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Purpose No definite treatment option with reasonable outcome has been presented for old and refractory flexion contracture after total knee arthroplasty (TKA). We describe a surgical technique for 21 refractory cases of knee flexion contracture, including 12 patients with history of failed manipulation under anesthesia (MUA). Methods Retrospective review was conducted for procedures performed by a single surgeon between 2005 and 2016. Twenty‐one knees (19 patients) with knee flexion contracture after primary TKA were treated with all the following procedures: posterior capsular release, hamstring tenotomy, prophylactic peroneal nerve decompression, and botulinum toxin type A injections. Twelve of the 21 knees had at least 1 prior unsuccessful MUA before this soft‐tissue release procedure. Mean age at intervention was 60 years (range 46–78 years). Mean preoperative knee range of motion (ROM) was – 27° extension (range – 20° to – 40°) to 100° flexion (range 90°–115°). All radiographs were evaluated for proper component sizing and signs of loosening. Results Full extension was achieved immediately after surgery in all patients. Only one knee required repeat botulinum toxin type A injection. All patients had full extension at mean follow‐up of 31 months (range 24–49 months). No significant change was observed in knee flexion after the procedure (n.s.). Significant improvement was noted in the postoperative Knee Society Score (KSS) (mean 80, range 70–90) when compared with preoperative KSS (mean 45, range 25–65) (p = 0.008). Conclusion The proposed surgical technique is efficacious in treating patients with refractory knee flexion contracture following TKA to gain and maintain full extension at minimum 2‐year follow‐up. Level of evidence IV, retrospective case series.

A 16-year-old male was admitted to the paediatric ICU with acute onset of vomiting, somnolence, and chest pain, and electrocardiogram showing 2nd degree heart block after ingesting an Aleurites moluccana (Candlenut) seed as a herbal weight loss supplement. Electrocardiogram showed progressively worsening heart block with down-sloping of the ST segments, resembling digoxin toxicity. After 2 days of ICU observation, his symptoms began to improve and eventually resolved. The side effects of herbal supplements are often unknown but by analysing cases such as these, physicians can develop a better understanding of these substances to help guide management.

Introduction: DKA is the leading cause of hospitalizations in children with type 1 diabetes mellitus (T1DM). Although most cases are preventable, DKA continues to occur in established patients. Aim: To identify contributing factors and outcomes of DKA pediatric admissions in a tertiary referral center with a large rural catchment area to assess for actionable items to prevent DKA. Methods: A retrospective, single-center chart review assessing children ˂19 years old admitted in DKA from October 2014 to May 2018. DKA was defined as a pH of ≤7.3 or bicarbonate of ≤15. Demographic data included gender, age, zip code, insurance type and ethnicity. Admission measures included HbA1c, DKA group (new-onset “NT1” or “ET1” established T1DM diagnosis), DKA severity (severe pH <7.1, CO2 <5mEq/L), contact with clinic, home insulin delivery. Outcomes included length of stay (LOS), total admission costs (TAC) and reimbursements amounts (RA). Results: 272 patients were included (mean age 11.7 y, range 4.4-16; 60% female, 83% Caucasian, 14% African American). Of these, 33% were NT1 DKA. Compared to NT1 DKA, ET1 DKA patients were older (8.7 vs. 13.1 years, p < 0.001), more likely female (49% vs. 65%, p 0.034) with public insurance (55% vs 63%, p 0.028); 73% didn’t contact the diabetes team prior to admission and 52% used an insulin pump. There were no significant differences in HbA1c or DKA severity. LOS was similar between NT1 and ET1 DKA (p 0.051). Severe DKA was associated with longer LOS (RR 1.47, p < 0.0001). Public vs. private insurance was associated with 1.28 times longer LOS (p < 0.0001). While there was no difference in TAC between NT1 and ET1 DKA groups (p 0.877), costs were higher with public vs. private insurance (>$900, p 0.050) and severe DKA (RR 1.92; 95% CI 1.62-2.27; p <0.0001). TAC were different between regions within central Illinois (RR 1.39; 95% CI 1.08-1.80; p 0.002). Hospital RA was higher for NT1 vs. ET1 group (RR 1.26; 95%CI 1.03-1.54; p 0.0237) and higher DKA severity (RR 1.57; 95% CI 1.26-1.95; p <0.0001); but lower for public vs. private insurance (RR 0.43; 95% CI 0.35-0.52; p <0.0001). Discussion: Established DKA patients tended to be rural teenage females, poorly controlled and public health insured. Severity of DKA and LOS did not differ between the groups. While TAC were similar among the groups, TAC were higher with public insurance and severe DKA. Lower hospital RA were seen for recurrent cases and public insurance. This study provides valuable information about non-metropolitan at-risk population characteristics to inform targeted preventive interventions. These findings suggest a significant difference in hospitalization RA, providing incentive for health care facilities / providers to invest in early outpatient interventions and QI initiatives.