Tripler Army Medical Center

Background Opioid-induced movement disorders (OIMD) are a rare cause of dystonia in the perioperative setting. Here we present a case of OIMD, responsive to naloxone, immediately after cesarean delivery. Objective(s): The purpose of this report is to describe the critical parts of our workup that helped determine the etiology of this patient’s new movement disorder. Study Design Case report of a single patient seen at Tripler Army Medical Center. Case Summary (Results): A 34-year-old G2P0 at 37+6 days’ gestation with preeclampsia with severe features was delivered of a live female, vigorous infant via cesarean section due to arrest of decent. The patient’s pain was managed with fentanyl-bupivacaine via epidural catheter, IV fentanyl, and IV morphine. At the time of skin closure, the patient developed episodic, dystonic neck and upper extremity movements, and confusion. She remained hemodynamically stable and responsive. The patient’s symptoms resolved with IV Naloxone, with no recurrence of these episodes in the post-partum period. Conclusion(s): To the best of our knowledge, this is the first case of OIMD in a peripartum patient. The unique physiologic conditions of pregnancy can contribute to development of movement disorders. OIMDs, although rare, are an important etiology to consider in post-operative or post-analgesic dystonia. Naloxone is the treatment of choice in OIMDs.

Childhood cancer survivors treated with large-field radiation may develop late secondary effects across multiple organ systems. We present a 60-year-old male whose PET/CT revealed an absent thyroid gland with multiple metastatic foci, a surgically absent spleen and bladder with an ileal conduit, severe pulmonary outflow tract calcifications, and transcatheter aortic valve replacement (TAVR), bilateral proximal humeral osteonecrosis, and bilateral total hip arthroplasties. Though each individual finding may be readily recognizable on imaging, the key to this case is interpreting the constellation of findings as potential late effects of radiation therapy (RT), especially since severe pulmonary artery calcifications and multifocal osteonecrosis involving both shoulders and hips due to RT are exceedingly rare. Review of the patient's medical history, obtained only after persistent follow-up with the treating facility, revealed prior high-dose, large-field external beam radiation for stage IIIA childhood Hodgkin's lymphoma, administered in the 1970s. Awareness of these characteristic sequelae allows medical providers to correctly contextualize seemingly disparate findings, particularly when the details of prior radiation history are not readily available.

A 40-year-old man underwent a comprehensive arthroscopic management procedure to address right glenohumeral arthritis. He presented on postoperative day 1 with severe thoracolumbar back pain and paresthesias overlying the left paraspinal muscles. He had elevated creatinine kinase levels, and magnetic resonance imaging demonstrated significant paraspinal edema. Intracompartmental pressures confirmed paraspinal compartment syndrome, and a compartment release was performed, resolving the patient's pain and paresthesias. Acute paraspinal compartment syndrome following extremity orthopaedic surgery is unreported in the literature. This case describes the diagnosis and management of this condition and highlights paraspinal compartment syndrome as a potential postoperative complication.

Background: The post-acute sequelae of SARS-CoV-2 infection represent a growing public health concern. While associations between COVID-19 and metabolic disorders have been reported, less is known about this risk in young, healthy populations. This study aimed to quantify the risk of developing new-onset metabolic disorders following SARS-CoV-2 infection among U.S. active-duty service members. Methods: We conducted a propensity score-matched cohort study using U.S. Military Health System data between July 2020 and June 2021 of active-duty service members (ADSM) aged 18 to 65 years old. COVID-19 infections were identified through ICD-10 codes or laboratory results. A 1:2 matched cohort compared 103,789 COVID-19 exposed individuals with 207,578 controls. Outcomes included incident diagnoses of type 2 diabetes mellitus (T2DM), hypertension (HTN), hyperlipidemia (HLD), metabolic dysfunction-associated steatotic liver disease (MASLD), and metabolic syndrome (MetS) within one year. Cox proportional hazards models calculated adjusted hazard ratios (aHR) while controlling for obesity and overweight status. Results: The median age for both those with and without COVID-19 infection was 26 years (interquartile range 22–33 years), with males comprising the majority of participants (81.1% male, 18.9% female). COVID-19 infection was associated with significantly increased hazards for incident HTN (aHR 1.09; 95% CI, 1.01–1.18), HLD (aHR 1.30; 95% CI, 1.10–1.54), and MASLD (aHR 1.36; 95% CI, 1.15–1.60). However, no significant increased risk was observed for T2DM or MetS. Conclusions: COVID-19 infection was associated with significantly increased risk of developing HTN, HLD, and MASLD, highlighting important long-term metabolic consequences in a young, healthy population.

Catheter-associated urinary tract infections (CAUTIs) are a significant cause of morbidity and mortality among hospitalized patients, prompting the implementation of various strategies to reduce their incidence, including the use of male external catheters (MEC). However, the effectiveness of MEC in preventing urinary tract infections (UTIs) remains uncertain. This study aimed to systematically summarize existing research and conduct a meta-analysis to evaluate the impact of MEC on UTI rates and related outcomes. We searched PubMed, Medline, Embase, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform for peer-reviewed articles and clinical trials from inception until June 30, 2024, ultimately including 42 of 1,545 publications in our systematic review, comprising 40 observational studies and two randomized controlled trials (RCTs). Our meta-analysis focused on eight articles with complete methodology and outcomes, revealing a non-significant 27% decrease in UTIs among MEC users (odds ratio 0.73, confidence interval 0.44-1.22) with moderate heterogeneity (I2 = 58.47%). Additionally, asymptomatic bacteriuria was associated with a non-significant 3% lower risk for MEC (odds ratio 0.97, confidence interval 0.61-1.54) and mild heterogeneity (I2 = 29.79%). The incidence rate ratio (IRR) for UTIs significantly decreased when comparing MEC users to indwelling urinary catheter (IUC) users (odds ratio, 0.20; 95% confidence interval, -0.03 to 0.43), demonstrating significant heterogeneity (I2 = 99.98%). Our findings indicated variability in the reporting of secondary outcomes, with a non-significant decrease in UTI and asymptomatic bacteriuria events among MEC users compared to IUC users. However, effect sizes were associated with significant heterogeneity. We recommend standardized reporting of secondary outcomes in future studies to enhance comparability and reliability.

A 23-year-old man presented to the orthopaedic clinic with chronic thigh pain 5 years after a sprinting injury with weakness and deformity. He was found to have a distal rectus femoris tendon rupture with 20 cm of retraction. An onlay reconstruction was performed using peroneus longus and achilles allografts, and the patient regained full strength and range of motion 1 year postoperatively. Chronic ruptures of the rectus femoris tendon are poorly described in the literature. Retraction may require use of allograft tissue to improve extensor mechanism function. Although outcomes may be improved postoperatively, expectation management is paramount for high demand patients.

Maxillomandibular fixation (MMF) is essential for many surgeries on the bony middle and lower face. MMF techniques have multiplied in recent years, each with unique benefits and drawbacks. This review catalogs MMF trends and evidence for and against the most prevalent MMF methods. Traditional Erich arch bars remain the most robust technique in establishing MMF, particularly for comminuted/complicated fractures. Drawbacks are increased operative time required, wire stick injuries, poor oral hygiene, and gingival trauma. Screw-based techniques save considerable time but cannot stabilize comminuted fractures as adequately and risk tooth root and nerve damage. Embrasure wires offer time and cost savings but are solely for intraoperative use and uncomplicated fractures. Similarly, dental occlusion ties provide the benefits of reduced time and wire sticks, with the added capability of postoperative use, but require adequate dentition and minimally displaced fractures. Recent studies show decreased use of wire-based techniques, with increased adoption of hybrid systems and dental occlusion ties. MMF techniques each have unique advantages and weaknesses. Selection should depend on surgical goals, including the severity of fractures, the need to maintain occlusion postoperatively, application/removal time, safety, and patient comfort.