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 iatrogenic injury to the periarticular soft-tissue structures with subsequent reduction in the local and systemic inflammatory response, enhancing early outcomes. Despite the increased costs and radiation exposure associated with CT-based navigation, these many benefits have facilitated the adoption of imaged based robotic surgery into routine practice. Further research on ultra-low-dose CT scans and exploration of the possible translation of the use of 3D imaging into improved clinical outcomes are required to justify its broader implementation. Cite this article: Bone Joint J 2024;106-B(9):892–897

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: Bone Joint J 2015;97-B:1447–55.

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! (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-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.

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 iatrogenic neurovascular injury. Three-stitch antegrade nailing technique is a novel method to treat diaphyseal humerus fractures and provides excellent results. It has various advantages such as minimal invasiveness, minimal injury to the rotator cuff, fewer infection rates, minimal iatrogenic injuries, and good functional outcomes. Therefore, this treatment modality can be effectively used for open humerus diaphyseal fractures

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 iatrogenic injury was noted and a new line was drawn from the same portal to the border of the PN. The danger area was measured from the first line to the new direct line along the joint capsule. In 28 adult patients, the closest distances from each line to the PN in standard knee MRI images were significantly shorter than arthroscopic position MRI images (all p-values < 0.05). All danger areas assessed in the actual arthroscopic position MRIs were included within the danger areas as assessed by the standard knee MRIs. We found that the standard knee MRIs can be used to determine the risk of peroneal nerve injury in arthroscopic lateral meniscal repair, although the risks are slightly overestimated

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 iatrogenic injury to surrounding structures. Results. 135 patients were included in the final analysis. 129 patients (95.5%) achieved union. The median time to fusion was 98 days. All cases were performed through sinus tarsi portals. 38 cases were performed with an additional posterolateral portal. Most cases (107/77%) were performed with 2 screws. 3 cases (2.2%) were converted to open procedures. The median tourniquet time was 86 minutes but available in only 88 (65%) cases. There were 4 (2.9%) superficial infections and no deep infections. 1 patient sustained an injury to FHL and there were no reported nerve injuries. Conclusions. At present this is the largest series of arthroscopic subtalar arthrodeses. We demonstrate that this operation can achieve high rates of union with low rates of infection with an equally low likelihood of needing to convert to an open procedure with modest operative times. In our experience the addition of a posterolateral portal does not appear to increase the incidence of nerve injury and aids in the visualisation of all 3 facets

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 iatrogenic injury to local structures. Biceps tenoscopy allowed visualisation to the musculotendinous junction in all cases. The mean length of the tendon visualised was therefore significantly greater at biceps tenoscopy (104 mm) than at standard glenohumeral arthroscopy (33 mm) (mean difference 71 mm, p<0.0001). Biceps tenoscopy was safe with regards to compartment syndrome and there was no difference between pre- and post-operative pressure measurements (mean difference 0 mmHg, p=1). No iatrogenic injuries were identified at open dissection. Biceps tenoscopy allows excellent visualisation of the entire length of the LHB tendon and therefore has the potential to reduce the rate of missed diagnoses. This study did not demonstrate any risk of iatrogenic injury to important local structures or any risk of compartment syndrome. Clinical evaluation is required to further validate this technique

Introduction: Injury to the distal third of the axillary artery is well recognised as a complication of proximal humeral fractures. However the risk of iatrogenic injury at shoulder surgery has not, to date, been fully appreciated. Patients: Four female patients aged 59 and over who suffered iatrogenic injury to the axillary artery at the time of shoulder surgery are reported. Two occurred during surgery for planned elective shoulder arthroplasty, while two occurred while treating elderly patients who had previously sustained a 3 part proximal humeral fracture. In all 4 cases the injury probably started as an avulsion of the anterior or posterior humeral circumflex vessels. Results: Vascular surgeons were called in urgently to help with the management of all 4 cases. In two cases the axillary artery was found to have extensive atheroma, was frail and, after initial attempts at end-to-end repair, it became clear that a reversed vein graft was required. Three patients had a satisfactory outcome after reconstruction, while one patient who had previously had local radiotherapy for malignancy, but was now disease free, developed a completely ischaemic upper limb and required a forequarter amputation to save her life. Message: The axillary artery can be very frail in the elderly, is often diseased with atheroma, and is vulnerable to iatrogenic injury at surgery. If injury occurs at surgery, small bulldog clamps should be applied to the cut ends and a vascular surgeon should be called immediately. A temporary arterial shunt should be considered urgently to provide an early return of vascularisation to the limb and to prevent serious complications. The axillary artery is very difficult to repair, and, in our experience may require a vein graft. In addition, distal clearance of the main brachial artery with a Fogarty catheter which is an essential part of the management

Controversy remains regarding the optimal treatment for iatrogenic injury to the medial collateral ligament (MCL) during primary total knee arthroplasty (TKA). Some authors have recommended converting to a prosthesis that provides varus/valgus constraint while others have recommended primary repair. In this study we report the results of a 45 patients who sustained intra-operative MCL injuries during primary TKA that were treated with primary repair. Of 3922 consecutive primary TKA there were 48 (1.2%) intra-operative MCL lacerations or avulsions. One patient was lost and one died before 24-month follow-up. All but one patient underwent primary repair with placement of components without varus/valgus constraint. This left 45 knees with a mean follow up of 89 months (range, 24 – 214 months). The mean HSS knee scores increased from 47 to 85 points (p<0.001). No patients had subjective complaints of instability. No patients had excessive varus/valgus laxity when tested in full extension and 30 degrees of flexion. The range of motion at the time of final follow-up averaged 110 degrees (range, 85 – 130 degrees). Five knees required treatment for stiffness with 4 knees undergoing manipulation under anesthesia and 1 knee undergoing open lysis of adhesions with polyethylene articular surface exchange. Two knees underwent revision for aseptic loosening of the tibial component. In the three knees that underwent open revision, the MCL was noted to be in continuity and without laxity. Primary repair with 6 weeks of post-operative hinged bracing after iatrogenic injury to the MCL during primary TKA was successful at preventing instability although stiffness was seen in approximately 10% of patients. The increased morbidity associated with implantation of a semi-constrained or constrained implant may be unwarranted in this situation

Controversy remains regarding the optimal treatment for iatrogenic injury to the medial collateral ligament (MCL) during primary total knee arthroplasty (TKA). Some authors have recommended converting to a prosthesis that provides varus/valgus constraint while others have recommended primary repair. In this study, we report the results of 45 patients who sustained intra-operative MCL injuries during primary TKA that were treated with primary repair. Of 3922 consecutive primary TKA there were 48 (1.2%) intra-operative MCL lacerations or avulsions. One patient was lost and one died before 24 months follow up. All but one patient underwent primary repair with placement of components without varus/valgus constraint. This left 45 knees with a mean follow up of 89 months (range, 24 to 214 months). The mean HSS knee scores increased from 47 to 85 points (p<0.001). No patients had subjective complaints of instability. No patients had excessive varus/valgus laxity when tested in full extension and 30 degrees of flexion. The range of motion at the time of final follow-up averaged 110 degrees (range, 85 to 130 degrees). Five knees required treatment for stiffness with 4 knees undergoing manipulation under anaesthesia and 1 knee undergoing open lysis of adhesions with polyethylene articular surface exchange. Two knees underwent revision for aseptic loosening of the tibial component. In the three knees that underwent open revision, the MCL was noted to be in continuity and without laxity. Primary repair with 6 weeks of post-operative hinged bracing after iatrogenic injury to the MCL during primary TKA was successful at preventing instability although stiffness was seen in approximately 10% of patients. The increased morbidity associated with implantation of a semi-constrained or constrained implant may be unwarranted in this situation

Controversy remains regarding the optimal treatment for iatrogenic injury to the medial collateral ligament (MCL) during primary total knee arthroplasty (TKA). Some authors have recommended converting to a prosthesis that provides varus/valgus constraint while others have recommended primary repair. In this study we report the results of a 45 patients who sustained intraoperative MCL injuries during primary TKA that were treated with primary repair. Of 3922 consecutive primary TKA there were 48 (1.2%) intraoperative MCL lacerations or avulsions. One patient was lost and one died before 24 months follow up. All but one patient underwent primary repair with placement of components without varus/valgus constraint. This left 45 knees with a mean follow up of 89 months (range, 24–200). The mean HSS knee scores increased from 46.8 to 84.8 points (p<0.001). No patients had subjective complaints of instability. No patients had excessive varus/valgus laxity when tested in full extension and 30 degrees of flexion. The range of motion at the time of final follow-up averaged 110 degrees (range, 85 degrees to 130 degrees). Five knees required treatment for stiffness with 4 knees undergoing manipulation under anesthesia and 1 knee undergoing open lysis of adhesions with polyethylene articular surface exchange. Two knees underwent revision for aseptic loosening of the tibial component. In the three knees that underwent open revision, the MCL was noted to be in continuity and without laxity. Primary repair with 6 weeks of postoperative hinged bracing after iatrogenic injury to the MCL during primary TKA was successful at preventing instability although stiffness was seen in approximately 10% of patients. The increased morbidity associated with implantation of a semiconstrained or constrained implant may be unwarranted in this situation

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 iatrogenic injury. The commonly injured vessel during the ACDF surgery was the left vertebral artery. Haemostatic control was achieved via tamponade and haemostatic agents. The left common carotid was iatrogenically injured in one case and was treated by microvascular repair. Three patients were treated with antiplatelet therapy for three months duration. The patient with an iatrogenic injury was treated with anticoagulation therapy for three months duration. All computerized tomographic angiograms at three months follow up illustrated patent vessels. Conclusion:. There is an increased incidence of intra operative vascular injuries during ACDF associated with corpectomies. It is essential to be aware of the low incidence of intra operative arterial injury during ACDF and to have a management approach, such as tamponade or microvascular repair. Anticoagulation and antiplatelet therapy is effective in decreasing the complications of vascular injuries post ACDF

Introduction and Aims: The Lateral Femoral Cutaneous Nerve is placed at risk of iatrogenic injury in the dual incision minimally invasive approach THA. A number of trials have indicated rates of injury up to 30%. This clinical and cadaver study examined the morphology of the nerve in 101 cadaver specimens and in 78 dual incision THA patients. Method: One hundred and one lateral femoral cutaneous nerves of the thigh were dissected in fresh and formalin embalmed specimens. Dissection was limited to the anterior thigh and the branch pattern of the LFCN recorded. Dual incision patients were followed prospectively and examined with regard to LFCN paraesthesia. Results: Despite the variability of the nerve, three basic morphologic patterns emerged. Approximately 55% had a major medial trunk and smaller lateral branch, 30% involved two distinct large branches and 15% had a trifurcation or other pattern. In our clinical series, over 30% of patients experienced paraesthesia and some experienced a burning dysaesthesia in the distribution of the LFCN. Conclusion: Iatrogenic injury to the LFCN is relatively common in the dual incision minimally invasive THA and patients must be informed of such a risk. Based on this study we have slightly modified our incision and approach

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. Iatrogenic injury to the common peroneal nerve by medial-to-lateral proximal oblique locking screws is therefore a significant risk during tibial nailing

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 iatrogenic injury and may be detrimental to the mechanically sensitive afferent nerve fibers which participate in the regulation of knee joint stability. Measured resection TKA approaches typically rely on making bone cuts based off of generic alignment strategies and then releasing soft tissue afterwards to balance gaps. Conversely, gap-balancing techniques allow for pre-emptive adjustment of bone resections to achieve knee balance thereby potentially reducing the amount of ligament releases required. No study to our knowledge has compared the rates of soft tissue release in these two techniques, however. The objective of this study was, therefore, to compare the rates of soft tissue releases required to achieve a balanced knee in tibial-first gap-balancing versus femur-first measured-resection techniques in robotic assisted TKA, and to compare with release rates reported in the literature for conventional, measured resection TKA [1]. Methods. The number and type of soft tissue releases were documented and reviewed in 615 robotic-assisted gap-balancing and 76 robotic-assisted measured-resection TKAs as part of a multicenter study. In the robotic-assisted gap balancing group, a robotic tensioner was inserted into the knee after the tibial resection and the soft tissue envelope was characterized throughout flexion under computer-controlled tension (fig-1). Femoral bone resections were then planned using predictive ligament balance gap profiles throughout the range of motion (fig-2), and executed with a miniature robotic cutting-guide. Soft tissue releases were stratified as a function of the coronal deformity relative to the mechanical axis (varus knees: >1° varus; valgus knees: >1°). Rates of releases were compared between the two groups and to the literature data using the Fischer's exact test. Results. The overall rate of soft tissue release was significantly lower in the robotic gap-balancing group, with 31% of knees requiring one or more releases versus 50% (p=0.001) in the robotic measured resection group and 66% (p<0.001) for conventional measured resection (table-1) [1]. When comparing as a function of coronal deformity, the difference in release rates for robotic gap-balancing was significant when compared to the conventional TKA literature data (p<0.0001) for all deformity categories, but only for varus and valgus deformities for robotic measured resection with the numbers available (varus: 33% vs 50%, p=0.010; neutral 11% vs 50%, p=0.088, valgus 27% vs 53%, p=0.048). Discussion. Robotic-assisted tibial-first gap-balancing techniques allow surgeons to plan and adjust femoral resections to achieve a desired gap balance throughout motion, prior to making any femoral resections. Thus, gap balance can be achieved through adjustment of bone resections, which is accurate to 1mm/degree with robotics, rather than through manual releasing soft tissues which is subjective and less precise. These results demonstrated that the overall rate of soft tissue release is reduced when performing TKA with predictive gap-balancing and a robotic tensioning system. For any figures or tables, please contact authors directly

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: Iatrogenic nerve injury, pin site infection, and re-operation. The quality of evidence for all the individual outcomes was low or very low. Conclusions. There is no evidence that delaying supracondylar fracture surgery negatively influences outcomes in the absence of vascular compromise. There are, however, notable limitations to the existing available literature

Aims

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.

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 iatrogenic injury to the lesser saphenous vein, the posterior tibial neurovascular bundle, the sural artery and pseudoaneurysm formation. The authors describe the results of their new tenotomy technique, the ‘Posterior to Anterior Controlled’ (PAC) technique in an attempt to eliminate such complications. This is a prospective study. Infants < 1 year of age with idiopathic clubfoot were taken up for the Ponseti technique of correction. Tenotomy was performed by the ‘PAC’ technique under local anaesthesia if passive dorsiflexion was found to be < 15 degrees. Outcome measures included completeness of the tenotomy (by ultrasonography), improvement in the equinus angle and occurrence of neurovascular complications. 40 clubfeet in 22 patients underwent ‘PAC’ tenotomy. The mean age was 3.5 months. The tenotomy was found to be complete in all cases. The equinus angle improved by an average of 78.5 degrees (range 70–95 degrees), which was statistically significant (p < 0.05, students t test). Mild soakage of the cast with blood was noted in 21 (52.5%) cases. No neurovascular complication was noted. The average follow-up was 12.2 months (range 9–18 months). The ‘PAC’ tenotomy virtually eliminates the possibility of neurovascular damage, maintains the percutaneous nature of the procedure, is easy to learn and can be performed even by relatively inexperienced surgeons safely and effectively as an office procedure under local anaesthesia

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 iatrogenic injury to the abductors, and reduces the incidence of complications

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 iatrogenic injury to the nerve. The tendon bridge can be left if correction is sufficient, otherwise passive dorsiflexion of the ankle results in completion. Post-operatively, patients are able to mobilise fully with crutches and passive ankle physiotherapy is commenced immediately. We performed 22 MAGS procedures in 17 patients. There were no Sural nerve injuries and no wound complications. All patients were delighted with cosmesis. Average pre-operative equinus contracture with the leg extended was 18 degrees. Average intra-operative correction of 24 degrees was obtained and at 3 months follow-up, all patients were able to dorsiflex past neutral

Aims

This systematic review aimed to summarize the full range of complications reported following ankle arthroscopy and the frequency at which they occur.

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 iatrogenic injury. Materials and Methods. 10 paired normal cadaver feet were used. All procedures were performed using a mini C-arm in a cadaveric lab by 2 surgeons: 1 consultant who has attended a cadaveric MIS course but does not perform MIS in his regular practice (8 feet), and 1 registrar who was supervised by the same consultant (2 feet). In each foot, the surgeon performed a lateral release, a MICA (minimally invasive chevron and Akin) procedure for the correction of hallux valgus, and a minimally invasive DMO (distal metatarsal extra-articular osteotomy) procedure. Each foot was then dissected and photographed to identify any neurovascular or tendon injury. Results. The dorsal medial cutaneous and the plantar interdigital nerves were intact in all specimens. There was no obvious damage to the arterial plexus supplying the first metatarsal head. No flexor or extensor tendon injuries were identified. There is a significant learning curve to performing the osteotomy cuts in the desired plane. In the DMO, the dissection also revealed some intact soft tissue at the osteotomy site indicating that the metatarsal heads were not truly floating. Discussion. Although there has been concern regarding neurovascular and tendon injury, our findings indicate minimal risk, which is consistent with reports in the literature. This study also reflects the learning curve. Conclusion. We suggest that training on cadaveric specimens may be advantageous, particularly, with regard to the plane of the osteotomy

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 iatrogenic injury of the radial nerve. Conclusion: The external fixation, used in the treatment of humerus fractures, is a semi-interventional method, easy to apply, well-tolerated by the patient and with very good functional results. It a very good alternative of both the conservative treatment and internal fixation

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 iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate. Results: In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees. Conclusion: This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations

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 iatrogenic injury to a vertebral artery during anterior cervical decompression were reviewed to assess the mechanisms of injury, their operative management, and the subsequent outcome. All had been undergoing a partial vertebral body resection for spondylitic radiculopathy or myelopathy (4), tumour (2), ossification of the posterior longitudinal ligament (1), nonunion of a fracture (2), or osteomyelitis (1). The use of an air drill had been responsible for most injuries. The final control of haemorrhage had been by tamponade (3), direct exposure and electrocoagulation (1), transosseous suture (2), open suture (1), or open placement of a haemostatic clip (3). Five patients had postoperative neurological deficits, but most of them resolved. We found direct arterial exposure and control to be safe, quick and reliable. Careful use of the air drill, particularly in pathologically weakened bone, as in infection or tumour, is essential. Arterial injury is best avoided by a thorough knowledge of the anatomical relationships of the artery, the spinal canal, and the vertebral body

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%), iatrogenic injury 1(6%), and 1 gunshot injury (6%). Four patients had an associated nerve injury with varying severity. Skeletal fixation preceded vascular repair in most of the cases. Peroperative arterial shunting was not used in any patient. The primary vascular procedures included end-to-end anastamosis 2(11%), bypass grafting 1(6%), interposition vein grafts 8(43%), vein patch 1(6%), direct arterial repair 2(11%), ligation 2(11%), primary amputation 1(6%), reposition of normal course of artery 1(6%). During a 17 months follow-up period, the upper and lower limb preservation rate was 100 and 89%, respectively. Nine patients (50%) were symptom free; three patients (16.6%) had a neurological deficit. Conclusion: Vascular injury is uncommon in the orthopaedic patients. High suspicion and early intervention is essential to optimise outcome and function

The axillary nerve injuries most commonly are observed after trauma such as contusion-stretch, gunshot wound, laceration and iatrogenic injuries. Two of the most commons causes seem to be the glenohumeral dislocation and the proximal humerus fractures. The axillary nerve may sustain a simple contusion, or its terminal elements may be avulsed from the deltoid muscle. Compressive neuropathy in the quadrilateral space also has been reported (quadrilateral space syndrome, Calhill and Palmer, 1983). The axillary nerve injuries incidence represents less than 1% of all nerve injuries. Aim: The purpose of this study was to analyze outcome in patients, who presented with injuries to the axillary nerve. Material and methods: We report a series of 15 cases of axillary nerve lesions, which were operated between 1995 and 2002. These injuries resulted from shoulder injury either with or without fracture and or dislocation. Patients were operated between 3 to 6 months after trauma and an anterior deltopectoral approach was usually followed during surgery. The follow up period ranged from 1 to 8 years. Results: The results were considered as satisfactory in 11 out of 15 axillary nerve lesions. According to clinical examination, of the function of the shoulder and the muscle strength the results were classified as excellent in 5 cases, good in 6 cases and poor in 4 cases. Conclusions: If indicated, nerve repair can lead to useful function in carefully selected patients

Aims

Staphylococcus aureus is a major cause of septic arthritis, and in vitro studies suggest α haemolysin (Hla) is responsible for chondrocyte death. We used an in vivo murine joint model to compare inoculation with wild type S. aureus 8325-4 with a Hla-deficient strain DU1090 on chondrocyte viability, tissue histology, and joint biomechanics. The aim was to compare the actions of S. aureus Hla alone with those of the animal’s immune response to infection.

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 iatrogenic injury from gentle repositioning. Physeal instability in SCFE is common and should be assessed clinically on admission. It is indicated by joint effusion or inability to bear weight. A slip is very unlikely to be unstable in a child able to bear weight and with no sonographic effusion

Aims

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.

Introduction:. A surgical hip dislocation provides circumferential access to the femoral head and is essential in the treatment pediatric and adult hip disease. Iatrogenic injury to the femoral head blood supply during a surgical may result in the osteonecrosis of the femoral head. In order to reduce vessel injury and incidence of AVN, the Greater Trochanteric Osteotomy (GTO) was developed and popularized by Ganz. The downside of this approach is the increased morbidity associated with the GTO including non-union in 8% and painful hardware requiring removal in 20% of patients. (reference) Recent studies performed at our institution have mapped the extra-osseous course of the medial femoral circumflex artery and provide surgical guidelines for a vessel preserving posterolateral approach. In this cadaveric model using Gadolinium enhanced MRI, we investigate whether standardized alterations in the postero-lateral surgical approach may reliably preserve femoral head vascularity during a posterior surgical hip dislocation. Methods:. In 8 cadaveric specimens the senior author (ES) performed a surgical hip dislocation through the posterolateral approach with surgical modifications designed to protect the superior and inferior retinacular arteries. In every specimen the same surgical alterations were made using a ruler: the Quadratus Femoris myotomy occurred 2.5 cm off its trochanteric insertion, the piriformis tenotomy occurred at its insertion and extended obliquely leaving a 2 cm cuff of conjoin tendon (inferior gemellus), and the Obturator Externus (OE) was myotomized 2 cm off its trochanteric insertion. (Figure 1) For the capsulotomy, the incision started on the posterior femoral neck directly beneath the cut obturator externus tendon and extending posteriorly to the acetabulum. Superior and inferior extensions of the capsulotomy ran parallel to the acetabular rim creating a T-shaped capsulotomy. After the surgical dislocation was complete, the medial femoral circumflex artery (MFCA) was cannulated and Gadolinium-enhanced MRI performed in order to assess intra-osseous femoral head perfusion and compared to the gadolinium femoral head perfusion of the contra-lateral hip as a non-operative control. Gross-dissection after polyurethane latex injection in the cannulated MFCA was performed to validate MRI findings and to assess for vessel integrity after the surgical dislocation. Results:. In 8 cadaveric specimens MRI quantification of femoral head perfusion was 94.3% and femoral head-neck junction perfusion was 93.5% compared to the non-operative control. (Figure 2) Gross dissection after latex injection into the MFCA demonstrated intact superior and inferior retinacular arteries in all 8 specimens. (Figure 3). Discussion and Conclusions:. In this study, perfusion to the femoral head and head-neck junction is preserved following posterior surgical dislocation through the postero-lateral approach. These preliminary findings suggest that specific surgical modifications can protect and reliably maintain vascularity to the femoral head after surgical hip dislocation. This approach may benefit hip resurfacing and potentially decease risk of femoral neck fracture secondary to osteonecrosis. In addition this may allow a vascular preserving surgical hip dislocation to be performed without the need for a GTO

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 iatrogenic injury. All 9 patients with double crush syndrome have no improvement in function. Conclusions: Acetabular fractures associated with sciatic nerve injuries are devastating injuries with signiþcant long term morbidity. 50% patients showed improvement with time. Identiþcation of double crush lesion is vital as it is associated with poorer functional recovery as compared to single lesion

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 iatrogenic injury. Proximal rotational stability is maintained by a unique ‘Trio Wire’, which passes through the nail and fans out in the head of the humerus. Distal rotational stability is maintained by the transverse plate. In all cases early pain relief was obtained with return of shoulder and elbow functions. By 6 weeks 98% of patients could perform the majority of daily tasks. No significant complication was noted except a loss of extension of the elbow by 10–15 degrees. This new nail provides stable fixation of difficult distal humeral fractures, even in cases with poor bone quality. Early pain relief with a rapid return of shoulder and elbow functions denote a successful outcome of these operations

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 iatrogenic vascular injury during surgical interventions about the hip. Cite this article: Bone Joint J 2015;97-B:1204–13

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. Iatrogenic injury during internal fixation or entrapment within periosteal callus are occasionally observed. The classical indications for early radial nerve exploration include open fractures requiring surgical debridement, or fractures with vascular compromise, or when the osteosynthesis is done by a plate. In all other cases, we recommend to investigate the integrity of the radial nerve by echography. In the absence of discontinuity, spontaneous neurological recovery is likely to occur and is monitored clinically and by electromyography; prevention of joint contracture is done by physiotherapy and by a wrist splint, maintaining the joint in slight dorsiflexion. In case of persistent palsy, neurolysis is indicated several months after the initial injury, the precise delay depending on the level of the fracture. Palliative treatment by tendon transfers offers in cases of persistent palsy excellent functional results. Tendon transfers may be indicated early after the fracture, in case of an irreparable radial nerve lesion

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 iatrogenic injury to the nerve root during surgery

Supracondylar humeral fractures are the most common elbow injury in children, usually sustained from a fall on the outstretched hand. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring. NNH is the number of cases needed to treat in order to have one adverse outcome. A systemic review was undertaken to calculate relative risks, risk difference and number needed to harm following management of supracon-dylar fractures with cross or lateral K wires. It was found that there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires. The aim of this study was to calculate the number of cross K wiring of supracondylar fractures of the humerus that would need to be performed for one iatrogenic ulnar nerve injury to occur. Iatrogenic ulnarnerve injury is not uncommon following cross K wiring of supracondylar fractures of the humerus. To date there are no clinical trials showing the benefit of cross K wiring over lateral K wiring in the management of supracondylar fractures of the humerus in children. If it can be confirmed that lateral K wiring is as effective as crossed K wiring, iatrogenic ulnar nerve injury can be avoided. A systematic review of iatrogenic ulnar nerve injuries following management of supracondylar fractures was conducted. The databases MEDLINE 1966 – present, EMBASE 1980 – present, CINAHL 1982 – present, CDSR, and DARE were searched along with a meticulous search of the Journal of Paediatric Orthopaedics from 1998 to 2004. Of the two hundred and forty-eight papers identified, only thirty-six met the inclusion criteria. The papers where both lateral crossed K wires were used as treatment were identified for calculating relative rates, risk difference and number needed to harm. NNH was 7.69. When a sensitivity analysis removing two studies that had five subjects or fewer and a 100% ulnar nerve injury rate was peformed, the NNH was 27.7. In other words, there was one iatrogenic ulnar nerve injury for every twenty-seven cases that were managed with crossed K wires

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 iatrogenic injury of the glenoid or humeral surface, loosening and migration of the staple. The preferred techniques are easy implantable suture anchors made of titanium (Fastak). Our experience suggests, that if proper selection criteria are employed, normal patients and overhead-athletes may benefit from the advantages of an arthroscopic repair without accepting an increased risk for recurrence. From 4/96 to 10/00 we performed a prospective analysis of 242 shoulders, who underwent arthroscopic shoulder stabilization with FASTak-(n = 159) Panalok-(n = 26) and Sure-tac suture anchors (n = 57) in our clinic. The patients were re-examined with a follow-up of at least 12 months. The best results were in the FASTak-group. After 2 years 4.7% suffered a redislocation. 28.6% (2 patients) needed a revision, but none of the shoulders required a second open stabilization. The reason for redislocation or sub-luxation were traumatic injuries, participating in contact sports or in one case a generalized ligamentous laxity. The Rowe score was 83.1 ± 20.9 points. There was a high satisfaction of the patients with the operative result and 60.9% could go back to their pre-op sports level. At 24-months follow-up this study demonstrates good results of arthroscopic shoulder stabilisation with FASTak suture anchors. In combination with the LACS-Procedure or the Electro thermally assisted capsular shift (ETACS) not only the capsular detachment but also the capsular redundancy may be adressed and a lower failure rate can be expected

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 iatrogenic nerve injury in elbow arthroscopy; and Complex reconstruction of total elbow revisions

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: Bone Joint J 2024;106-B(4):312–318.