In this study, we discuss 68 cases in which peripheral nerve trunks were inadvertently divided by surgeons. Most of these accidents occurred in the course of planned operations. Delay in diagnosis and in effecting repair was common. We list the nerves particularly at risk and the operations in which special care is needed. We recommend steps to secure prompt diagnosis and early treatment.
Advanced 3D imaging and CT-based navigation have emerged as valuable tools to use in total knee arthroplasty (TKA), for both preoperative planning and the intraoperative execution of different philosophies of alignment. Preoperative planning using CT-based 3D imaging enables more accurate prediction of the size of components, enhancing surgical workflow and optimizing the precision of the positioning of components. Surgeons can assess alignment, osteophytes, and arthritic changes better. These scans provide improved insights into the patellofemoral joint and facilitate tibial sizing and the evaluation of implant-bone contact area in cementless TKA. Preoperative CT imaging is also required for the development of patient-specific instrumentation cutting guides, aiming to reduce intraoperative blood loss and improve the surgical technique in complex cases. Intraoperative CT-based navigation and haptic guidance facilitates precise execution of the preoperative plan, aiming for optimal positioning of the components and accurate alignment, as determined by the surgeon’s philosophy. It also helps reduce
Percutaneous stabilisation of tibial fractures by locking plates has become an accepted form of osteosynthesis. A potential disadvantage of this technique is the risk of damage to the neurovascular bundles in the anterior and peroneal compartments. Our aim in this anatomical study was to examine the relationship of the deep peroneal nerve to a percutaneously-inserted Less Invasive Stabilisation System tibial plate in the lower limbs of 18 cadavers. Screws were inserted through stab incisions. The neurovascular bundle was dissected to reveal its relationship to the plate and screws. In all cases, the deep peroneal nerve was in direct contact with the plate between the 11th and the 13th holes. In ten specimens the nerve crossed superficial to the plate, in six it was interposed between the plate and the bone and in the remaining two specimens it coursed at the edge of the plate. Percutaneous insertion of plates with more than ten holes is not recommended because of the risk of injury to the neurovascular structures. When longer plates are required we suggest distal exposure so that the neurovascular bundle may be displayed and protected.
Vascular injuries during total hip arthroplasty
(THA) are rare but when they occur, have serious consequences. These have
traditionally been managed with open exploration and repair, but
more recently there has been a trend towards percutaneous endovascular
management. We performed a systematic review of the literature to assess
if this change in trend has led to an improvement in the overall
reported rates of morbidity and mortality during the last 22 years
in comparison with the reviews of the literature published previously. We found a total of 61 articles describing 138 vascular injuries
in 124 patients. Injuries because of a laceration were the most
prevalent (n = 51, 44%) and the most common presenting feature,
when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis
was associated with the type of vascular lesion (p <
0.001) and
the clinical presentation (p = 0.002). Open exploration and repair was the most common form of management,
however percutaneous endovascular intervention was used in one third
of the injuries and more constantly during the last 13 years. The main overall reported complications included death (n = 9,
7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9,
7.3%). When compared with previous reviews there was a similar rate
of mortality but lower rates of amputation and permanent disability,
especially in patients managed by endovascular strategies. Cite this article:
I never considered this to be a significant problem if it is noticed. (back to that later) Aaron Rosenberg's report seems to have agreed, but at the last members meeting of the Knee Society, Boston, September 2009, others had experience that contradicted my view. With their experience, ultimately the results were very substantially compromised. This video and presentation show you how to avoid a bad result, actually obtain a perfect result, if you or your student assistant, resident or fellow, bags the MCL. There are three important points. (1) One needs to recognise the occurrence. (2) The setting is usually varus and so direct end-to-end repair cannot be depended upon. (3) Use of a semitendinosis tenodesis, together with an imperfect, distracted direct repair works perfectly well! (1) Recognition: The setting is usually varus, but I have had one case in which the chief resident, working with the fellow succeeded in getting the MCL in a valgus knee! In this usually tight varus setting the key feature is that at some point in the case, before component placement, one notices that the exposure is all of a sudden better! Now, the guilty resident or just a passive assisting resident/fellow will usually disagree. The extension space is not so obviously lax, but the flexion space is. Secondly, you do not feel an intact ligament in flexion. And, to prove it I have had to do a little more exposure of the superficial MCL to show the tear. There are at least three mechanisms. Most common is a saw cut. Next is possibly injury with the scalpel or cutting cautery during exposure, and last is damage essentially pre-operatively by a very sharp medial osteophyte which has thoroughly abraded the ligament. Laxity in full flexion is not necessarily obvious as the posterior capsular integrity helps hide the instability. Again, the really intact ligament is well felt, and in the situation of laceration, the tibia pulls forward more on the medial side, the medial flexion space opens, and what was usually a tight exposure gets suddenly better. (2) When varus is the setting, I have found it impossible or at least uncomfortable to depend upon direct repair. When the soft tissues are needing to be released or simply undergoing more stress than usual and a lot more than on the lateral side, I see it as unwise to expect or depend upon only a medial repair to hold. (3) The semitendinosis tenodesis has worked essentially perfectly in every one of my cases. These patients have had no post-operative instability and they have had better than average to extremely good ROM. A presumably key point is not to alter the patient's post-operative regimen! And, to avoid some passive alteration of PT, I advise specifically that the surgeon or those in his/her team do not mention the occurrence to the patient, the family or the PT! I put the whole story in the op-note, and weeks later I will specifically tell the patient what the staple in place is all about.
I never considered this to be a significant problem if it is noticed. (back to that later) Aaron Rosenberg's report seems to have agreed, but at the last members' meeting of the Knee Society, Boston, September 2009, others had experience that contradicted my view. With some experience, ultimately the results were very substantially compromised. This video and presentation show you how to avoid a bad result, actually obtain a perfect result, if you or your student assistant, resident or fellow, bags the MCL. There are three important points. (1) One needs to recognise the occurrence. (2) The setting is usually varus and so direct end-to-end repair cannot be depended upon. (3) Use of a semitendinosis tenodesis, together with an imperfect, distracted direct repair works perfectly well!
Recognition: The setting is usually varus, but I have had one case in which the chief resident, working with the fellow succeeded in getting the MCL in a valgus knee! In this usually tight varus setting the key feature is that at some point in the case, before component placement, one notices that the exposure is all of a sudden better! Now, the guilty resident or just a passive assisting resident/fellow will usually disagree. The extension space is not so obviously lax, but the flexion space is. Secondly, you do not feel an intact ligament in flexion. And, to prove it I have had to do a little more exposure of the superficial MCL to show the tear. There are at least three mechanisms. Most common is a saw cut. Next is possibly injury with the scalpel or cutting cautery during exposure, and last is damage essentially pre-op by a very sharp medial osteophyte which has thoroughly abraded the ligament. Laxity in full flexion is not necessarily obvious as the posterior capsular integrity helps hide the instability. Again, the really intact ligament is well felt, and in the situation of laceration, the tibia pulls forward more on the medial side, the medial flexion space opens, and what was usually a tight exposure gets suddenly better. When varus is the setting, I have found it impossible or at least uncomfortable to depend upon direct repair. When the soft tissues are needing to be released or simply undergoing more stress than usual and a lot more than on the lateral side, I see it as unwise to expect or depend upon only a medial repair to hold. The semitendinosis tenodesis has worked essentially perfectly in every one of my cases. These patients have had no post-operative instability and they have had better than average to extremely good ROM. A presumably key point is not to alter the patient's post-operative regimen! And, to avoid some passive alteration of PT, I advise specifically that the surgeon or those in his/her team do not mention the occurrence to the patient, the family or the PT! I put the whole story in the op-note, and weeks later I will specifically tell the patient what the staple in place is all about.
To evaluate the functional outcome of open humerus diaphyseal fractures treated with the Three-stitch technique of antegrade humerus nailing. This is a retrospective study conducted at the Department of Orthopaedics in D. Y. Patil University, School of Medicine, Navi Mumbai, India. The study included 25 patients who were operated on from January 2019 to April 2021 and follow-ups done till May 2022. Inclusion criteria were adult patients with open humerus diaphyseal fractures (Gustilo-Anderson Classification). All patients with closed fractures, skeletally immature patients, and patients with associated head injury were excluded from the study. All patients were operated on with a minimally invasive Three-stitch technique for antegrade humerus nailing. All patients were evaluated based on DASH score. Out of the 25 patients included in the study, all patients showed complete union. The mean age of the patients was 40.4 years (range 23–66 years). The average period for consolidation of fracture was 10.56 weeks (range 8–14 weeks). The DASH score ranged from 0 to 15.8 with an average score of 2.96. Five patients reported complications with three patients of post-operative infection and delayed wound healing and two patients with screw loosening. All complications were resolved with proper wound care and the complete union was noted. None of the patients had an
Several studies have evaluated the risk of peroneal nerve (PN) injuries in all-inside lateral meniscal repair using standard knee magnetic resonance imaging (MRI) with the 30 degrees flexed knee position which is different from the knee position during actual arthroscopic lateral meniscal repair. The point of concern is “Can the risk of PN injury using standard knee MRIs be accurately determined”. To evaluate and compare the risk of PN injury in all-inside lateral meniscal repair in relation to both borders of the popliteus tendon (PT) using MRIs of the two knee positions in the same patients. Using axial MRI studies with standard knee MRIs and figure-of-4 with joint fluid dilatation actual arthroscopic lateral meniscal repair position MRIs, direct lines were drawn simulating a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the PT. The distance from the tip of each line to the PN was measured. If a line touched or passed the PN, a potential risk of
Background. Open subtalar arthrodesis has been associated with a moderate rate of non-union, as high 16.3%, and high rates of infection and nerve injury. Performing this operation arthroscopically serves to limit the disruption to the soft tissue envelope, improve union rates and reduce infection. Our study describes our outcomes and experience of this operation. Method. Retrospective review of all patients who underwent an arthroscopic subtalar arthrodesis between 2023 and 2008. We excluded patients undergoing concurrent adjacent joint arthrodesis. The primary aim was to report on rates of union. Secondary outcomes included reporting on conversion to open procedure, duration of surgery, infection, and
Recent literature has demonstrated that conventional arthroscopic techniques do not adequately visualise areas of predilection of pathology of the long head of biceps (LHB) tendon and are associated with a 30–50% rate of missed diagnoses. The aim of this study was to evaluate the safety, effectiveness and ease of performing biceps tenoscopy as a novel strategy for reducing the rate of missed diagnoses. Five forequarter amputation cadaver specimens were studied. The pressure in the anterior compartment was measured before and after surgical evaluation. Diagnostic glenohumeral arthroscopy was performed and the biceps tendon was tagged to mark the maximum length visualised by pulling the tendon into the joint. Biceps tenoscopy was performed using 3 different techniques (1. Flexible video-endoscopy, 2. Standard arthroscopy via Neviaser portal. 3. Standard arthroscope via antero-superior portal with retrograde instrumentation). Each was assessed for safety, ease of the procedure and whether the full length of the extra-articular part of the LHB tendon could be visualised. The t-test was used to compare the length of the LHB tendon visualised at standard glenohumeral arthroscopy vs that visualised at biceps tenoscopy. An open dissection was performed after the arthroscopic procedures to evaluate for an
Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of
Controversy remains regarding the optimal treatment for
Controversy remains regarding the optimal treatment for
Controversy remains regarding the optimal treatment for
Objective:. To observe the incidence of intra-operative vascular injuries during anterior cervical decompression and fusion (ACDF). Secondly, management and monitoring of the outcome post vascular injury during ACDF. Methods:. This a prospective study. A review of all spinal patients' records was performed from June 2006 to April 2011. A comprehensive literature review was also utilized. Inclusion criteria – all patients had ACDF post trauma. All non-traumatic cases were excluded. Results:. The study consisted of 55 patients; 15 were females and 40 were males. The age distribution was 23–65 years. Two patients were excluded due to non-traumatic causes. Of the remaining 53 patients, four sustained intra-operative vascular injuries during ACDF surgery. All 4 patients had corpectomies, and one case was an
Introduction and Aims: The Lateral Femoral Cutaneous Nerve is placed at risk of
Intramedullary tibial nailing was performed in ten paired cadavers and the insertion of a medial-to-lateral proximal oblique locking screw was simulated in each specimen. Anatomical dissection was undertaken to determine the relationship of the common peroneal nerve to the cross-screw. The common peroneal nerve was contacted directly in four tibiae and the cross-screw was a mean of 2.6 mm (1.0 to 10.7) away from the nerve in the remaining 16.
Introduction. Soft tissue releases are often required to correct deformity and achieve gap balance in total knee arthroplasty (TKA). However, the process of releasing soft tissues can be subjective and highly variable and is often perceived as an ‘art’ in TKA surgery. Releasing soft tissues also increases the risk of
Aims. We set out to determine if there is a difference in perioperative outcomes between early and delayed surgery in paediatric supracondylar humeral fractures in the absence of vascular compromise through a systematic review and meta-analysis. Materials and Methods. A literature search was performed, with search outputs screened for studies meeting the inclusion criteria. The groups of early surgery (ES) and delayed surgery (DS) were classified by study authors. The primary outcome measure was open reduction requirement. Meta-analysis was performed in the presence of sufficient study homogeneity. Individual study risk of bias was assessed using the Risk of Bias in Non-Randomised Studies – of Interventions (ROBINS-I) criteria, with the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria used to evaluate outcomes independently. Results. A total of 12 studies met the inclusion criteria (1735 fractures). Pooled mean time to surgery from injury was and 10.7 hours for ES and 91.8 hours for DS. On meta-analysis there was no significant difference between ES versus DS for the outcome of open reduction requirement. There was also no significant difference for the outcomes:
Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap).Aims
Methods
Percutaneous Achilles tenotomy is an integral part of the Ponseti technique. Though considered as a simple procedure, many authors have reported serious neurovascular complications that include
We reviewed the outcome, at a mean follow-up of 14 months, of 21 two-column fractures of the acetabulum treated by operation through one or two non-extensile approaches. Eighteen procedures resulted in reduction of the articular surfaces to within 3 mm. The blood loss and operating time when two combined non-extensile approaches were used were similar to those reported for extended acetabular approaches. The incidence of heterotopic ossification which limited joint motion was low, and the average Harris hip score was 81 points. The use of non-extensile approaches for acetabular fractures in which both columns are involved avoids
Equinus contracture of the ankle due to a tight Gastrocnemius has been implicated in the pathogenesis of a number of foot and ankle conditions. There are numerous described procedures for release of the Gastrocnemius such as the Strayer procedure. Our indications for release are in patients with a symptomatic forefoot and an equinus contracture of 5 degrees or more in extension as defined by the Silfverskiöld test. The release is usually combined with a reconstructive procedure. The advantages of our technique are its simplicity, excellent visualisation of the tendon and sural nerve, good wound healing and patient comfort post-operatively. The procedure can be performed without tourniquet. A 2.5cm incision is made over the medial calf, just distal to the Gastrocnemius muscle indentation. The deep fascia is incised and the edge of the tendon can be visualised. Blunt digital dissection is performed on either side of the tendon to develop a plane. A metal Cusco speculum is inserted to visualise the full width of the tendon. The tenotomy is performed starting medially and the last 5mm of the lateral tendon is left uncut. This reduces the chance of
This systematic review aimed to summarize the full range of complications reported following ankle arthroscopy and the frequency at which they occur. A computer-based search was performed in PubMed, Embase, Emcare, and ISI Web of Science. Two-stage title/abstract and full-text screening was performed independently by two reviewers. English-language original research studies reporting perioperative complications in a cohort of at least ten patients undergoing ankle arthroscopy were included. Complications were pooled across included studies in order to derive an overall complication rate. Quality assessment was performed using the Oxford Centre for Evidence-Based Medicine levels of evidence classification.Aims
Methods
MIS (minimally invasive surgery) aims to improve cosmesis and facilitate early recovery by using a small skin incision with minimal soft tissue disruption. When using MIS in the forefoot, there is concern about neurovascular and tendon damage and cutaneous burns. The aim of this anatomical study was to identify the structures at risk with the proposed MIS techniques and to determine the frequency of
Aim: The retrospective evaluation of external fixation as a treatment of choice for fractures of humeral diaphysis. Material – Method: 24 patients with an equal number of fractures of humerus diaphysis (21 closed, 3 open) were treated with external fixation. Time to bony union, the seriousness and type of complications, the clinical, radiological and functional outcome were evaluated. The minimum time of follow up was six months. Results: Excellent 20, good 2, fair 1, poor 1. The cause of fair and poor results was limitation of shoulder motion. 22 fractures united within 2–5 months. Complications were 2 cases of non-union, 3 pin-track infections, 3 remanipulations. There was no case of deep infection at the fracture site and no
The June 2023 Knee Roundup360 looks at: Cementless total knee arthroplasty is associated with early aseptic loosening in a large national database; Is cementless total knee arthroplasty safe in females aged over 75 years?; Could novel radiological findings help identify aseptic tibial loosening?; The Attune cementless versus LCS arthroplasty at introduction; Return to work following total knee arthroplasty and unicompartmental knee arthroplasty; Complications and downsides of the robotic total knee arthroplasty; Mid-flexion instability in kinematic alignment better with posterior-stabilized and medial-stabilized implants?; Patellar resurfacing does not improve outcomes in modern knees.
Aims: Distal humeral shaft fractures are difficult to treat by antegrade humeral nails. In this study we have used a new retrograde nail to treat these fractures. Methods and Material: Since 1997 we have treated 15 extra articular fractures using this device. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any
The August 2023 Wrist & Hand Roundup360 looks at: Complications and patient-reported outcomes after trapeziectomy with a Weilby sling: a cohort study; Swelling, stiffness, and dysfunction following proximal interphalangeal joint sprains; Utility of preoperative MRI for assessing proximal fragment vascularity in scaphoid nonunion; Complications and outcomes of operative treatment for acute perilunate injuries: a systematic review; The position of the median nerve in relation to the palmaris longus tendon at the wrist: a study of 784 MR images; Basal fractures of the ulnar styloid? A randomized controlled trial; Proximal row carpectomy versus four-corner arthrodesis in SLAC and SNAC wrist; Managing cold intolerance after hand injury: a systematic review.
Ten patients who suffered
The August 2024 Trauma Roundup360 looks at: Does topical vancomycin prevent fracture-related infections in closed fractures undergoing open reduction and internal fixation? A randomized controlled trial; Is postoperative splinting advantageous after upper limb fracture surgery?; Does suprapatellar nailing resolve knee pain?; Locking versus non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens; Revolutionizing recovery metrics: PROMIS versus SMFA in orthopaedic trauma care; Dorsal hook plating of patella fractures: reliable fixation and satisfactory outcomes; The impact of obesity on subtrochanteric femur fracture outcomes; Low-dose NSAIDs (ketorolac) and cytokine modulation in orthopaedic polytrauma: a detailed analysis.
Introduction: Vascular injuries associated with limb bone fractures are relatively uncommon. Aim: To determine the mechanisms of injury and evaluate the outcome of combined orthopaedic and vascular injuries. Method: A retrospective review of all patients with vascular injury associated with limb bone fractures between January 1992 and July 2006 was performed. Data collected included demographic details, clinical presentation, assessment, management and outcome. Results: Of 22,340 fractures treated during the 14 years period 36 patients sustained a vascular injury that required surgical intervention. Of those, 18 patients (50%) had a concomitant fractures or other orthopaedic injury this group form the basis of the audit. The median age was 31.1 (range 3–80) years, and 66% were male. Road traffic accidents accounted for 12 injuries (66%), other accidents 4(22%),
The axillary nerve injuries most commonly are observed after trauma such as contusion-stretch, gunshot wound, laceration and
Adult male C57Bl/6 mice (n = 75) were randomized into three groups to receive 1.0 to 1.4 × 107 colony-forming units (CFUs)/ml of 8325-4, DU1090, or saline into the right stifle joint. Chondrocyte death was assessed by confocal microscopy. Histological changes to inoculated joints were graded for inflammatory responses along with gait, weight changes, and limb swelling.Aims
Methods
In an unselected series of 55 cases of slipped capital femoral epiphysis (SCFE) we observed an incidence of 25% of epiphyseal reduction, mostly unintentional. Reduction indicated physeal instability and was associated with an effusion, detected by sonography on admission, and inability to bear weight. The true prevalence of instability may be higher since an effusion was noted in 33 cases (60%) on the initial sonographic assessment. Serial radiographs showed reduction in 12 (22%), with an average change of 15.1 degrees in the head-neck angle. Serial sonography showed reduction in 7 out of 20 cases (35%), with an average change of 3.7 mm in displacement. In two cases reduction was seen on sonography but not on radiography. Of the hips which showed subsequent reduction, 12 had had a bone scan on admission; three showed initial epiphyseal avascularity but only one progressed to symptomatic avascular necrosis. All stable hips had normal epiphyseal vascularity on the initial bone scan. This indicates the importance of injury from the initial displacement in causing avascular necrosis, rather than effusion, vascular compromise or
Both anatomical and reverse total shoulder arthroplasty (aTSA and rTSA) provide functional improvements. A reported benefit of aTSA is better range of motion (ROM). However, it is not clear which procedure provides better outcomes in patients with limited foward elevation (FE). The aim of this study was to compare the outcome of aTSA and rTSA in patients with glenohumeral osteoarthritis (OA), an intact rotator cuff, and limited FE. This was a retrospective review of a single institution’s prospectively collected shoulder arthroplasty database for TSAs undertaken between 2007 and 2020. A total of 344 aTSAs and 163 rTSAs, which were performed in patients with OA and an intact rotator cuff with a minimum follow-up of two years, were included. Using the definition of preoperative stiffness as passive FE ≤ 105°, three cohorts were matched 1:1 by age, sex, and follow-up: stiff aTSAs (85) to non-stiff aTSAs (85); stiff rTSAs (74) to non-stiff rTSAs (74); and stiff rTSAs (64) to stiff aTSAs (64). We the compared ROMs, outcome scores, and complication and revision rates.Aims
Methods
Introduction:. A surgical hip dislocation provides circumferential access to the femoral head and is essential in the treatment pediatric and adult hip disease.
Aims: To identify the incidence of neurological deþcit and functional outcome following displaced acetabular fractures. Methods: We carried out a prospective study of 136 patients who underwent skeletal stabilization of displaced acetabular fractures. Patients with sciatic nerve injuries were identiþed, assessed and followed up clinically. Routine EMG and nerve conduction studies were performed post-operatively on all cases with clinical proven neurological lesions to correlate the level, severity of the lesion and monitor progress of recovery. Results: 27 patients (19.8%) have neurological deþcit identiþed preoperatively. In 12 patients where the femoral heads were dislocated posteriorly. 20 were male and 7 were female. The mean age was 33.8 years (range 16–66). 15 patients had associated injuries but none of the patients had injury to the spinal cord. The mean ISS was 12.6 (range 9–34). The mean follow up was 3.4 years (range 1.5–6 years). 13 patients with complete drop foot at presentation. 9 patients had EMG proven double crush lesion. 3 patients had ipsilateral knee injury. 2 patients had intraopearative
Displaced fractures of the distal humerus are very difficult to treat. Numerous techniques have been developed for internal fixation, e.g. plating, Rush nail fixation, IM nailing etc. Results are not very good in majority of the cases. Conventional ‘antigrade’ nailing sometimes may not be suitable for these types of fractures. This new nail is inserted by a close retrograde technique using a special interlocking system to avoid axillary nerve and rotator cuff damage. This nail also allows stable fixation of these distal fractures via a plate welded its distal end, which maintain the rotational stability. Since 1997 we have treated 15 displaced extra particular fractures using this device. 12 of them were widely displaced fractures, some comminuted, and 3 were pathological fractures. The nail is introduced through the roof of the olecranon fossa, thus leaving the rotator cuff of the shoulder free from any
This study investigates and defines the topographic
anatomy of the medial femoral circumflex artery (MFCA) terminal
branches supplying the femoral head (FH). Gross dissection of 14
fresh–frozen cadaveric hips was undertaken to determine the extra
and intracapsular course of the MFCA’s terminal branches. A constant
branch arising from the transverse MFCA (inferior retinacular artery;
IRA) penetrates the capsule at the level of the anteroinferior neck,
then courses obliquely within the fibrous prolongation of the capsule
wall (inferior retinacula of Weitbrecht), elevated from the neck,
to the posteroinferior femoral head–neck junction. This vessel has
a mean of five (three to nine) terminal branches, of which the majority
penetrate posteriorly. Branches from the ascending MFCA entered
the femoral capsular attachment posteriorly, running deep to the
synovium, through the neck, and terminating in two branches. The
deep MFCA penetrates the posterosuperior femoral capsular. Once
intracapsular, it divides into a mean of six (four to nine) terminal
branches running deep to the synovium, within the superior retinacula
of Weitbrecht of which 80% are posterior. Our study defines the
exact anatomical location of the vessels, arising from the MFCA
and supplying the FH. The IRA is in an elevated position from the
femoral neck and may be protected from injury during fracture of
the femoral neck. We present vascular ‘danger zones’ that may help
avoid
A radial nerve palsy complicates 1.8 to 17% (mean 11%) diaphyseal humeral fractures (13.7% in our series of 156 humeral fractures and nonunions treated by external fixation – Tsiagadigui, 2000). In about 75%, it is a primary lesion, related to the fracture before any attempt at treatment. In 60%, the fracture, most commonly with an oblique fracture line, involves the middle third. In children, a supracondylar fracture may be complicated by radial nerve palsy. Most nerve lesions correspond to neurapraxia or axonotmesis, due to traction or compression associated with bone angular deformity. Unfrequently, the nerve is impaled or severed by bone fragments, or may be trapped within the fracture in case of a spiral oblique middle or distal third humeral fracture with lateral displacement of the distal fragment.
Purpose: Inadequate disc fragment excision, suboptimal bony decompression of the lateral recess, and persistent foraminal and far lateral compressive lesions are the most common cited causes for persistent radiculopathy after lumbar decompressive surgery. This study examines the utility of continous intraoperative monitoring of electromyographic (EMG) nerve root potentials during decompression of lumbar radiculopathy using a proprietary neurophysiological EMG monitoring system (Neurovision; Nuvasive; San Diego, CA). Methods: A prospective, non-blinded, non-randomized study was undertaken in 43 patients with symptomatic lumbar radiculopathy and weakness undergoing decompressive surgery. All had previously failed conservative therapy. Preoperative and postoperative data for neurological strength examination, EMG amplitudes, VAS scores for radiculopathy were recorded. Continuous EMG nerve root potentials were monitored and recorded during surgery. Results: At the time of surgery, 39 of 43 patients demonstrated measurable asymmetric EMG amplitudes. Of these 39, 30 patients had clinical strength improvements. Intraoperative EMG improvements were seen in 21 of these 30 patients with an overall sensitivity of 70%. Of 9 patients who did not improve in strength, 8 demonstrated no improvement or worsening on EMG for a specificity of 89%. Overall, EMG nerve root monitoring had a positive predictive value of 95.5% and a negative predictive value of 47.1% with regards to strength improvement. 3 cases had worsened transient weakness that resolved within 3 months. In detecting such injury, EMG was 100% sensitive, 97% specific with a positive predictive value of 75% and a negative predictive value of 98%. Conclusions: Use of intraoperative EMG nerve root surveillance may provide a useful adjunct in determining the adequacy of decompression during surgery of compressive lumbar radiculopathy and may help to predict the degree of motor improvement. Although a rare complication, EMG is particularly sensitive at detecting
Supracondylar humeral fractures are the most common elbow injury in children, usually sustained from a fall on the outstretched hand.
The goal for arthroscopic stabilization of anterior glenohumeral instability is to achieve an outcome equivalent to or better than open procedures. A number of arthroscopic procedures have been advocated to reestablish continuity of the inferior glenohumeral ligament complex (IGHLC) with the glenoid. Implantable suture anchors were developed to avoid the problems associated with arthroscopic staple capsulorrhaphy like
The December 2013 Shoulder &
Elbow Roundup. 360 . looks at: Platelet-rich plasma; Arthroscopic treatment of sternoclavicular joint osteoarthritis; Synchronous arthrolysis and cuff repair; Arthroscopic arthrolysis; Regional blockade in the beach chair; Recurrent instability; Avoiding
The advent of modular porous metal augments has ushered in a new form of treatment for acetabular bone loss. The function of an augment can be seen as reducing the size of a defect or reconstituting the anterosuperior/posteroinferior columns and/or allowing supplementary fixation. Depending on the function of the augment, the surgeon can decide on the sequence of introduction of the hemispherical shell, before or after the augment. Augments should always, however, be used with cement to form a unit with the acetabular component. Given their versatility, augments also allow the use of a hemispherical shell in a position that restores the centre of rotation and biomechanics of the hip. Progressive shedding or the appearance of metal debris is a particular finding with augments and, with other radiological signs of failure, should be recognized on serial radiographs. Mid- to long-term outcomes in studies reporting the use of augments with hemispherical shells in revision total hip arthroplasty have shown rates of survival of > 90%. However, a higher risk of failure has been reported when augments have been used for patients with chronic pelvic discontinuity. Cite this article: