Norberto J. Torres Lugo

Introduction: Pseudotumors are well-known complications following total hip arthroplasty (THA), usually attributed to debris-induced inflammation from direct metal-on-metal contact between implants. In total knee arthroplasty (TKA), the traditional use of polyethylene as a bearing surface prevents direct metal articulation. Thus, pseudotumor formation in TKA usually suggests atypical metal interaction between the prosthetic components. Presentation of case: We presented the case of a 65-year-old male who developed a progressively growing mass in the left posterior knee after revision TKA, debuting as heterotopic ossification (HO) based on the radiographic assessment. Subsequent histopathological examination establishes the diagnosis of a pseudotumor. Discussion: Pseudotumors impose a diagnostic challenge in TKA due to their non-specific presentation and imaging, which may overlap with other etiologies. Currently, there are no standardized guidelines for pseudotumor assessment in TKA, and each case should be approached individually without relying on a simple diagnostic tool. Conclusion: Physicians should consider a comprehensive approach supported by a high index of suspicion to include pseudotumors within the differential diagnosis of knee periprosthetic masses. Highlights:

Background: Rotational abnormalities of the hip have been implicated in the etiology of diseases, such as hip dysplasia, osteoarthritis, and femoroacetabular impingement. Despite the extensive literature on hip morphology, there is a gap in knowledge regarding variations in the Hispanic population. Purpose: To describe the bony anatomy variations of the acetabulum in a Hispanic population. Material and Methods: This is a cross-sectional study. We studied 182 computed tomography (CT) images in patients aged older than 21 years, who had undergone pelvic CT for any condition, except hip fracture. Measurements of acetabular version, anterior and posterior acetabular sector angles (AASA/PASA) and horizontal acetabular sector angles (HASA) were made. Acetabular variations were then compared to weight and sex data. Results: The mean acetabular anteversion was greater in women ( P < 0.001). Women exhibited a greater PASA ( P < 0.05); however, men had a greater AASA ( P < 0.05). Underweight individuals had a smaller PASA ( P < 0.01) and HASA ( P < 0.05) than individuals with a normal weight. Conclusion: The Hispanic hip is morphologically similar to other populations previously reported in the literature; however, Hispanic men have less coverage of the femoral head by the posterior acetabular wall when compared to women of the same ethnicity. These abnormalities have a direct impact on management and surgical approach in patients treated for femoroacetabular impingement and hip dysplasia.

Case: A 29-year-old man presented nontraumatic diffuse thoracic pain. Magnetic resonance imaging of the spine showed a cortical lesion with peripheral hyperintensity, a central sclerotic hypointense nidus, and surrounding paraspinal inflammatory changes at the T3 vertebral body. Clinical and radiologic findings were consistent with an osteoid osteoma. The patient successfully underwent an endoscopic partial corpectomy and mass resection. At the 6-month follow-up, radiographs showed complete tumor resolution. Conclusion: Endoscopic resection is an adequate and minimally invasive technique for the complete resection of osteoid osteomas.

Background: Adequate pain control after total knee arthroplasty (TKA) has been associated with improved patient mobility and satisfaction, and is a task that has historically relied on opioids. Multimodal analgesic regimens can be considered a therapeutic alternative for postoperative pain control to avoid opioid consumption and its adverse side effects. This study aimed to evaluate the use of a multimodal analgesia protocol based on nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as an alternative to reduce opioid consumption in Hispanic patients undergoing primary TKA. Methods: An institutional review board-approved, randomized controlled trial evaluated postoperative pain control after TKA in a Hispanic population. The experimental opioid-sparing group received 30-mg ketorolac intravenously every 6 hours and 1-g acetaminophen orally every 6 hours as the patient requested. The experimental group had the option to use morphine and oxycodone combined with acetaminophen as a rescue therapy. The control group received opioids in the form of 0.1-mg/kg morphine intravenously every 6 hours and/or oxycodone combined with acetaminophen (2.5 and 325 mg), 2 tablets orally every 6 hours, as the patient requested. Sociodemographic, operative, and immediate postoperative data and pain intensity measurements according to the numerical rating scale (NRS) were compared between groups. Analgesic efficacy was assessed according to the NRS scores at 12, 24, and 48 hours postoperatively. Results: Eighty-one Hispanic patients met inclusion criteria: 42 patients in the experimental group and 39 patients in the control group. None of the patients in the experimental group requested oxycodone combined with acetaminophen as a rescue therapy. Only 2 patients in the experimental group used a mean of 3.0 ± 1.4 mg of rescue morphine; in comparison, the control group consumed a mean of 28.0 ± 7.9 mg of morphine and 64.8 ± 26.0 mg of oxycodone per patient. A pain intensity decrease was observed in the experimental and control groups, with no postoperative evaluation differences at 12 hours (6.7 ± 2.9 compared with 5.9 ± 2.8; p = 0.209), 24 hours (6.2 ± 2.0 compared with 6.1 ± 2.2; p = 0.813), and 48 hours (4.7 ± 2.1 compared with 4.6 ± 1.7; p = 0.835). Conclusions: The use of a multimodal analgesic regimen based on intravenous ketorolac and oral acetaminophen was adequate in reducing postoperative pain and opioid consumption in Hispanic patients undergoing TKA. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background and Objectives: Primary care physician shortage represents a challenge for many countries and territories, including Puerto Rico (PR), where a significant proportion of the graduating medical students preferred the continental United States (C-US) to complete their training and even as the definitive setting for their practice. We surveyed medical students who graduated from medical schools in PR and have been accepted in a residency program to evaluate the influence of a set of demographics, academic, and personal factors in their decision to pursue a primary care residency program in the C-US. Methods: A 19-item questionnaire was distributed by institutional email to those medical students who graduated from one of the four Liaison Committee on Medical Education fully accredited medical schools in PR in 2019. We summarized our data by frequency and percentages. We performed data analysis with statistical significance considered for P values <.05. Results: The questionnaire had a response rate of 51% (138/273), where 49% (67/138) were accepted in a primary care residency. Sixty percent (40/67) matched in a primary care program in the C-US. Among the evaluated factors, a prior degree in C-US (65%) and first-degree relatives living in the C-US (70%) were associated with students who matched in the mainland. First-degree relatives living in PR (96%) were associated with students who remained on the island for training. Conclusions: The results provide insight into the influence that personal factors have on the decision of medical students in PR to pursue primary care training in the C-US.