... guided infraclavicular brachial plexus blocks AbstractText: We present an adult patient with posterior elbowdislocation that is treated with reduction after applying an ultrasound-guided infraclavicular brachial plexus ... excellent alternative to sedoanalgesia and other brachial plexus blocks for the management of elbowdislocations in the emergency department Keyword: elbowdislocation.
AIMS: Restoring the pre-morbid anatomy of the proximal humerus is a goal of anatomical shoulder arthroplasty, but reliance is placed on the surgeon's experience and on anatomical estimations. The purpose of this study was to present a novel method, 'Statistical Shape Modelling', which accurately predicts the pre-morbid proximal humeral anatomy and calculates the 3D geometric parameters needed to restore normal anatomy in patients with severe degenerative osteoarthritis or a fracture of the proximal humerus.
MATERIALS AND METHODS: From a database of 57 humeral CT scans 3D humeral reconstructions were manually created. The reconstructions were used to construct a statistical shape model (SSM), which was then tested on a second set of 52 scans. For each humerus in the second set, 3D reconstructions of four diaphyseal segments of varying lengths were created. These reconstructions were chosen to mimic severe osteoarthritis, a fracture of the surgical neck of the humerus and a proximal humeral fracture with diaphyseal extension. The SSM was then applied to the diaphyseal segments to see how well it predicted proximal morphology, using the actual proximal humeral morphology for comparison.
RESULTS: With the metaphysis included, mimicking osteoarthritis, the errors of prediction for retroversion, inclination, height, radius of curvature and posterior and medial offset of the head of the humerus were 2.9° (± 2.3°), 4.0° (± 3.3°), 1.0 mm (± 0.8 mm), 0.8 mm (± 0.6 mm), 0.7 mm (± 0.5 mm) and 1.0 mm (± 0.7 mm), respectively. With the metaphysis excluded, mimicking a fracture of the surgical neck, the errors of prediction for retroversion, inclination, height, radius of curvature and posterior and medial offset of the head of the humerus were 3.8° (± 2.9°), 3.9° (± 3.4°), 2.4 mm (± 1.9 mm), 1.3 mm (± 0.9 mm), 0.8 mm (± 0.5 mm) and 0.9 mm (± 0.6 mm), respectively.
CONCLUSION: This study reports a novel, computerised method that accurately predicts the pre-morbid proximal humeral anatomy even in challenging situations. This information can be used in the surgical planning and operative reconstruction of patients with severe degenerative osteoarthritis or with a fracture of the proximal humerus. Cite this article: Bone Joint J 2017;99-B:927-33.
Muscular and Skeletal Diseases (5) Osteoarthritis (5), more mentions
Elbowreconstruction with vascularized composite allotransplantation (VCA) may hold promise in treating end-stage arthritis as no current treatment is both functional and durable. We describe the vascular and gross anatomy of the elbow in the context of VCA procurement and propose a step-by-step surgical technique for human elbow VCA.We injected latex in the arterial tree of ...
BACKGROUND: Anatomic reduction and placement of an inferior calcar screw are strategies to prevent fixation failure in proximal humerus factures. Optimal position of the calcar screw remains unknown.
METHODS: There were 168 shoulders (68.5% female; average age, 63.6 ± 11.5 years) that underwent open reduction and internal fixation of a displaced proximal humerus fracture involving the surgical or anatomic neck. Univariate and multivariate analyses were performed on preoperative clinical, preoperative radiographic, and postoperative radiographic variables to determine association with fixation failure. A receiver operating characteristic curve was performed to determine a maximum distance from the inferior screw to the calcar ("calcar distance") as well as a maximum ratio of this distance and the head diameter ("calcar ratio").
RESULTS: There were 26 of 168 (15.5%) patients with radiographic failures (19 related to fixation failure). Univariate analysis and multivariate analyses found quality of reduction (P < .001), calcar distance (P < .001), and calcar ratio (P < .001) to be significantly associated with radiographic success. In all patients, receiver operating characteristic analysis found quantifiable thresholds of 12 mm or within the bottom 25% of the humeral head as measures to prevent fixation failure.
CONCLUSIONS: Quality of reduction, calcar distance, and calcar ratio independently correlated with fixation failure. This study provides optimal distances and ratios for calcar screw placement that can be used clinically.
AIMS: Resection of the proximal humerus for the primary malignant bone tumour sometimes requires en bloc resection of the deltoid. However, there is no information in the literature which helps a surgeon decide whether to preserve the deltoid or not. The aim of this study was to determine whether retaining the deltoid at the time of resection would increase the rate of local recurrence. We also sought to identify the variables that persuade expert surgeons to choose a deltoid sparing rather than deltoid resecting procedure.
PATIENTS AND METHODS: We reviewed 45 patients who had undergone resection of a primary malignant tumour of the proximal humerus. There were 29 in the deltoid sparing group and 16 in the deltoid resecting group. Imaging studies were reviewed to assess tumour extension and soft-tissue involvement. The presence of a fat rim separating the tumour from the deltoid on MRI was particularly noted. The cumulative probability of local recurrence was calculated in a competing risk scenario.
RESULTS: There was no significant difference (adjusted p = 0.89) in the cumulative probability of local recurrence between the deltoid sparing (7%, 95% confidence interval (CI) 1 to 20) and the deltoid resecting group (26%, 95% CI 8 to 50). Patients were more likely to be selected for a deltoid sparing procedure if they presented with a small tumour (p = 0.0064) with less bone involvement (p = 0.032) and a continuous fat rim on MRI (p = 0.002) and if the axillary nerve could be identified (p = 0.037).
CONCLUSION: A deltoid sparing procedure can provide good local control after resection of the proximal humerus for a primary malignant bone tumour. A smaller tumour, the presence of a continuous fat rim and the identification of the axillary nerve on pre-operative MRI will persuade surgeons to opt for a deltoid resecting procedure. Cite this article: Bone Joint J 2017;99-B:1244-9.
BACKGROUND: Distal biceps brachii tendon ruptures lead to substantial deficits in elbow flexion and supination; surgical repair restores muscle strength and endurance.
PURPOSE: To examine clinical and surgical outcomes for distal biceps tendon repairs in a large, multispecialty, integrated health care system.
STUDY DESIGN: Cohort study; Level of evidence, 3.
METHODS: Retrospective cohort study of distal biceps tendon repairs performed between January 1, 2008, and December 31, 2015. The repair methods were classified as double-incision approach using bone tunnel-suture fixation or anterior single-incision approach. Anterior single incisions were further classified according to the fixation method: cortical button alone, cortical button and interference screw, or suture anchors alone. Patient demographics, surgeon characteristics, range of motion, and complications were analyzed for all repair types.
RESULTS: Of the 784 repairs that met the inclusion criteria, 639 (81.5%) were single-incision approaches. When comparing double-incision and single-incision repairs, there was a significantly higher rate of posterior interosseous nerve palsy (3.4% vs 0.8%, P = .010), heterotopic bone formation (7.6% vs 2.7%, P = .004), and reoperation (8.3% vs 2.3%, P < .001). The most common nerve complication encountered was a lateral antebrachial cutaneous nerve palsy (n = 162), which was significantly more common in the single-incision repairs than in the double-incision repairs (24.4% vs 4.1%, P < .001). When excluding lateral antebrachial cutaneous nerve palsies, there was no significant difference in the overall nerve palsies between single-incision and double-incision (5.8% vs 6.9%, P = .612). The overall rate of tendon rerupture was 1.9% (single incision, 1.6%; double incision, 2.8%; P = .327). The overall rate of postoperative wound infection was 1.5% (single incision, 1.3%; double incision, 2.8%; P = .182). The average time from surgery to release from medical care was 14.4 weeks (single incision, 14 weeks; double incision, 16 weeks; P = .286). Patients treated with cortical button plus interference screw were released significantly sooner than were patients with other single-incision repair types (13.1 ± 8.01 weeks, P = .011). There were no significant differences in rates of motor neurapraxia, infection, rerupture, and reoperation with regard to surgeon's years of practice, fellowship training, or case volume.
CONCLUSION: The surgical repair of distal biceps tendon ruptures has an overall low rate of serious complications, regardless of approach or technique. However, the double-incision technique has a higher rate of posterior interosseous nerve palsy, heterotopic bone formation, and reoperation rate. Surgeon's years of practice, fellowship training, and case volume do not affect the rate of major complications.
Paralysis (3), Tendinosis (1), Surgical Wound Infections (1), more mentions
BACKGROUND: The humeral subluxation index (HSI) is frequently assessed on computed tomography (CT) scans in conditions of the shoulder characterized by humeral displacement. An arbitrarily set HSI cutoff value of 45% for anterior subluxation and 55% for posterior subluxation has been widely accepted. We studied whether mean values and thresholds of humeral subluxation, in relation to the glenoid and scapula, were influenced by different imaging modalities.
METHODS: The HSIs referenced to the scapula (SHSI) and glenoid (GHSI) were compared between conventional CT scans, CT scans reoriented into the corresponding reference plane (ie, scapular plane for the SHSI and glenoid center plane for the GHSI), and 3-dimensional (3D) CT reconstructions of 120 healthy shoulders. The 95% normal range determined the cutoff values of humeral subluxation.
RESULTS: The SHSI thresholds for conventional, reoriented, and 3D CT scans were 33%-61%, 44%-68%, and 49%-61%, respectively. A different mean SHSI was found for each imaging modality (conventional, 47%; reoriented, 56%; 3D, 55%; P ≤ .014), with the conventional SHSI showing an underestimation in 89% of the cases. GHSI thresholds for conventional, reoriented, and 3D CT scans were 40%-61%, 44%-56%, and 46%-54%, respectively. The mean GHSI did not differ between each imaging modality (conventional, 51%; reoriented, 50%; 3D, 50%; P = .146).
CONCLUSIONS: The SHSI and GHSI are susceptible to different imaging modalities with consequently different cutoff values. The redefined HSI cutoff values guide physicians in the evaluation of humeral subluxation in conditions characterized by humeral displacement, depending on the available image data.
Muscular and Skeletal Diseases (1) Osteoarthritis (1), more mentions
BACKGROUND: The anterior oblique bundle (AOL) of the ulnar collateral ligament (UCL) is composed of anterior and posterior bands. This study evaluated the anatomy of the anterior and posterior bands in the AOL of the UCL for their separate visualization with ultrasound (US).
METHODS: We dissected 18 cadaveric elbow joints and recorded the direction of each band from the lateral view to determine the proper position for the US transducer. To determine the proper inclination of the transducer, we measured the inclinations of each band at the proximal and distal insertions from the transverse view. A paired t test was used for comparisons between both bands. Values of P < .05 were considered statistically significant.
RESULTS: The mean angles of the directions in the anterior and posterior bands were 10° ± 4° and 24° ± 9°, respectively. At the medial epicondyle, the mean inclination angles of both bands were 61° ± 5° and 67° ± 5°, respectively. At the sublime tubercle, the mean inclination angles of both bands were 14° ± 7° and 44° ± 9°, respectively. The inclination angles at the proximal ulna and the directions in both bands were significantly different (P < .001).
CONCLUSIONS: This study shows that the directions of both bands and inclination angles of the bony attachments in both bands can assist with correct placement of the US transducer and allow for separate visualization of each band.
BACKGROUND: Primary osteoarthritis of the elbow is a less common indication for total elbow arthroplasty (TEA). Higher complication rates in younger, active patients may offset short-term improvements in pain and function. The purpose of this study was to determine pain relief, functional outcomes, complications, and survival of TEA in this population.
METHODS: Between 1984 and 2011, 20 consecutive TEAs were performed for primary elbow osteoarthritis. Two patients died before the 2-year follow-up. Mean age at surgery was 68 years (range, 51-85 years). Outcome measures included pain, motion, Mayo Elbow Performance Score, satisfaction, complications, and reoperations. Mean follow-up was 8.9 years (range, 2-20 years).
RESULTS: Three elbows sustained mechanical failures. Complications included intraoperative fracture (n = 2), wound irrigation and débridement (n = 1), bony ankylosis (n = 1), humeral loosening (n = 1), humeral component fracture (n = 1), and mechanical failure of a radial head component (n = 1). Fifteen elbows without mechanical failure were examined clinically. Pain improved from 3.6 to 1.5 (P < .001). Range of motion remained clinically unchanged (P > .05), with preoperative flexion contractures not improving. Mayo Elbow Performance Scores were available for 13 elbows without mechanical failure, averaging 81.5 points (range, 60-100 points); these were graded as excellent (n = 5), good (n = 2), and fair (n = 6). Subjectively, all patients without mechanical failure were satisfied.
CONCLUSION: TEA represents a reliable surgical option for pain relief in patients with primary osteoarthritis. However, restoration of extension is not always obtained, indicating that more aggressive soft tissue releases or bony resection should be considered. Complications occurred in a large number of elbows, but mechanical failure was low considering the nature of this population and the length of follow-up.
Muscular and Skeletal Diseases (5) Osteoarthritis (5), Ankylosis (1), Contracture (1), more mentions
... was significantly higher than that of the intact and reconstructed conditions from 5° to 55° of flexion (P = .018. The contact pressure of the intact elbow was never significantly different from that of the reconstructedelbow, except at 5° of flexion (P ≤ .008... There was no difference in contact pressures among the 3 coronoid reconstruction techniques Keyword: Elbow. Keyword: congruity.
We hypothesized that the LCL tear is required for elbowsubluxation/joint incongruity and that an elbow affected by an anteromedial ... elbow), an anteromedial subtype 2 coronoid fracture with a PMCL tear (COR+PMCL-elbow) and a PMRI injury (PMRI-elbow), after adding an LCL tear, were tested ... .001) AbstractText: The LCL lesion in PMRI is necessary for elbowsubluxation and causes marked elevations in contact pressures.
BACKGROUND: The aim of this study was to assess proximal humeral fracture patterns using 3-dimensional computed tomography images and relate them to the normal osseous landmarks and soft-tissue attachments.
METHODS: Forty-eight 3-dimensional computed tomography scans of proximal humeral fractures were retrospectively collected, and the fractures were transcribed onto proximal humeral templates. We analyzed the common location and orientation of the fracture lines, with a focus on fractures of the articular surface, tuberosities, metaphysis, and proximal diaphysis. These fractures were compared with the attachments of the rotator cuff and glenohumeral capsule.
RESULTS: Fifty-two percent of the fractures involved the articular surface. No fractures passed through the bicipital groove, and fractures were more commonly found on the posterior lesser tuberosity and on the anterior greater tuberosity, coinciding with the intervals between the rotator cuff tendon insertions. Intracapsular fractures of the calcar were more common (68%) than extracapsular fractures (32%). On the anterolateral aspect of the proximal humerus, fractures radiated from the articular margin, vertically down through the tuberosity zone between the rotator cuff footprints, meeting horizontally oriented fractures in the metaphyseal zone. On the posterior aspect, vertical fractures from the tuberosity zone continued downward to the metaphyseal zone adjacent to the infraspinatus and teres minor footprints.
CONCLUSIONS: Fractures of the proximal humerus follow characteristic patterns. Fractures frequently split the greater tuberosity and are closely related to the intervals of the rotator cuff attachments.
BACKGROUND: The Bayley Walker (Stanmore Implants, Elstree, UK) reversed polarity, linked shoulder replacement is designed to provide stable function in the treatment of a painful shoulder with poor soft tissue coverage. We reviewed the results of the prosthesis in destructive pathologic lesions of the proximal humerus at a United Kingdom tumor center.
METHODS: We identified 8 patients (2 men, 6 women) in our database. Clinical information and functional outcome scores were collected, including range of movement, Toronto Extremity Salvage Score, the Musculoskeletal Tumor Score. Radiographs from the last clinic follow-up were analyzed.
RESULTS: Of the 8 patients, 2 were revisions for aseptic loosening around proximal humeral endoprosthetic replacements. Indications for surgery included chondrosarcoma in 4, metastatic disease in 2, Ewing sarcoma in 1, and osteomyelitis in 1. Patients were a mean age at diagnosis of 49 years (range, 16-78 years). One patient died of metastatic disease during follow-up. Mean follow-up was 49 months (range, 36-90 months). At the latest follow-up, there was 100% survivorship using revision as the end point. There were no local recurrences. Three of 5 patients returned to their previous occupation. Neuropathic pain developed in 1 patient postoperatively, but no other postoperative complications were noted. Radiographs showed no progressive lucencies or scapula notching. Mean range of movement at final follow-up was abduction, 62°; forward flexion, 71°; and external and internal rotation, 50°.
CONCLUSION: The Bayley Walker prosthesis gives excellent medium-term survivorship and pain relief in patients with pathologic lesions of the proximal humerus requiring wide local excision.
Fractures of the distal radius are common and occur in all age groups. The incidence is high in older populations due to osteoporosis and increased falls risk. Considerable practice variation exists in the management of distal radius fractures in older patients ranging from closed reduction with cast immobilisation to open reduction with plate fixation. Plating is currently the most common surgical treatment. While there is evidence showing no significant advantage for some forms of surgical fixation over conservative treatment, and no difference between different surgical techniques, there is a lack of evidence comparing two of the most common treatments used: closed reduction and casting versus plating. Surgical management involves significant costs and risks compared with conservative management. High-level evidence is required to address practice variation, justify costs and to provide the best clinical outcomes for patients.
METHODS AND ANALYSIS: This pragmatic, multicentre randomised comparative effectiveness trial aims to determine whether plating leads to better pain and function and is more cost-effective than closed reduction and casting of displaced distal radius fractures in adults aged 60 years and older. The trial will compare the two techniques but will also follow consenting patients who are unwilling to be randomised in a separate, observational cohort. Inclusion of non-randomised patients addresses selection bias, provides practice and outcome insights about standard care, and improves the generalisability of the results from the randomised trial.
ETHICS AND DISSEMINATION: CROSSFIRE(Combined Randomised and Observational Study of Surgery for Fractures In the distal Radius in the Elderly) was reviewed and approved by The Hunter New England HREC (HNEHREC Reference No: 16/02/17/3.04). The results of the trial will be published in a peer-reviewed journal and will be disseminated via various forms of media. Results will be incorporated in clinical recommendations and practice guidelines produced by professional bodies.
REGISTRATION: CROSSFIRE has been registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR: ACTRN12616000969460).
Muscular and Skeletal Diseases (1) Osteoporosis (1), more mentions