect nerve location by increasing the distance between the AXN and SNH ( = .027).

Discussion/conclusion: The AXN is vulnerable to injury during both open and arthroscopic shoulder procedures. This injury can be either a result of direct trauma to the nerve or secondary to traction placed on the nerve with reconstructive procedures that distalize the humerus. Our study demonstrates that the AXN can be found as little as 5.6 mm from the IGR and 6.9 mm from the SNH. In addition, we illustrate the relationship between patient height and the LTA to AXN distance and complete rotator cuff tears and the SNH to AXN distance. Our study is the first to demonstrate the nerve's proximity to important surgical landmarks of the shoulder using a large sample size of high-resolution images in living human shoulders.
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http://dx.doi.org/10.1016/j.jseint.2020.06.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7738427PMC
December 2020

Electric Scooter Orthopaedic Injury Demographics at an Urban Level I Trauma Center.

J Orthop Trauma 2020 11;34(11):e424-e429

Department of Orthopaedic Surgery, University of California, San Diego, CA.

Objectives: This study highlights demographics and orthopaedic injuries of electric scooter-related trauma that presented to our institution over a 27-month period.

Design: Retrospective review.

Setting: Urban Level 1 trauma center.

Patients: Patients presenting to the emergency department, trauma bay, or outpatient clinic after electric scooter injury were identified from November 2017 through January 2020 using ICD-10 diagnosis codes.

Main Outcomes: Patient charts were reviewed for demographics, injury characteristics, imaging, treatment, perioperative data, and Injury Severity Scores.

Results: Four hundred eighty-five patients presented during the study period. Of these, 44% had orthopaedic injuries, including 30% with pelvis or extremity fractures. There were 21 (10%) polytraumatized patients in the orthopaedic cohort. The age ranged from 16 to 79 years (average 36 years), with 58% men, and 18% were visitors from out of town. Of 49 patients requiring orthopaedic surgery, 8 underwent surgery on an urgent basis. The average Injury Severity Score for orthopaedic patients was 8.4 with a median of 5.0 for nonoperative injuries versus a significantly higher median of 16.0 for operative injuries. Twenty-nine percent of patients were intoxicated and only 2% wore a helmet.

Conclusions: Electric scooter injuries are increasing, and many patients sustain high-energy injuries. As electric scooter use continues to increase, the prevalence of orthopaedic injuries is also likely to rise. Further studies are needed to fully understand the impact scooter-related injuries have on individual patients and the health care system.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001803DOI Listing
November 2020

Greater trochanteric fractures with lntertrochanteric extension identified on MRI: What is the rate of displacement when treated nonoperatively?

Injury 2020 Nov 6;51(11):2648-2651. Epub 2020 Aug 6.

Department of Radiology, University of California, San Diego, Unites States.

Introduction: . Despite the ability of MRI to identify intertrochanteric (IT) fracture extension for greater trochanteric (GT) fractures, there is no consensus about which fractures require operative intervention. Previous studies have suggested GT fractures with >50% extension into the IT region might benefit from fixation. We sought to evaluate the rate at which GT fractures with IT extension displaced, requiring operative fixation.

Patients And Methods: . This is a Retrospective Chart Review performed at a Level 1 Trauma Center. Patients included all nonoperatively treated GT fractures (OTA/AO 31A1.1) with IT extension identified on MRI between 2010 and 2017 at our institution. Patients lost to follow up prior to radiographic evidence of healing or fracture displacement were excluded. Patient charts and imaging were reviewed for demographic data, treatment plan, percent extension into the IT region (as determined from coronal MRI images), and clinical and radiographic evidence of fracture healing. Percent extension into the IT region was measured using coronal T1-weighted MRI images. The primary outcome measures were fracture displacement requiring operation and nonunion.

Results: . Seventeen patients met initial inclusion criteria, with two subsequently excluded due to no radiographic follow-up. Of the 15 patients, zero had displacement of their IT fracture. None required operative intervention. All 15 patients healed their fractures. Fourteen of 15 (93%) had IT extension of 50% or less across the IT region. One patient had initial IT extension of 60%, this patient also healed without displacement.

Discussion: . Incomplete intertrochanteric femur fractures are a relatively newer diagnosis that have become more prevalent with the increased usage and availability of MRI. Currently, there is no consensus on the ideal treatment of these injuries. To our knowledge, this is the largest series of its kind to help guide treatment of these GT fractures with IT extension.

Conclusions: . Fractures with less than 50% extension into the IT region have a low likelihood of future displacement and high union rates when treated nonoperatively.

Level Of Evidence: . IV.
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http://dx.doi.org/10.1016/j.injury.2020.08.002DOI Listing
November 2020

Antibiotic-Impregnated Intramedullary Cement Nail-Induced Acute Generalized Exanthematous Pustulosis and Septic Shock: A Case Report.

JBJS Case Connect 2020 Apr-Jun;10(2):e0441

1Department of Orthopedic Surgery, University of California-San Diego, San Diego, California.

Case: A 28-year-old woman with an infected proximal femur nonunion was treated with an antibiotic-coated intramedullary nail. Shortly after discharge, the patient presented to the emergency department and was readmitted with a morbilliform rash sparing the left lower extremity. She became hemodynamically unstable, despite cessation of intravenous antibiotics, requiring transfer to the intensive care unit and urgent removal of her antibiotic nail. She improved after surgery, and biopsy results from the rash confirmed acute generalized examthematous pustulosis.

Conclusion: Acute generalized exanthematous pustulosis is a rare, dermatologic crisis that can be precipitated by antibiotics, even in the form of antibiotic cement.
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http://dx.doi.org/10.2106/JBJS.CC.19.00441DOI Listing
February 2021

BRAF and epithelial-mesenchymal transition in papillary thyroid carcinoma - challenging the roles of Snail and E-Cadherin?

Am J Transl Res 2016 15;8(11):5076-5086. Epub 2016 Nov 15.

ENT Specialists, Inc. 825 Washington St # 310, Norwood, MA 02062, UK.

Objective: In papillary thyroid carcinoma (PTC), while the role of BRAF is well established, the contribution of BRAF to epithelial-mesenchymal transition is not.

Study Design/setting: To elucidate the relationship between BRAF, surrogates of epithelial-mesenchymal transition (Snail, E-cadherin) and established histopathologic prognosticators in papillary thyroid carcinoma.

Subjects/methods: In this IRB approved cross-sectional study, 50 cases of archived annotated PTC samples were retrieved and immunohistochemically stained for Snail and E-cadherin protein. A semi-quantitative scoring system (incorporating proportion and intensity) was utilized.

Results: Snail and E-cadherin expression were noted in 44% and 84% of BRAF mutant and, in 29% and 95% of BRAFWT samples, respectively. No statistically significant correlations were noted between Snail, E-cadherin and histopathologic prognosticators. However, a trend was noted between Snail expression and tumor size <5 cm (P=0.07). Statistically significant differences between BRAF mutant and BRAFWT samples were noted in the following groups: conventional (68% vs. 5%) and tall cell (32% vs. 0%) histopathologic variants, extrathyroidal extension (32% vs. 5%), infiltrative growth pattern (80% vs. 48%), presence of desmoplasia (72% vs. 29%), psammona bodies (48% vs. 10%), and cystic change (32% vs. 5%). Among follicular variant of papillary thyroid carcinoma compared to BRAF mutant samples, BRAFWT samples were more commonly of the encapsulated variety (52% vs. 4%), and microcarcinomas (29% vs. 0%) (P<0.001 and =0.007, respectively).

Conclusion: Our findings, supporting the utility of BRAF as a putative therapeutic target in PTC, suggest that the interaction between BRAF and epithelial-mesenchymal transition in papillary thyroid carcinoma is not through induction of the Snail/E-cadherin pathway.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5126351PMC
November 2016

BRAF and Epithelial-Mesenchymal Transition: Lessons From Papillary Thyroid Carcinoma and Primary Cutaneous Melanoma.

Adv Anat Pathol 2016 Jul;23(4):244-71

*University of Florida College of Medicine, Gainesville, FL †Department of Otolaryngology, Tufts Medical center, Boston, MA ‡Dermatopathology Section, Department of Pathology and Laboratory Medicine, VA Consolidated Laboratories, West Roxbury, MA.

The increased prevalence of BRAF mutations in thyroid carcinoma and primary cutaneous melanoma (PCM) hint that dysregulation of BRAF might contribute to the noted association between PCM and thyroid carcinoma. A recent study evaluating the rate of BRAFV600E mutations among patients who had been diagnosed with primary papillary thyroid carcinoma (PTC) and PCM showed that patients with either PCM or PTC were at an increased risk of developing the other as a second primary malignant neoplasm. Furthermore, the authors noted that samples from patients suffering from both malignancies exhibited a higher rate of incidence of the BRAFV600E mutation, compared with patients not suffering from both malignancies. These studies support the hypothesis that the pathogenesis of these 2 malignancies might share a conserved molecular pattern associated with dysregulation of the BRAF protein. One mechanism through which BRAF might contribute to PCM and thyroid carcinoma progression is through induction of epithelial-mesenchymal transition (EMT). Specifically, the Snail/E-cadherin axis has been demonstrated as a pathway dysregulated by BRAF, leading to EMT in both malignancies. Our analysis focuses on the results of these recent investigations, and through a review of select molecules relevant to EMT, looks to provide a context by which to better understand the relevance and role of stromal-parenchymal signaling and the BRAF mutation in the pathogenesis of PTC and PCM.
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http://dx.doi.org/10.1097/PAP.0000000000000113DOI Listing
July 2016

BRAF and epithelial-mesenchymal transition in primary cutaneous melanoma: a role for Snail and E-cadherin?

Hum Pathol 2016 06 1;52:19-27. Epub 2016 Feb 1.

Dermatopathology Section, VA Consolidated Laboratories, Department of Pathology and Laboratory Medicine (113), West Roxbury, MA 02132. Electronic address:

In vitro studies in melanoma indicate that up-regulation of the transcriptional repressor Snail occurs with a concomitant decrease of its target E-cadherin, both hallmarks of epithelial-mesenchymal transition-an association not established in vivo. We sought to elucidate the relationship between BRAF, Snail, E-cadherin, and established histopathologic prognosticators in primary cutaneous melanoma. Archived annotated samples with a diagnosis of primary cutaneous melanoma were retrieved (n = 68 cases; 34 BRAF mutant and 34 BRAF wild type) and immunohistochemically stained for Snail and E-cadherin protein expression. A semiquantitative scoring system was used. Multivariate logistic analysis was used to control confounders of BRAF. Snail expression was significantly associated only with ulceration (42% versus 13%; P = .02). E-cadherin expression was present in 26% of BRAF mutant and 71% of BRAF wild-type cases (P = .0003). Loss of E-cadherin expression was associated with female sex (60% versus 34%; P = .05), BRAF mutation (74% versus 29%; P = .0003), thickness greater than or equal to 1 mm (68% versus 32%; P = .004), mitosis (63% versus 25%; P = .007), and ulceration (75% versus 44%; P = .05). BRAF mutation was associated with male sex (60% versus 30%; P = .02), Breslow thickness (P = .007), thickness greater than or equal to 1 mm (68% versus 29%; P = .002), and ulceration (75% versus 42%; P = .02). Snail expression did not correlate with loss of E-cadherin expression (47% versus 53%; P = .79). After controlling for potential confounding, BRAF mutation was associated with loss of E-cadherin (adjusted odds ratio, 8.332; 95% confidence interval, 2.257-30.757; P = .0015) and Breslow thickness greater than 1 mm (adjusted odds ratio, 7.360; 95% confidence interval, 1.534-35.318; P = .0126). Our findings, indicating that mutant BRAF represses E-cadherin expression, implicating a catalytic role for BRAF in epithelial-mesenchymal transition.
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http://dx.doi.org/10.1016/j.humpath.2015.12.030DOI Listing
June 2016

Perineural invasion in cutaneous squamous cell carcinoma: role of immunohistochemistry, anatomical site, and the high-affinity nerve growth factor receptor TrkA.

Hum Pathol 2015 Aug 22;46(8):1209-16. Epub 2015 May 22.

Department of Pathology and Laboratory Medicine (113), VA Medical Center, 1400 VFW PKWY, MA 02132 USA, USA. Electronic address:

Perineural invasion (PNI) has been recently added to the American Joint Committee on Cancer cutaneous squamous cell carcinoma (cSCC) staging criteria as a high-risk tumor characteristic and is purportedly more common in cSCCs of the head and neck (H&N). Expression of the high-affinity nerve growth factor receptor TrkA has been shown to be associated with PNI in noncutaneous neoplasms. Given this, we sought to ascertain the incidence of PNI in cSCCs using double immunostaining (DIS) and to investigate PNI's relationship with TrkA and established histopathologic prognosticators. Fifty-seven cSCCs from the H&N and 53 from non-H&N areas were immunohistochemically analyzed for PNI (DIS with S-100 and p63) and TrkA expression. Comparing H&N versus non-H&N areas, using hematoxylin and eosin, PNI was detected in 11% versus 6% cases, respectively, and, using DIS, in 23% versus 15%, respectively, with significant disagreement between both methods (κ = 0.47; P = .002). There was a 2.33-fold increase in PNI detection with DIS compared to hematoxylin and eosin (95% confidence interval, 1.12-4.87; P = .02). TrkA expression was 1.96 times more frequently observed in cSCCs from the H&N compared to those from non-H&N areas (P = .01). Regardless of site, TrkA expression was associated with decreased degree of differentiation (odds ratio, 6.46; P = .0006) and high-risk morphologic variants (odds ratio, 6.53; P = .002) but not significantly associated with PNI (P = .33). Increased PNI detection with DIS underscores the adjunctive utility of immunohistochemistry in microstaging. Significantly more common TrkA expression in cSCCs of the H&N argues in favor of heterogeneity among SCCs from different anatomical sites.
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http://dx.doi.org/10.1016/j.humpath.2015.05.003DOI Listing
August 2015

Neurotrophin receptors and perineural invasion in desmoplastic melanoma.

J Am Acad Dermatol 2015 May 7;72(5):851-8. Epub 2015 Mar 7.

Dermatopathology, Section, Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts. Electronic address:

Background: Perineural invasion (PNI) in desmoplastic melanoma is associated with increased local recurrence and reduced disease-free survival. The biological mechanisms underlying PNI remain unclear although several lines of evidence implicate neurotrophins and their receptors.

Objectives: We investigated the expression of p75NGFR and TrkA, and the presence of functional RET polymorphism (RETp) as they relate to PNI in desmoplastic melanoma.

Methods: In all, 43 cases of desmoplastic melanoma were immunohistochemically evaluated for TrkA and p75NGFR expression and RETp was detected by direct DNA sequencing.

Results: PNI was present in 67% of cases. On univariate analysis, p75NGFR was associated with PNI (expression detected in 79% of PNI-positive cases compared with 36% of PNI-negative cases, P = .005), increased Breslow depth (P = .007), and greater Clark level (P = .01). RETp was noted in 28% of cases but was not significantly associated with PNI (P = .27) or other histopathologic variables. TrkA expression was absent in all cases. PNI was associated with increased Breslow depth and Clark level (P = .01 and P = .009, respectively). Controlling for the association between p75NGFR and depth, p75NGFR remained associated with an increased propensity for PNI (odds ratio 4.68, P = .04).

Limitations: The sample size was limited.

Conclusion: In desmoplastic melanoma, p75NGFR expression is significantly associated with PNI and a more locally aggressive phenotype.
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http://dx.doi.org/10.1016/j.jaad.2015.01.026DOI Listing
May 2015

Correlation of chemokine receptor CXCR4 mRNA in primary cutaneous melanoma with established histopathologic prognosticators and the BRAF status.

Melanoma Res 2014 Dec;24(6):621-5

aDivision of Graduate Medical Sciences bSchool of Public Health cBoston University School of Medicine dDepartment of Pathology eDepartment of Dermatology, Dermatopathology Section, Boston University School of Medicine, Boston, Massachusetts, USA.

Dysregulation of the chemokine receptor CXCR4 is relevant in melanoma progression, and the CXCR4/CXCL12 axis has been shown to activate cell cycle progression and malignant cell migration through stimulation of the mitogen-activated protein kinase pathway. Studies ascertaining the potential utility of CXCR4 mRNA as a prognosticator in melanoma have focused mainly on metastatic melanoma with conflicting results. In the light of this, we sought to explore the potential relationship between CXCR4 mRNA expression with established histopathologic prognosticators and BRAF status in melanoma. Archived consecutive samples (n=107) of primary cutaneous melanoma were retrieved and assessed for the following: CXCR4 mRNA (semiquantitative RT-PCR) and BRAF exon 15 status (DNA Sanger sequencing). Statistical analyses included correlation between CXCR4 mRNA levels and established histopathologic prognosticators as well as the BRAF status using univariate and multiple linear methods. Multivariable analyses revealed a significant correlation between elevated CXCR4 mRNA (low ΔCt value) and the presence of BRAF mutation (P=0.02). Absence of a brisk host response was associated with elevated CXCR4 mRNA expression (P=0.04). CXCR4 mRNA was significantly lower in AJCC stage 2 compared with stage 1 after controlling for significant clinical prognosticators (P=0.02). The association between elevated CXCR4 mRNA and absence of a brisk host response suggests that CXCR4 may be involved in regulation of the host immune response in melanoma and is a molecule of potential utility as a biomarker for recruiting melanoma patients for immunotherapy. Higher CXCR4 mRNA in patients with a BRAF mutation suggests its utility as a putative therapeutic target.
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http://dx.doi.org/10.1097/CMR.0000000000000120DOI Listing
December 2014

Protein expression of the chemokine receptor CXCR4 and its ligand CXCL12 in primary cutaneous melanoma--biomarkers of potential utility?

Hum Pathol 2014 Oct 2;45(10):2094-100. Epub 2014 Jul 2.

Dermatopathology section, Department of Dermatology, Boston University School of Medicine, Boston, MA 02118. Electronic address:

Dysregulation of the CXCR4/CXCL12 axis, relevant in melanoma progression, activates cell cycle progression and migration via stimulation of the MAPK pathway. We sought to ascertain the cooperativity of the CXCR4/CXCL12 axis with established prognosticators and BRAF status in melanoma. Samples (n = 107) of primary cutaneous melanoma were assessed for protein expression of CXCR4 and CXCL12, and molecular analyses were performed to ascertain BRAF status. Univariate analyses of CXCR4 protein showed that the proportion of CXCR4 positives was greater in melanomas with absence of mitoses (P < .0001), absence of ulceration (P = .0008), and absence of regression (P = .02). Patients presenting at shallower stages (American Joint Committee on Cancer [AJCC] 1-2) exhibited a larger proportion of CXCR4 positives (76.9%, P < .0001 and 69.0%, P = .008), whereas those at deeper stages (AJCC 3-4) exhibited a larger proportion of negatives (75.0%, P = .004 and 66.7%, P = .22). In a multivariate analysis, lower odds of CXCR4 protein expression were associated with AJCC stage 3 (odds ratio [OR]=0.16, P = .01), AJCC stage 4 (OR=0.17, P = .04), and mitoses (OR=0.21, P = .01). Univariate analyses of CXCL12 protein showed that the proportion of CXCL12 negatives was significantly smaller in melanomas with depth of at least 1 mm, absence of ulceration, and absence of vascular invasion (P < .0001 for all). CXCR4 and CXCL12 appear to be biomarkers associated with established prognosticators of good and poor clinical outcome, respectively, in primary cutaneous melanoma. A BRAF mutation does not appear to be associated with CXCR4/CXCL12 axis upregulation in primary cutaneous melanoma.
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http://dx.doi.org/10.1016/j.humpath.2014.06.018DOI Listing
October 2014

Trends in psychostimulant and antidepressant use by children in 2 Canadian provinces.

Can J Psychiatry 2008 Mar;53(3):152-9

Faculty of Pharmacy, University of Manitoba, Winnipeg, Manitoba.

Objective: We used population-based administrative prescription medication data to examine regional differences in psychostimulant and antidepressant (AD) use among children from 2 Canadian provinces: British Columbia (BC) and Manitoba (MB).

Method: Using 1997 to 2003 prescription data, annual rates of psychostimulant and AD use were determined for children aged 19 years and under in both provinces. Further comparisons of rates were made according to sex, age group, and specific classes of dispensed medications.

Results: During 1997 to 2003, psychostimulant use rose by 44.9% in MB and 13.3% in BC. Among male children, psychostimulant use increased by 40.2% in MB, compared with an increase of only 8.6% in BC. AD utilization was similar between provinces, with increases of 80% and 75% in MB and BC, respectively. In both provinces, AD use was highest among older children.

Conclusions: Our observations of regional variation in psychotropic medication use potentially reflect provincial differences in drug benefit policies, disease prevalence, and (or) physician diagnosis and treatment.
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http://dx.doi.org/10.1177/070674370805300305DOI Listing
March 2008
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