Publications by authors named "David Beaton Comulada"

11 Publications

  • Page 1 of 1

Musculoskeletal Manifestations of Child Abuse: Analysis at a Level 2 Trauma Center in Puerto Rico.

P R Health Sci J 2020 12;39(4):283-287

Department of Orthopaedic Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR.

Objective: To describe the epidemiological manifestations and assess major risk factors in children under the age of three years presenting with non-accidental injury (NAI) fractures in a level two trauma center in Puerto Rico.

Methods: An IRB approved retrospective descriptive study was performed by reviewing case records of 75 patients who presented with a NAI fracture at the Pediatric University Hospital of the Puerto Rico Medical Center. The study time period was from October 1996 to October 2014. The inclusion criteria for our population consisted of: (1) patients between the ages of zero to three years, (2) suffered a long bone fracture, and (3) had a history of suspected child abuse at our academic institution. The exclusion criteria were: (1) patients older than three years, (2) no history of NAI, or (3) had a congenital bone disorder.

Results: A total of 117 long bone fractures were observed in our population. Similar distribution was seen between sex,, with 52% being male and 48% being female. The mean age was 10.8 months. The group with the highest frequency of NAI fractures were children under the age of one year (57.3 %). The most commonly involved fractured bone for all age groups was the femur (48.0 %). No statistical significance was observed when comparing sex, age, associated injuries or multiple fractures.

Conclusion: Children younger than one year of age who present with long bone fracture, multiple fractures, low household income and parental unemployment are associated with an increased risk of NAI fractures.
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December 2020

Bilateral Posterior-Stabilized Total Knee Arthroplasty in a Patient With Osteopetrosis and Literature Review.

Arthroplast Today 2020 Dec 1;6(4):866-871. Epub 2020 Nov 1.

Department of Orthopaedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA.

We present a case report of a patient with osteopetrosis and refractory bilateral knees osteoarthritis who underwent bilateral total knee arthroplasties (TKAs). After conservative management has failed, surgical treatment with arthroplasty is an excellent alternative with satisfactory outcomes. TKA in patients with osteopetrosis has only been described in 6 other case studies, none of which underwent bilateral TKA. To perform this procedure, additional attention should be directed toward the presurgical planning because of the amplified difficulty of the procedure and the altered bone biology that increases the risks of intraoperative fractures and markedly extends the time of surgery. This report describes a case of osteopetrosis with refractory osteoarthritis managed with bilateral TKA, the surgical technique and special considerations, complications, and future recommendations.
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http://dx.doi.org/10.1016/j.artd.2020.09.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7606532PMC
December 2020

Anterior tibialis artery pseudoaneurysm after minimally invasive plate osteosynthesis in the proximal tibia: a case report.

J Surg Case Rep 2020 Aug 26;2020(8):rjaa168. Epub 2020 Aug 26.

Orthopaedic Surgery Department, University of Puerto Rico Medical Sciences Campus, San Juan, PR, USA.

Tibial plateau fractures are common fractures associated with high-energy trauma. The treatment of these fractures remains a challenge today. Recent management of fractures has moved from open surgery toward minimally invasive surgery to reduce complications and improve functional outcomes. Nevertheless, such a minimalistic approach makes visualization of neurovascular structures difficult, placing them at risk. We report the case of a 39-year-old male who developed a pseudoaneurysm of the anterior tibial artery following minimally invasive plate osteosynthesis of the right proximal tibia. Diagnosis was made through noninvasive duplex ultrasound and was referred to endovascular service. Understanding of the anatomy of the surgical site is vital to minimize complications. In addition, proper postsurgical patient evaluation is important to monitor the insurgence of such complications.
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http://dx.doi.org/10.1093/jscr/rjaa168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449390PMC
August 2020

Hindfoot Fusion Nail with Adjuvant Hybrid External Fixation used as Limb-Salvage Procedure after Failed Open Reduction Internal Fixation of Ankle Fracture in a Charcot Joint: A Case Report.

P R Health Sci J 2018 12;37(4):235-238

Department of Orthopedic Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR.

The failure of the internal fixation of an ankle fracture due to Charcot joint/ neuroarthropathy is rare; such occurred in the case of a 52-year-old woman with uncontrolled diabetes who sustained a right ankle fracture after falling from standing height. The patient was treated with the internal fixation of both malleoli, which procedure failed as the patient progressed, until she eventually was diagnosed with Charcot arthropathy. The post operative images were reviewed and showed a catastrophic fixation failure with a diagnosis of Charcot neuroarthropathy. At that point, we decided to treat the problem presented with salvage arthrodesis, combining hindfoot fusion nail with adjuvant external fixation. This treatment was selected to augment stability and achieve stable fixation. The post-operative visits showed wound healing without complications and painless weight bearing. The follow-up radiographs showed tibiotalar fusion with painless union of the subtalar joint at 48 weeks.
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December 2018

Total knee arthroplasty in patients with multiple hereditary exostoses.

Arthroplast Today 2018 Sep 7;4(3):325-329. Epub 2018 May 7.

Department of Orthopaedic Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico.

We present a case report of a patient with severe valgus deformity of the right knee due to multiple hereditary exostoses (MHEs) treated with total knee arthroplasty (TKA). The surgical management of MHE affecting the knee encompasses exostoses resection, joint deformity rectification, and limb-length discrepancy alignment. On rare occasions, distraction osteogenesis and TKA have been used to correct valgus deformities of the knee. TKA in MHE patients with knee involvement has only been described in 6 cases. Several considerations, such as extensive knowledge of frequently occurring skeletal aberrations, are required to successfully correct the deformities associated with MHE via TKA. This report describes a case of severe valgus knee deformity with a rotational component in MHE managed with TKA, the surgical technique, and future recommendations.
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http://dx.doi.org/10.1016/j.artd.2017.11.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6123178PMC
September 2018

Bilateral Tibial Fibrous Dysplasia in a Pediatric Patient treated with Intramedullary Nailing.

P R Health Sci J 2018 03;37(1):58-61

Department of Orthopedic Surgery, School of Medicine, University of Puerto Rico, Medical Sciences Campus, San Juan, PR.

Fibrous dysplasia is a benign developmental disorder of bone in which fibrous connective tissue containing abnormal bone with irregular trabeculae replaces normal cancellous bone. It may affect 1 (monostotic) or multiple bones (polyostotic). Polyostotic disease is the less common of the 2, occurring in only 20 to 25% of fibrous dysplasia patients and tending to affect those who are younger than 10 years of age; patients having this form tend to experience bone enlargement beyond normal skeletal maturation, which can cause pain, progressive damage, and increased risk of pathological fracture. There are limited reports of bilateral involvement in fibrous dysplasia, with said involvement presenting most frequently in early childhood. We describe the rare case of an adolescent presenting with bilateral fibrous dysplasia in the tibial diaphysis (in the exact same location) that was successfully treated with bilateral intramedullary nailing of both tibias.
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March 2018

Clinical Considerations for the Use Lower Extremity Arthroplasty in the Elderly.

Phys Med Rehabil Clin N Am 2017 11 25;28(4):795-810. Epub 2017 Aug 25.

Department of Orthopaedic Surgery, School of Medicine, University of Puerto Rico, University of Puerto Rico Medical Sciences Campus, PO Box 365067, San Juan, PR 00936-5067, USA.

There is an increase in the aging population that has led to a surge of reported cases of osteoarthritis and a greater demand for lower extremity arthroplasty. This article aims to review the current treatment options and expectations when considering lower extremity arthroplasty in the elderly patient with an emphasis on the following subjects: (1) updated clinical guidelines for the management of osteoarthritis in the lower extremity, (2) comorbidities and risk factors in the surgical patient, (3) preoperative evaluation and optimization of the surgical patient, (4) surgical approach and implant selection, and (5) rehabilitation and life after lower extremity arthroplasty.
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http://dx.doi.org/10.1016/j.pmr.2017.06.011DOI Listing
November 2017

The Use of Bone Morphogenetic Protein in Spinal Transforaminal Lumbar Interbody Fusion: Our Experience.

P R Health Sci J 2017 09;36(3):173-178

VA Caribbean Healthcare System (VACHS), Pharmacy Service, San Juan, Puerto Rico.

Objective: Since its introduction and FDA approval, rhBMP-2 has been adopted by spine surgeons as a substitute for ICBG in numerous spinal fusion techniques. As broad clinical use increased, reports on potential complications associated with rhBMP-2 also increased. We provide our experience with TLIF using rhBMP-2 or ICBG in an entirely Hispanic population.

Methods: This was a 2-year retrospective study of 67 patients, with 26 in the rhBMP-2 group and 41 in the ICBG group, who underwent TLIF. Pertinent information was obtained through review of the medical records documenting complications, intraoperative times, and EBL, among other things.

Results: There were 28 post-operative complications with 15 (53.6%) in the ICBG group and 13 (46.4%) in the rhBMP-2 group. The average EBL was 572.3 mL (SD: 411.8) in the ICBG group and 397.9 mL (SD: 312.2) in the rhBMP-2 group. The average intraoperative time was 243.1 minutes (SD: 79.5) in the ICBG group and 226.5 minutes (SD: 64.7) in the rhBMP-2 group. Fifty-two patients underwent open TLIF and 15 patients underwent MI TLIF. The average EBL was 571.2 mL (SD: 375.3) in the open TLIF group and 228.3 mL (SD: 299.3) in the MI-TLIF group. The average intraoperative time was 241.0 minutes (SD: 76.0) for patients in the open TLIF group and 218.8 minutes (SD: 65.0) for those in the MI-TLIF group. There were no new cancer events at any of the 2-year follow-up visits.

Results: Our results suggest that the safety profile of rhBMP-2 may be inferior to that of ICBG, rejecting the possibility of ICBG being replaced by rhBMP-2 as the gold standard for spinal fusion.
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September 2017

Radial Head Ingrowth Anatomic Implant Versus Smooth Stem Monoblock Implant in Acute Terrible Triad Injury: A Prospective Comparative Study.

J Orthop Trauma 2017 Sep;31(9):503-509

*Department of Orthopaedic Surgery, University of Puerto Rico School of Medicine, San Juan, PR; and †School of Public Health, University of Puerto Rico School of Medicine, San Juan, PR.

Objective: This study aimed to compare clinical outcomes and radiographic findings between patients who received 2 different implants (smooth-stemmed modular implant or an anatomic press-fit implant) on patients with acute terrible triad injuries.

Design: Prospective cohort.

Setting: Level II Trauma center, University hospital.

Patients/participants: Thirty-four patients with an isolated terrible triad injury were divided into 2 study groups (n = 17 each) with different sets of radial head implants and followed for 2 years. A total of 14 patients in each group (n = 28) completed the study.

Intervention: Group 1 received a smooth-stemmed round modular monopolar implant. Group 2 received an in-growth modular monopolar press-fit anatomic implant.

Main Outcome Measurements: Clinical outcomes were evaluated using the Visual Analog Scale, Mayo Index, and Disabilities of the Arm, Shoulder, and Hand (DASH) survey. Radiographs were evaluated for ectopic bone formation and loosening.

Results: No difference in clinical outcome when comparing range of motion and functionally scores between groups. Ectopic bone formation occurred equally with implants. Bone formation at the proximal radius under the implant occurred more in group 1 (85.7%), (P = 0.046). Five press-fit stems had radiolucent lines at 2-year follow-up. Two were removed because of symptomatic loosening.

Conclusions: Short-term outcomes for both implants showed to be equally effective treatment options. The in vitro biomechanical advantages of anatomic implants do not translate into short-term improved outcomes. Symptomatic aseptic loosening in anatomic implants is common. Bone formation at the proximal radial neck was observed more with smooth-stemmed implants; further studies should assess this findings and clinical implication.

Level Of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000885DOI Listing
September 2017

Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?

J Am Acad Orthop Surg 2017 Mar;25(3):230-238

From the Department of Orthopaedic Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico.

Background: Open tibial shaft fractures require emergent care. Treatment with intravenous antibiotics and fracture débridement within 6 to 24 hours is recommended. Few studies have examined outcomes when surgical treatment is performed >24 hours after occurrence of the fracture.

Methods: This retrospective study included 227 patients aged ≥18 years with isolated open tibial shaft fractures in whom the time to initial débridement was >24 hours. The statistical analysis was based on time from injury to surgical débridement, Gustilo-Anderson classification, method of fixation, union status, and infection status.

Results: Fractures débrided within 24 to 48 hours and 48 to 96 hours after injury did not show a statistically significant difference in terms of infection rates (P = 0.984). External fixation showed significantly greater infection rates (P = 0.044) and nonunion rates (P = 0.001) compared with intramedullary nailing.

Conclusion: Open tibial shaft fractures should be débrided within 24 hours after injury. Our data indicate that after the 24-hour period and up to 4 days, the risk of infection remains relatively constant independent of the time to débridement. Patients treated with external fixation had more complications than did patients treated with other methods of fixation. Primary reamed intramedullary nailing appears to be a reasonable option for the management of Gustilo-Anderson types 1 and 2 open tibial shaft fractures.

Level Of Evidence: Level III retrospective study.
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http://dx.doi.org/10.5435/JAAOS-D-16-00127DOI Listing
March 2017

Acute Shortening and re-lengthening in the management of open tibia fractures with severe bone of 14 CMS or more and extensive soft tissue loss.

Bol Asoc Med P R 2016 ;108(1):91-94

Introduction: A traumatic event to the tibia with more than 14 cm of bone and soft tissue loss represents a challenge to most orthopedic surgeons and is considered a limb-threatening condition. Few solutions are available in such clinical situations and among them is the acute shortening and re-lengthening of bone and soft tissue.

Materials And Methods: Our study presents the management of 7 patients with grade III B open fractures (according to the Gustillo-Anderson classification) of the tibia who underwent resection of all the devitalized tissues, acute limb shortening to close the defect, application of an external fixator, and metaphyseal osteotomy for re-lengthening. The patient outcomes were based on different parameters using the evaluation system established by Paley et al.

Results: Results acquired during the study show an average bone loss of 19cm (with a minimum of 14 cm and a maximum of 31.50cm). The average time to full recovery of all patients was 19 months with a minimum of 14 months and a max of 34 months. Patient presented with excellent bony union and none existent or small refractory leg length discrepancy and did not require bone grafts or free flaps. Complications that the patients had were contractures, which required secondary procedures such as Achilles tendon re-lengthening and recurrent infections.

Discussion: Overall patients had excellent bone union and were able to perform activities of their daily living. The Ilizarov technique of compression-dis- traction osteogenesis is an elegant treatment option that should be considered in patients suffering such traumatic events providing excellent bony union and good functional outcomes for the patient.
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December 2017
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