Background: To stimulate a debate as to whether neurological compromise as a result of spinal instrumentation is the result of direct or indirect cord injury of more the result of cord ischaemia due to the highly abnormal vascular anatomy encountered in these patients. Methods: Review of three cases of neuromuscular scoliosis who underwent angiograms under general anaesthetic. Graphical comparisons with normal patterns spinal vascular anatomy. Results: Vascular anatomy was found to be so abnormal in these patients that the series was discontinued due to the perceived risk of paraplegia as a result of the angiogram procedure itself. Conclusion: We plan to perform CT angiograms in patients with neuromuscular scoliosis to further elucidate the vascular anatomy in these patients

Shoulder Arthroscopy techniques may pose surgical risk to vascular structures that may cause active bleeding during surgery. The vascularity of the subacromial structures showed constant patterns of distribution and specific sources of bleeding were analyzed. Knowledge of the vascular anatomy may decrease the bleeding during subacromial arthroscopy surgery. Shoulder Arthroscopy techniques may pose surgical risk to vascular structures that may cause active bleeding during surgery. A detailed anatomy map of frequent sources of bleeding is more than desired in order to properly identify these bleeding points, and avoid the unnecessary overuse of thermal tools and pressure pumps to control the hemorrhage. Our purpose is to study the vascular anatomy of the subacromial space, and to map the major sources of expected bleeding during subacromial arthroscopy surgery. Ten shoulders of five adult cadavers underwent whole body arterial perfusion with a mixture of lead oxide, gelatin and water. The shoulders were dissected, photographed, tissue specimens were radio graphed, scanned and analyzed with a digital software analyzer. Careful dissection of the different arteries of the subacromial bursa, and anatomic landmarks of the walls were documented. Correlations of bleeding areas during subacromial arthroscopic surgery and cadaver dissection were carried out. A vascular map of the bursa was created. The vascularity of the subacromial structures showed constant patterns of distribution and specific sources of bleeding were analyzed. We divided this space into walls with their major arteries as follows: Anterior wall: Acromial branch of the thoracoacromial artery. Posterior wall: Acromial branch of the suprascapular artery. Medial wall: Anterior and posterior Arteries of the AC joint. Lateral wall: No major arteries identified. Vascularity of the roof and floor is also described. The subacromial space is highly vascular. Knowledge of the vascular anatomy may decrease the bleeding during subacromial arthroscopy surgery

Introduction: It may not be possible to obtain anatomical reduction of displaced supracondylar fractures in children by closed manipulation. We have found difficulties performing open reduction using the described surgical approaches. We report an approach based on studies of the vascular anatomy of triceps, which provides a wide exposure facilitating surgery. Material And Methods: Between 2002 and 2004 we performed open reduction and internal fixation on 12 children (8 girls, 4 boys: mean age 6). Our vascular injection studies indicate that the blood supply to triceps brachii is proximally based. We used a posterior approach identifying the ulnar nerve. We mobilised lateral triceps and anconeus in continuity preserving the vascularity and separated the components of distal triceps through an intermuscular septum. The fractures were reduced and fixed using K wires. Results: The fractures healed in the anatomical position in each child and all 12 demonstrated a full range of elbow movements within 6–8 weeks of K wire removal. We observed no complications. Discussion: Although closed reduction and percutaneous K wire fixation remains the treatment of choice for displaced supracondylar humeral fractures, anatomical reduction must be achieved ideally and residual rotation of the fracture fragments avoided. We have found that this surgical approach has reduced our reluctance to proceed to surgical treatment of these difficult fractures and consequently a tendency to accept sub optimal reduction. Conclusion: A surgical approach based on the vascular anatomy of triceps can be used to provide a wide, symmetrical and safe exposure facilitating open reduction and internal fixation of supracondylar fractures of the humerus in children whilst avoiding complications including residual elbow stiffness

The Delto-pectoral approach is the workhorse of the shoulder surgeon, but surprisingly the common variants of the cephalic vein and deltoid artery have not been documented. The vascular anatomy encountered during one hundred primary elective delto-pectoral approaches was documented and common variants described. Two common variants are described. A type I (71%), whereby the deltoid artery crosses the interval and inserts directly in to the deltoid musculature. In this variant the surgeon is unlikely to encounter any vessels crossing the interval apart from the deltoid artery itself. In a type II pattern (21%) the deltoid artery runs parallel to the cephalic vein on the deltoid surface and is highly likely to give off medial branches (95%) that cross the interval, as well as medial tributaries to the cephalic vein (38%). Knowledge of the two common variants will aid the surgeon when dissecting the delto-pectoral approach and highlights that these vessels crossing the interval are likely to be arterial, rather than venous. This study allows the surgeon to recognize these variations and reproduce bloodless, safe and efficient surgery

Shoulder girdles of 20 cadavers (68–94yrs) were harvested. The anterior (ACHA) and posterior circumflex humeral arteries (PCHA) were injected with ink and the extra and intraosseous courses of the dyed vasculature dissected through the soft tissues and bone to the osteotendinous junctions of the rotator cuff. The ink injection and bone dissection method was newly developed for the study. Rates of cross-over at the osteotendinous juntion were 75% in the supraspinatus, 67% in subscapularis, 33% in infraspinatus and 20% in teres minor. The supraspinatus and subscapularis insertions were vascularised by the arcuate artery, a branch of the ACHA. The insertions of the infraspinatus and teres minor were supplied by an unnamed terminal branch of the PCHA. The insertions of the rotator cuff receive an arterial supply across their OTJ's in 50% of cases. This may explain observed rates of AVN in comminuted proximal humeral fractures. The terminal branch of the PCHA supplying the infraspinatus and teres minor insertions was named the “Posterolateral Artery”. Finally, the new method employed for this study which allowed for direct visualisation of intraosseous vasculature, will enhance our understanding of skeletal vascular anatomy and have clinical applications in orthopaedic and reconstructive surgery

Introduction. The vascular anatomy of the femoral head and neck has been previously reported, with the primary blood supply attributed to the deep branch of the Medial Femoral Circumflex Artery (MFCA). This understanding has led to development of improved techniques for surgical hip dislocation for multiple intra-capsular hip procedures including Hip Resurfacing Arthroplasty (HRA). However, there is a lack of information in the literature on quantitative analysis of the contributions of the Lateral Femoral Circumflex Artery (LFCA) to femoral head and neck. Additionally, there is a lack of detailed descriptions in the literature of the anatomic course of the LFCA from its origin to its terminal branches. Materials & Methods. Twelve fresh-frozen human pelvic cadaveric specimens were studied (mean age 54.3 years, range 28–69). One hip per specimen was randomly assigned as the experimental hip, with the contralateral used as a control. Bilateral vascular dissection was performed to cannulate the MFCA and LFCA. Specimens were assigned as either LFCA-experimental or MFCA-experimental. All specimens underwent a validated quantitative-MRI protocol: 2mm slice thickness with pre- and post- MRI contrast sequences (Gd-DTPA diluted with saline at 3:1). In the LFCA-experimental group 15ml of MRI contrast solution was injected into the LFCA cannula. In the MFCA-experimental group 15ml of contrast solution was injected into the MFCA cannula. On the control hip contrast solution was injected into both MFCA and LFCA cannulas, 15ml each (30ml total for the control hip). Following MRI, the MFCA and LFCA were injected with polyurethane compound mixed with barium sulfate (barium sulfate only present in either MFCA or LFCA on each hip). Once polymerization had occurred, hips underwent thin-slice CT scan to document the extra- and intra-capsular course of the LFCA and MFCA. Gross dissection was performed to visually assess all intra-capsular branches of both the MFCA and LFCA and assess for extravasation. Quantitative-MRI analysis was performed based on Region of Interest (ROI) assessment. Femoral heads were osteotomized at the level of the largest diameter proximal to the articular margin and perpendicular to the femoral neck, for placement of a 360° scale. Measurements using the 360° scale were recorded. For data processing, we used right-side equivalents and integrated our 360° data into the more commonly used imaginary clock face. Results. Quantitative analysis of contributions of the MFCA and LFCA are detailed (Table 1). Thin slice CT scan graphical analysis of the LFCA provided (Figure 1). Topographic 360° scale (and imaginary clock face) results are also detailed in a diagram (Figure 2). Discussion. This study provides the first comparative results for quantitative assessment of arterial contributions from both the MFCA and LFCA for the femoral head and neck. The MFCA is the dominant vessel for both the femoral head and neck, supplying 82% of the femoral head and 67% of the femoral neck. The LFCA plays its largest role in the inferoanterior femoral neck (with a 48% arterial contribution). This finding highlights the importance of protecting the LFCA in addition to the MFCA during intra-capsular hip procedures including Hip Resurfacing Arthroplasty

Aims. Meningococcal septicaemia can result in growth arrest and angular deformities. The aim of this case series was to review the pattern of involvement in the lower leg. Patients and Methods. The notes and radiographs of all patients presenting with a growth arrest or deformity affecting the lower leg following meningococcal septicaemia between 1995 and 2010 were reviewed. There were fourteen patients, eight girls and six boys. The mean age of the patients at the time of presentation was 9.6 years. Results. There was a variety of deformities with some patients exhibiting several deformities in the same limb and/or bilateral deformities. Some of the deformities were complex. Nine patients had a lower limb length discrepancy (mean 4.8cms, range: 1 to 13cms). There were a total of 27 lower limb deformities; three patients had bilateral lower limb deformities. In 14 the proximal tibia was involved causing genu varum in 12 cases and genu valgum in two cases. Seven distal tibia deformities all resulted in varus deformity. In all cases, the fibula was spared. Discussion. In this series involvement of the tibial physeal growth plates was frequently asymmetric and with two exceptions resulted in a varus deformity. The medial and anterior proximal tibial physis seems particularly susceptible to the sequelae of meningococcal septicaemia whereas the fibula physeal plates were always spared. These observations confirm the work of other authors and this characteristic pattern of involvement is likely to reflect the vascular anatomy of the physeal plates. The fibula may be protected from damage because of the nature of its blood supply. Modern limb reconstruction techniques, particularly the Spatial frame now permit correction of these complex and difficult deformities

Vascular injury associated with hip surgery is a rare but serious complication. Hip surgeons need to understand the vascular anatomy around the acetabulum to avoid vascular injury. The aim of this study was to visualize the pelvic vascular structures thorough the osseous acetabulum using 3DCT angiography and to describe the three-dimensional relationship between the vessels and the acetabulum. A total of 100 patients who took 3DCT with intravenous contrast for intra-pelvic neoplastic disease were randomly chosen. Those patients with hip disease were excluded. Three examinations were performed. First, dual-phase helical CT data were transferred to a workstation (M900;Zio,Tokyo,Japan) and 3D visualizations of the vascular structures through the pelvis were reconstructed. Second, location of the external iliac, femoral and obturator vessels were investigated in axial CT images. Finally, influence of the age factor on the anatomical courses of the external iliac vessels was assessed. Reconstructed 3D images were able to provide spatial relationship between courses of the pelvic vascular structures and the acetabulum. We could visualize the pelvic vascular structures thorough the pelvis from similar operative viewpoints. Axial CT examinations revealed the external iliac vessels locate very closely to the pelvis as they exit the pelvic cavity. Especially, the left side vessels and vein were closer to the pelvis. The femoral vessels became closer to the acetabular edge with traveling distally. At the distal half of the acetabulum, the femoral vessels located just ventrally to the anterior acetabular edge. The obturator vessels courses inferiorly along the quadrilateral surface behind the acetabulum, they became very close to the inner cortex or the acetabulum. Straight type of the anatomical course of the external iliac vessels was the most common configuration in young patients, curved and the tortuous types were present in older patients. The results of this study are useful to understand the anatomical orientation of the vessels around the acetabulum. To avoid vascular injuries in hip surgery, knowledge of the vascular orientation is of critical importance for the hip surgeon

Aims

This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure.

Aims: Consideration of gravity of talar neck fractures and evaluation of their treatment results. Methods: From 1992 to 2001 were admitted to our department 26 patients, suffering from talar neck fractures. We were able to reexam 22 patients (17 males and 5 females), with mean age 34,14y. (16 to 64y.). Fourteen pt. (63,6%) were car accident victims. In the rest of them fracture occurred after fall from height more than 3m. There were 8 (36.3%) multi-injured patients. Preoperative diagnostic approach included simple x-rays and CT scan and Hawkins classiþcation was used. All patients underwent surgical treatment. Operative technique included open reduction and internal þxation using screws and/or K-Ws. Postoperatively patients were evaluated with radiological and clinical criteria according to Iowa Ankle Evaluation score. Results: Mean follow up was 58 months (from 12 months to 9 years). Results were excellent in 10 (45,4%), good in 6 (27.2%), fair in 4 (18.1%) and poor in 2 (11%) patients. Two cases developed avascular necrosis (1 type D and 1 type C) followed by body collapse and treated with ankle arthrodesis. Furthermore 1 patient underwent ankle and 6 patients subtalar arthrodesis because of arthritis caused from concomitant fractures. Conclusions: Treatment of talar neck fractures is a challenge because of high rate of complications, because of talusñ shape and vascular anatomy. Anatomic reduction and rigid internal þxation, in combination with immobilization and no weight bearing until restoration of talusñ architecture is achieved, are essential requirements for good result

Purpose: The purpose of this study is to investigate the external and internal vascular anatomy of the lunate bone. The genesis of lunatomalacia requires some combination of load, vascular risk and mechanical predisposition. The findings will be correlated with the major existing theories of the cause of lunatomalacia and the most frequent fractures associated with Kienbocks disease: transverse shear fracture and midcoronal fracture. Material and methods: We studied 21 cadaver upper limbs using latex injection and Spalteholz technique. We investigated the extra- and intraosseous blood supply. In 17 wrists we evaluate the incidence and distribution of anatomic features, arthrosis, and soft tissue lesions. Results: The lunate morphology was 5 Type I (29.4%), 11 Type II (64.7%) and 1 Type III (5.9%). The lunate was found to have a separate facet for the hamate in 47.1% (Size 3–6 mm). Most frequent arthrosis was identified in the radius (88.2%) and lunate (94.1%). The triangular fibrocartilage complex (TFCC) was found torn in 47%, the lunotriquetral interosseous ligament (LTIL) was torn in 23.5%, and the scapholunate interosseous ligament (SLIL) was torn in 53% of the wrists. Statistical analysis found a correlation between the presence of arthrosis at the proximal pole of the hamate and the presence of a lunate facet. There was also a correlation between the presence of a tear in the SLIL and the presence of cartilage erosion in the scaphoid (p= 0.002). Arthrosis on the lunate was found to have a correlation with an SLIL tear or TFCC tear. The nutrient vessels entered the lunate throught the dorsal and volar poles in all the specimens. Dorsal vessels enter the bone through one or two foramina in the proximal, ulnar, and nonarticular aspect of the bone. Two to six nutrient vessels were observed entering the volar pole throught a ligament insertion: radioscapholunate ligament of Testut-Kuentz, radio-lunate-triquetrum ligament and ulnar-lunate-triquetrum ligament. Conclusions: The lunate had consistent dorsal and palmar arteries entering the bone in all the specimens. The supply blood and foramina number is more important in the volar pole of the lunate than the dorsal pole. The vascular patterns support a theory of compression fracture from repeated trauma, or anatomical predispositions as the most likely cause of Kienbocks disease

Proximal humeral fractures account for approximately 4–5% of all fractures seen in the emergency departments. Of all shoulder injuries they account for aproximatelly 53%. In 1970 Neer published his classic study, in which he described a new method of classification, and gave recommendations for treatment. Neer recommended ORIF for three-part fractures, and prosthetic replacement for four-part fractures and fracture-dislocations. However there is still disagreement on the management of the displaced humeral fractures. Diagnosis. Accurate radiographic evaluation, is essential in order to make a correct classification of the proximal humeral fractures. The radiographic examination consists of films from three different views. The anterio-posterior (AP), lateral (Y view of the scapula), and the axillary one. The AP view will assess the fracture position, and by centring it 30 degrees posteriorly and obliquely, clearly image the glenohumeral joint space. The lateral view is taken perpendicular to the scapular plain. The head overlaps the glenoid, and projects on the centre of a “Y“, formed by acromion, the coracoid superiorly, and the scapular body inferiorly. In this projection any large avulsed greater tuberosity fragments are usually easy to visualise posteriorly, and the lesser tuberosity is visualised medialy. The axillary view is the most useful in assessing the relationship between the humeral head and the glenoid. Fracture dislocations, and true posterior dislocations can be easily distinguished in the axial view. Computer tomography, plain or with three dimensional reconstruction-views might also help the surgeon to make an accurate diagnosis and in preoperative planning. Classification. A valid classification system can be useful as a tool to select the optimal treatment. The system should be comprehensive enough to reflect the complex fracture pattern, and specific enough to allow an accurate diagnosis. The classification should be useful as a tool for identifying those fractures which should be operated upon. In 1935, Codman proposed a new classification system based on four different anatomical fragments of the proximal humerus. The anatomical head, the greater tuberosity, the lesser tuberosity and the humeral shaft. Codman stressed that the musculotendinous cuff attachment to each fragment was of major significance to the fracture pattern. In 1970 Neer further developed Codmans classification, stressing the importance of the biomechanical forces, and the degree of displacement for more complex fractures. When any of the four major segments is displaced over 1 cm or angulated more than 45 degrees, the fracture is considered to be displaced: Group 1: all fractures regardless of the level or number of fracture lines, in wich NO segments are displaced. Group 2: a two-part fracture is one in which one fragment is displaced in reference to the other three fragments. Group 3: a three-part fracture is one in which two fragments are displaced in relationship to each other and the other two are undisplaced fragments, but the head remains in contact with the glenoid. Group 4: a four-part fracture is one in which all four fracture fragments are displaced; the articular surface of the head is out of contact with the glenoid and angulated either laterally, anteriorly, posteriorly, inferiorly, or superiorly. Furthermore it is detached from both tuberosities. Neer has also emphasised the term fracture dislocation. It exists when the head is displaced outside the joint space rather than subluxated or rotated and there is, in addition, a fracture. The degree of displacement is directly related to the clinical outcome and the choice of treatment. In the 1970’s the AO group from Switzerland, emphasised the importance of the blood supply to the articular surface of the humeral head. Since the risk for avascular necrosis was high, they based their classification on the vascular anatomy of the proximal humerus. The system classified the fractures into three different categories:. Group A: Extra-articular, unifocal fracture. Group B: Partially extra-articular, bi-focal fracture. Group C: Articular fracture. Each group is sub-divided into three categories, from less to more serious lesions. This gave us 27 different sub-groups to analyse and interpret. The AO system is easy to use for the diaphyseal segments of the femur, tibia and humeral shaft, but applying it to the proximal humerus is confusing, and makes it more difficult to use than the Neer system. Consequently the AO classification system has not gained general acceptance among shoulder surgeons. The reliability and the reproducibility of these classifications have been questioned Unfortunately, we do not have a better classification system on hand and therefore the Neer system is still widely used. Treatment. Many methods of treatment of proximal humeral fractures have been proposed during the past 50 years, creating a great deal of controversy and confusion. There are two main treatment options: Non-operative treatment and operative. Conservative treatment. Approximately 80% of all proximal humeral fractures are non-displaced, or only minimally displaced, and the clinical outcome is satisfactory after conservative treatment. After some days of rest, early mobilisation with gentle physiotherapy is of great importance. Operative treatment. Various types of osteosynthesis have been suggested. Semitubular straight or angulated plates, screws, Rush pins, external fixators, cerclage wires, tension band technique or K-wires with bone grafting have been used. The results reported range from excellent to poor. In cases of three- and four- part fractures, most authors have used open reduction with internal fixation. Because of poor bone quality, and a torn cuff, especially in elderly patients, osteosynthesis is not always the best choice. Hemiarthroplasty is reported to give an excellent outcome in many studies. In fracture dislocations, when closed reduction is not possible, the only way to restore the dislocated shoulder joint is to perform an open reduction and stabilise the fracture with an osteosynthesis implant, or replace the humeral head with a hemiarthroplasty. Scoring systems for evaluation of the end results. There are two rating systems generally used. The Neer system from 1970 has been widely used in a number of studies, all over the world, and the Constant-Murley system from 1987 has been recommended for use in Europe. Neer’s rating system from 1970 is used to assess shoulder function, after fractures, arthroplasty and dislocations. It is based on a 100 units scale, with points for pain (35), function (30), range of motion (25), and anatomy (10). In 1987 Constant and Murley designed a European scoring system, claiming it to be applicable for measuring shoulder function regardless of diagnosis. This system is also based on a 100 point scale. The degree of pain, activities of daily living, strength, and active range of movement are assessed. The results are then related to gender, age and activity level of the patient. Both systems has recently been questioned because of its low reliability. Confusion remains because different authors from the USA and Europe continue to use their own criteria for evaluation. Consequently, it is not unusual that the reported results after fracture treatment vary, depending on which rating system was used

Pelvic and acetabular surgery may be associated with significant blood loss because of the vascularity and anatomy of the pelvis. Concerns continue in relation to blood transfusion because of the potential for disease transmission and because of the increasing cost of providing safe blood products. The purpose of this study was to examine in a retrospective fashion the blood transfusion requirements in a consecutive series of patients undergoing peri-acetabular osteotomy for hip dysplasia. Surgery was performed under general anaesthesia with an epidural in place in the majority of cases. A cell saver was not used and no pre operative autologous blood donation was performed. In seven cases one unit of blood was drawn off immediately prior to the operation in the anaesthetic room and re-infused towards the end of the operation. This practice was discontinued when one of these units clotted and could not be re-infused. A post-operative transfusion policy was adopted where an haemoglobin (Hb) concentration of < 7.5 g/dl was an indication for transfusion. There were 19 females and 2 males. The average age was 26.6 (range 14 – 40). The average duration of surgery was 233mins (range 180 – 285min). Pre-operatively the average Hb concentration was 13.68 g/dl (range 12.3 – 16.2 g/dl). Overall 16 patients did not require any cross-matched transfusion. Two patients received one unit of blood and three received two units. If the transfusion policy had been correctly followed, 4 of these patients would not have received cross-matched blood. The average post-op Hb in those not receiving transfusion was 8.6 g/dl (range 7.3 – 9.9 g/dl). This study shows that it is possible to safely perform peri-acetabular osteotomies in most cases without blood transfusion which is important in this group of patients who are generally young and female

Objectives

As well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures.