VCOM Carolinas Research Day Winners 2020

Bilateral Thyroid Associated Orbitopathy in an Antibody Negative, Euthyroid Patient Moore, M. OMS-III; Patel, J. DO Edward Via College of Osteopathic Medicine-Carolinas, Spartanburg, SC

CBR-20

Introduction Thyroid associated orbitopathy also known as Grave’s disease is an autoimmune mediated disease that affects orbital tissues. (1) We report a patient with clinical features of thyroid associated orbitopathy, including exophthalmos and CT evidence of rectus muscle enlargement who had negative antibody titers and normal thyroid functioning.

While euthyroid thyroid associated orbitopathy with negative antibodies is an atypical and rare presentation, there have been cases in the literature. In one case, hyperthyroidism and antibodies developed 24 months after initial presentation. (4) This suggests a potential progressive relationship between thyroid associated orbitopathy and the development of hyperthyroidism in patients with initial negative antibodies. While there is no official recommendation for how often to monitor patients who are euthyroid and have negative antibody titers, it is important to evaluate for any changes in symptomology or worsening of ophthalmic complaints. These symptoms include palpitations, rapid weight loss, hair thinning and goiter. Ultimately, patients who present with bilateral exophthalmos and other clinical features of thyroid associated orbitopathy can encounter difficult obstacles in treatment. This includes a potential delay in treatment if labs are interpreted as normal and thyroid associated orbitopathy is ruled out. This can lead to the dangerous complications like permanent exophthalmos, scarring and vision loss. (1,5) Thyroid associated orbitopathy must remain in the list of differentials among orbital cavernous hemangioma, orbital inflammatory syndrome, lymphoma, glioma and orbital cellulitis despite these normal lab values. A CT of orbit with contrast is necessary during this evaluation to show the characteristic rectus muscle enlargement. Conclusion

Thyroid function tests were normal:

Thyroid stimulating hormone (TSH) Free T4

Value 1.180 mcIU/mL 0.98 ng/dL

Reference Range 0.358-3.740 mcIU/mL 0.82-1.70 ng/dL 0.0-0.9 IU/mL 0.00-0.55 IU/L

Thyroglobulin antibody <1.0 IU/mL Thyroid stimulating immunoglobulin antibody <0.10 IU/L Table 1: Lab values and reference ranges.

Case Presentation

He was started on a 45-day taper of 10 mg oral Prednisone and 200 mcg Selenium. He was also educated on the harmful health effects of smoking including worsening of his exophthalmos. On his return visit 45-days later, he had improved conjunctival redness and resolved orbital pain. His exophthalmos remained stable and showed no progression. Discussion Thyroid associated orbitopathy has an incidence of 16 cases per 100,000 in women and 3 cases per 100,000 in men. (1) The most common onset of symptoms is between 30-50 years of age. (1) More severe cases tend to occur in male patients and those who are over 50 years of age. (1) Both of these demographics are consistent with our patient and presentation with more severe symptomology. The pathophysiology behind thyroid associated orbitopathy is an immune mediated reaction directed against orbital fibroblasts leading to expansion of orbital tissue. (3) The most common antibody associated is thyroid stimulating immunoglobulin. (1) Approximately less than 5% of patients with thyroid associated orbitopathy are euthyroid and have low antibody titers. (2) The mainstay of treatment for thyroid associated obritopathy include corticosteroids to decrease edema from inflammation and Selenium. (5) Selenium is an antioxidant and its primary mechanism is to to eliminate reactive oxygen species associated with this disease process. (6) If the exophthalmos becomes severe, orbital decompression surgery is a more invasive option. (5)

A 61-year-old male presented with an eight month history of eye lid retraction, exophthalmos, blurred vision and orbital pain. He had no other symptoms of thyroid dysfunction including palpitations, heat intolerance, tremor, fatigue and sweating. He had a history of hypertension controlled on Metoprolol Succinate ER 50 mg and used Olopatadine HCl 0.2% solution as needed for eye irritation. He smoked and continued to smoke one pack of cigarettes per day. On examination, he had bilateral upper and lower eye lid retraction, exophthalmos, bilateral lower lid fat pads and mild conjunctival redness. Visual acuity of right eye was 20/30 and left eye was 20/40. His Grave’s orbitopathy clinical activity score was three. The remainder of his physical examination was normal including fundal examination.

References

1. Edsel Ing. (2019, March 7). Thyroid-Associated Orbitopathy. Retrieved from https://emedicine.medscape.com/article/1218444-overview 2. Nishihara , E. (2013, November 26). Vol 7 Issue 2 p.4-5. Retrieved from https://www.thyroid.org/patient- thyroid-information/ct-for-patients/vol-7-issue-2/vol-7-issue-2-p-4-5/ 3. Pokhrel, B. (2019, June 3). Graves Disease. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK448195/ 4. Tabasum, A., Khan, I., Taylor, P., Das, G., & Okosieme, O. E. (2018, August 5). Thyroid antibody-negative euthyroid Graves' ophthalmopathy in: Endocrinology, Diabetes & Metabolism Case Reports Volume 2016 Issue 1 (2016). Retrieved from https://edm.bioscientifica.com/view/journals/edm/2016/1/EDM16-0008.xml 5. Zheng, H. (2018, September 28). Graves' disease. Retrieved from https://www.mayoclinic.org/diseases- conditions/graves-disease/diagnosis-treatment/drc-20356245 6. Zheng, H., Wei, J., Wang, L., Wang, Q., Zhao, J., Chen, S., & Wei, F. (2018, September 26). Effects of Selenium Supplementation on Graves' Disease: A Systematic Review and Meta-Analysis. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6178160/

Image 2: Right eye fundus.

Image 1: Left eye fundus.

CT of orbit with contrast showed mild bilateral enlargement of inferior rectus and medial rectus muscles consistent with thyroid associated orbitopathy. CT head with and without contrast showed mild-moderate atrophy with no acute intracranial event.

Arthroscopic Debridement of Morel-Lavallée Lesion Speeds Healing and Return to Activity: a case report

Joseph Bell, OMS III, Liam Ortega OMS III, Greg Colbath, M.D. Edward Via College of Osteopathic Medicine, Spartanburg, SC, 29301 Medical Groups of Carolinas, Skylyn Orthopedics, Spartanburg, South Carolinas, 29301

CBR-21

Abstract

Case Presentation

Discussion

A Morel-Lavallée lesion is a closed degloving injury of the soft tissue caused by post-trauma sequelae. The trauma force shears the subcutaneous tissue from the underlying fascia which creates a potential space for blood and fluid to accumulate over time and can serve as a potential nidus for infection and tissue necrosis. While Morel-Lavallée lesions are initially treated with percutaneous drainage and compression, surgical treatment is the definitive treatment. Open wound debridement has traditionally been the procedure of choice, however there are scant publications reporting the utilization of endoscopic treatment. After an extensive literature review, there have been only four other publications describing utilization of endoscopic repair in a Morel-Lavalée lesion to date. Standard guidelines do not exist for the appropriate surgical treatment of Morel-Lavallee lesions. This case report describes a Morel-Lavallée lesion that was successfully treated with arthroscopic debridement and allowed the patient to return to full activities pain-free. The results support prior reports that endoscopic debridement achieves similar to better outcomes when compared with open surgical debridement. This case illustrates expedited healing with the post-operative use of incisional wound vac, rapid return to activity without increased morbidity, and decreased length of hospital stay by utilizing the endoscopic approach. A Morel-Lavellée lesion (MLL) is an uncommon but well documented injury. It is a closed internal degloving injury that results from a traumatic shearing force. The result is a separation of the skin and hypodermis from the underlying fascia and the creation of a potential space. Complications from this potential space including formation of a hematoma, effusion, necrotic adipose tissue, and infection. 1 The diagnosis can be suspected with a careful history and physical exam, and can be confirmed with ultrasound or MRI. 2 Treatment options for MLL include both conservative and radical approaches without there being a definitive treatment algorithm. The most radical treatment option consists of open surgical debridement. Endoscopic debridements have been performed with a focus on surgical technique. 3-4 This case report focuses on a successful outcome based on pain control and return to activity for a patient who underwent endoscopic debridement of MLL. Introduction

Case Presentation: Patient is a 65-year-old female who sustained an injury to her left leg when she fell with her left hip getting caught in between a boat and the dock, causing a shearing force. She presented to the orthopedic office 11 days after injury. She complained of continuing pain as well as a large area of swelling. Pelvic AP and left hip x-rays were obtained that revealed an approximately 2cm X 2cm lesion intramedullary with no evidence of erosion of the cortex. There was soft tissue swelling noted along the lateral subcutaneous plane. Treatment: 2 ultrasound-guided aspirations of a large seroma to the lateral aspect of the hip were performed on post-injury day 11 and one week later that both yielded 200cc of sanguinous fluid. A left hip MRI prior to the second aspiration revealed 20cm X 10cm fluid-filled collection along the lateral aspect of the left IT band believed to be synovial hematogenous products and central reaccumulation of MLL. On day 31 post-injury, the patient underwent left hip arthroscopic debridement of seroma with IT band release. Patient’s left hip on exam the morning of surgery showed an ecchymotic swelling over the greater trochanter as seen in Figure 2. Planned portal sites including a superior lateral and distal mid lateral portal centered 3cm off the greater trochanter were marked out. Aspiration of 35cc of serosanguinous fluid was performed and did not have any evidence of infection. A plane was established down to the subcutaneous layer over the IT band that revealed a potential space. Debridement of all synovitic tissue and fibrinous material was performed. Several punctate holes were made along the entirety of the IT band, as seen in Figure 3, to assist with seroma decompression and initiate scarring along the IT band potential space. The IT band was incised in a cruciform fashion over the apex of the greater trochanter and IT band release was then performed. A 10cm X 40cm PICO incisional wound vac was placed along the wound following primary closure. It was believed at that time to help decompress the potential space and prevent recurrence. Outcome: Patient was weight-bearing with crutches for 2 weeks. She reported left hip soreness for two days following surgery. At her three-week post-op visit, she reported having only mild pain rarely and has returned to all her daily activities without concern. She was able to sleep on her previously injured leg without pain. On a post-op patient questionnaire completed at this visit she reported using only six opioid pain pills, having improved 100% compared to pre- surgery, and registering a zero out of ten on the pain scale in the office.

References Morel-Lavallée lesions (MLL) are rapid onset with swelling and progressive decreased mobility in subsequent days. MRI is the diagnostic imaging modality of choice. Ultrasound has continued to grow as a useful adjunct for imaging and a cost-effective MRI alternative in the diagnosis and monitoring of MLLs. 2 When diagnosing with US, MLLs represent hypoechoic or anechoic, fusiform compressible spaces with a well-defined margin. 6 Currently there are no current standards of care algorithms for MLL. Conservative treatment includes elastic compression bandaging, US-guided aspiration and sclerotherapy. Nickerson et al. showed that aspiration of >50 mL of fluid had a strong association of recurrent MLL that recurred (83%) and an indication that surgical intervention is needed for resolution. 7 The patient in this case had an initial aspiration of 200cc at 11 days post-injury with recurrence requiring a second 200cc aspiration one week later. Surgical intervention most commonly utilizes an open drainage and debridement. Though open surgical debridement is a successful definitive treatment, there is an increased risk of morbidity and prolonged course of healing. Hak et al. reported an infection rate of 13% in 24 patients with pelvic MLL who were treated with open debridement. 8 This patient underwent endoscopic debridement and a PICO incisional wound vac was then applied with the aim to prevent secondary seroma. The wound vac was able to be removed seven days following the operation. The patient reported that her pain was 100% resolved with only 6 opioid pills in the first week and by day 21 she was able to return to full ADL’s pain-free. The endoscopic surgical repair of a MLL on the lateral hip is an excellent approach in a patient after failure of conservative management. This technique facilitates a rapid return to activity and achieves the definitive treatment goal of an open surgical debridement without increased risk of morbidity. The surgical repair of MLL utilizing endoscopic techniques has only been published in 4 other instances at the time of this report. Based upon the positive outcomes from these reports, this surgical technique needs further investigation in comparison to open surgical debridement to determine the most effective modality to repair MLL with the fastest return to normal activities. 1. Greenhill, D., Haydel, C., & Rehman, S. Management of the morel-lavallée lesion. The Orthopedic Clinics of North America, 47 (1), 115-25 (2016). 2. Mukherjee, K., Perrin, S.M. & Hughes, P.M. Morel-Lavallee lesion in an adolescent with ultrasound and MRI correlation. Skeletal Radiol 36, 43–45 (2007). 3. Kim, S. Endoscopic treatment of morel-lavallee lesion. Injury, 47 (5), 1064-1066. (2016). 4. Walls, A., McMahon, S., MacDonald, J., Bunn, J. Endoscopic surgical management of a large Morel-Lavallee lesion. BMJ Case Rep. (2017). 5. Tseng S, Tornetta P. Percutaneous management of Morel-Lavallee lesions. J Bone Joint Surg Am 2006;88(1):92–6. 6. Neal C, Jacobson JA, Brandon C, Kallume-Brigido M, Morag Y, Girish G. Sonography of Morel-Lavallee lesions. J Ultrasound Med 2008;27(7):1077–81. 7. Nickerson TP, ZielinskiMD, Jenkins DH, Schiller HJ. TheMayo Clinic experience with Morel-Lavallee lesions: establishment of a practice management guideline. J Trauma Acute Care Surg 2014;76(2):493–7. 8. Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallee lesion. J Trauma 1997;42(6):1046–51.

Acknowledgements

Figure 3 . Perioperative endoscopic image obtained reveals the punctate holes made within the IT band.

Figure 2 . L ateral view of the left hip the morning of surgery reveals an edematous ecchymosis over the greater trochanter.

Figure 1. Ultrasound of lesion prior to the first and second aspirations, failure of conservative measures indicated the surgical repair by endoscopic technique.