Nerve transfer is an emerging treatment to restore upper limb function in people with tetraplegia. The objective of this study is to examine if a flexible collage sheet (FCS) can act as epineurial-like substitute to promote nerve repair in nerve transfer. A preclinical study using FCS was conducted in a rat model of sciatic nerve transection. A prospective case series study of nerve transfer was conducted in patients with C5-C8 tetraplegia who received nerve transfer to restore upper limb function. Motor function in the upper limb was assessed pre-treatment, and at 6-,12-, and 24-months post-treatment. Macroscopic assessment in preclinical model showed nerve healing by FCS without encapsulation or adhesions. Microscopic examination revealed that a new, vascularised epineurium-like layer was observed at the FCS treatment sites, with no evidence of inflammatory reaction or nerve compression. Treatment with FCS resulted in well-organised nerve fibres with dense neurofilaments distal to the coaptation site. Axon counts performed proximal and distal to the coaptation site showed that 97% of proximal axon count of myelinated axons regenerated across the coaptation site after treatment with CND. In the proof of concept clinical study 17 nerve transfers were performed in five patients. Nerve transfers included procedures to restore triceps function (N=4), wrist/finger/thumb extension (N=6) and finger flexion (N=7). Functional motor recovery (MRC ≥3) was achieved in 76% and 88% of transfers at 12 and 24 months, respectively. The preclinical study showed that FCS mimics epineurium and enable to repair nerve resembled to normal nerve tissue. Clinical study showed that patients received nerve transfer with FCS experienced consistent and early return of motor function in target muscles. These results provide proof of concept evidence that CND functions as an epineurial substitute and is promising for use in nerve transfer surgery

Abstract. Objectives. Falling studies have been conducted in controlled environments but not in field studies for ethical reasons; this limits the validity and applicability of previous studies. We performed field studies on existing YouTube © videos of skateboarders falling. The aims were to measure the wrist angle at impact on videos of real unprotected falls and to study the dynamics of the upper limbs when falling. Methods. Youtube © videos of skateboarders falling were studied assessing the direction of the fall, the positions of both upper limbs and especially the wrists on impact. This study would not be ethical by other means. Results. In study one (the more quantitative study) there were 48 men and 50 falls. The mean elbow flexion was 300 (range 00 to 800) and the mean maximal wrist extension was 800 (range 500 to 1100). The secondary wrist extended less or the same in > 90%. The second wrist only one (of 31) extended > 900 which should minimise the risk of toppling. Falls onto only one wrist gave significantly greater maximal wrist extension. In the second more qualitative study we observed the “upper limb falling reflex” where the response to falling is for the upper limb(s) to align with the direction of falling of the body with the elbow mostly but not fully extended. Initially the wrists extend c. 400–500 with the fingers held mildly flexed. Immediately before impact the fingers hyper-extend with some compensatory wrist flexion to c. 300. The fingertips impact the ground first followed by the hand. Conclusion. These studies confirm wrist extension at impact around 800 but the wrist(s) may hyper-extend risking toppling. Falls on both wrists minimise the risk of toppling. The “upper limb falling reflex” is defined; it is a rapid dynamic response leading to the fingers impacting the ground first on falling. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Current knowledge regarding upper limb myotomes is based on historic papers. Recent advances in magnetic resonance imaging (MRI) and surgical exploration with intraoperative nerve stimulation now allow accurate identification of nerve root injuries in the brachial plexus. The aim of this study is to identify the myotome values of the upper limb associated with defined supraclvicular brachial plexus injuries. 57 patients with partial supraclavicular brachial plexus injuries were identified from the Scottish brachial plexus database. The average age was 28 years and most injuries secondary to motor cycle accidents or stabbings. The operative and MRI findings for each patient were checked to establish the root injuries and the muscle powers of the upper limb documented. The main patterns of injuries identified involved (C5,6), (C5,6,7), (C5,6,7,8) and (C8, T1). C5, 6 injuries were associated with loss of shoulder abduction, external rotation and elbow flexion. In 30% of the 16 cases showed some biceps action from the C7 root. C5,6,7 injuries showed a similar pattern of weakness with the additional loss of flexor carpi radialis and weakness but not total paralysis of triceps in 85% of cases. C5,6,7,8 injuries were characterised by loss of pectoralis major, lattisimus dorsi, triceps, wrist extension, finger extension and as well as weakness of the ulnar intrinsic muscles. We identified weakness of the flexor digitorum profundus to the ulnar sided digits in 83% of cases. T1 has a major input to innervation of flexors of the radial digits and thumb, as well as intrinsics. This is the largest study of myotome values in patients with surgically or radiologically confirmed injuries in the literature and presents information for general orthopaedic surgeons dealing with trauma patients for the differentiation of different patterns of brachial plexus injuries. In addition we have identified new anatomical relationships not previously described in upper limb myotomes

Upper limb lacerations are a common injury. Traditionally, these have been assessed and treated in the Emergency Department (ED). This has become increasingly rare. A number of different reasons have been postulated. These include the increasingly junior status of those that work within the ED and the 4 hour target within the ED. After referral to the orthopaedic department, these patients are often assessed by increasingly junior staff. Thus, when these patients are assessed by a sufficiently qualified practitioner, there exists no option but to take them to theatre for repair of their injury. The aim of our study was identify the number of patients requiring surgery for hand and wrist lacerations and identify if these patients could be managed without the need for theatre. We collected data in a prospective fashion from 1/9/9 to 3/11/9 at a large district general hospital. Over this period, 36 patients required surgery for their hand or wrist laceration. 27 were male and 9 were female. The average age was 34 years. The average length of procedure from was 21 minutes. 32% of patients were admitted overnight. In two thirds of cases, the operating surgeon felt the procedure could have been performed in a suture room rather than in theatre. Among those patients who could've been operated on within a suture room, 21 would not have required an admission for any other reason. It seems likely that the number of referrals from the ED regarding patients with upper limb lacerations is not likely to decrease. It is, therefore, important to ensure that orthopaedic departments develop new ways of working to try and ensure that patients are treated in a prompt fashion. We believe that the addition of a suture room to the orthopaedic trauma room remains one possible way of achieving this

Neurological examination in children presenting with upper limb fractures is often poorly performed. In the peripatetic emergency department environment this may be confounded by patient distress or reduced comprehension. We aimed to assess the quality of documented neurological examination in children presenting with upper limb fractures and whether this could be improved following introduction of a simple guideline for paediatric neurological assessment. We reviewed the clinical notes of all children presenting to the emergency department with upper limb fractures over a three month period. Documentation of initial neurological assessment and clinical suspicion of any nerve injury were noted. Subsequently, we introduced a guideline for paediatric upper limb neurological examination (‘Rock, Paper, Scissors, OK’) to our hospital and performed a further 3 month review to detect resulting changes in practice. In the initial study period, 121 children presented with upper limb fractures. 10 (8%) had a nerve injury. Neurological examination was documented in 107 (88%) of patients. However, information on nerves examined was only recorded in 5 (5%) with the majority (85%) documented as ‘neurovascuarly intact’. None of the nerve injuries were detected on initial assessment. Following guideline introduction, 97 patients presented with upper limb fractures of which 8 children (8%) had a nerve injury. Documentation of neurological examination increased to 98% for patients presenting directly to our own hospital (Fisher's Exact Test, p=0.02) with details of nerves examined increasing to 69%. Within this cohort all nerve injuries with objective motor or sensory deficits were detected on initial examination. The recent British Orthopaedic Association Standards for Trauma (BOAST) guideline on peripheral nerve injuries emphasises the importance of clearly recorded neurological assessment in trauma patients. Our study shows that introduction of a simple guideline for neurological examination in children with upper limb fractures can significantly improve the quality of documented neurological assessment and detection of nerve injuries

Neurological examination is essential in patients with upper limb injuries and should be clearly documented. We aimed to assess the quality and documentation of neurological examination performed for children presenting with upper limb fractures to the emergency department. Clinical notes of all children admitted with upper limb fractures over a three month period were reviewed. Documentation of initial neurological assessment was analysed and clinical suspicion of any nerve injury noted. In parallel, we conducted an anonymous survey of emergency doctors evaluating their upper limb neurological examination in children. The casenotes of 121 children with upper limb fractures were reviewed. 10 children (8%) had a nerve injury (median = 4, ulnar = 2, radial = 2, anterior interosseous = 2). Neurological examination was documented in 107 (88%) of patients. However, none of the nerve injuries were detected on initial examination. In patients with nerve injuries, 5 (50%) were documented as being ‘neurovascularly intact’, 2 (20%) as ‘CSM normal’, 1 (10%) as ‘moving fingers’ and 2 (20%) had no documented neurological examination. 30 emergency doctors completed the questionnaires (5 consultants, 9 registrars, 16 foundation doctors). All doctors stated that they routinely performed an upper limb neurological examination and assessed median, ulnar and radial nerves. However, 30% of doctors described incomplete examination of median nerve function, 30% inadequate ulnar nerve assessment and 50% incomplete radial nerve examination. In addition, 75% of doctors failed to identify the need for assessment of anterior interosseous nerve function. While emergency doctors recognise the importance of neurological assessment in children with upper limb injuries, it is often performed inadequately. This in part may be due to difficulties performing neurological examination in paediatric patients. As a result of this study, we have introduced local guidelines to assist neurological assessment in children

Summary. Upper extremity activity was similar in patients and healthy subjects, showing no significant asymmetry between arms within subjects. Further improvements (e.g. thresholds, filters, inclinometer function) are needed to show the clinical value of AM for patients suffering shoulder complaints. Introduction. Activity monitoring is becoming a popular outcome tool especially in orthopaedics. The suitability of a single 3D acceleration-based activity monitor (AM) for patients with lower-extremity problems has been shown. However less is known about its feasibility to monitor upper-extremity activity. Insight into the amount and intensity of upper-extremity activity of the affected and non-affected arm (asymmetry) may be of added value for diagnostics, therapy choice and evaluating treatment effects. This study investigates the feasibility of a single AM to evaluate (asymmetry in) upper-extremity activity in daily life. Methods. Upper-extremity activity was measured in 12 patients with subacromial impingent syndrome (59±12yr) and 10 healthy subjects (29±11yrs). Subjects wore a single 3D accelerometer at both arms, just above the base of the Hueter triangle, for one day (min. 8 hours). Specific algorithms were used to derive quantity (activity duration, rest periods) and intensity (low-high) activity parameters (% of the day). The ratio in % activity between non-affected (dominant) and affected (non-dominant) arm was calculated. Asymmetry was expressed as the %-difference in activity between arms with regards to the non-affected (dominant) arm. Also popular PROMs were completed: DASH score (range 0–100;0=best) and SST score (range 0–12; 0=best). Independent t-test, Mann-Whitney U test, Pearson's r correlations were performed. Results. No significant differences in activity duration (Healthy: 50%, patients: 57% of the day) and intensity of upper-extremity activity were found between patients and healthy subjects, although PROMs were significantly worse in patients. Patients and healthy subjects use both arms in similar amounts of time per day. This corresponds to the ratio which almost equals 1 and the low asymmetry values (<10%) in both groups. Also the amount activity in low and high intensity was comparable between affected (non-dominant) and non-affected (dominant) arm. No correlations were found between AM data and PROMs. Discussion and Conclusion. Patients and healthy subjects move their upper arms approximately 53% of the day. No differences in amount and intensity of upper-extremity activity were found between healthy subjects and patients, neither between both arms. This suggests that subjects perform daily activities independent of pain, complaints or arm dominance. It could also hint at the algorithm operating with a too low activity threshold to include shuffling or misclassifying excitations from walking as intense arm movement. Both issues can be adjusted by adjusting thresholds and filter settings. The asymmetry in upper-extremity activity of healthy subjects (9.1%) assumes that a 10% asymmetry in arm activity seems natural, which coincides with similar values reported for functional shoulder tests (Koerver et al. CORS 2010). The lack of correlations between AM and PROMs suggests that both measure different outcome dimensions. The AM has some limitations which should be considered when improving the clinical feasibility of upper-extremity activity monitoring. The AM only allows to measure acceleration-related activities (speed, intensity), while upper-extremity activity often involves static force-related activities. However, the inclinometer capacity of accelerometers allows to measure upper-extremity activity at different elevations (upper arm above/below shoulder). This may add qualitative information, relevant for clinical purposes

Introduction

20 cases of bone defect have been treated by the induced membrane technique avoiding allograft, microsurgery and amputation

The risk of falls in patients undergoing orthopedic procedures is particularly significant in terms of health and socioeconomic effects. The literature analyzed closely this risk following procedures performed on the lower limb, but the implications following procedures on the upper limb remain to be investigated. Interestingly, it is not clear whether the increased risk of falling in patients undergoing shoulder surgery is due to preexisting risk factors at surgery or postoperative risk factors, such as anesthesiologic effects, opioid medications used for pain control, or brace use. Only one prospective study examined gait and fall risk in patients using a shoulder abduction brace (SAB) after shoulder surgery, revealing that the brace adversely affected gait kinematics with an increase in the risk of falls. The main purpose of the study was to investigate the influence of SAB on gait parameters in patients undergoing shoulder surgery. Patients undergoing elective shoulder surgery (arthroscopic rotator cuff repair, reverse total shoulder arthroplasty, and Latarjet procedure), who used a 15° SAB in the postoperative period, were included. Conversely, patients age > 65 years old, with impaired lower extremity function (e.g., fracture sequelae, dysmorphism, severe osteo-articular pathology), central and peripheral nervous system pathologies, and cardiac/respiratory/vascular insufficiency were excluded. Participants underwent kinematic analysis at four different assessment times: preoperative (T0), 24 hours after surgery (T1), 1 week after surgery (T2), and 1 week after SAB removal (T3). The tests used for kinematic assessment were the Timed Up and Go (TUG) and the 10-meter test (10MWT), both of which examine functional mobility. Agility and balance were assessed by a TUG test (transitions from sitting to standing and vice versa, walking phase, turn-around), while gait (test time, cadence, speed, and pelvic symmetry) was evaluated by the 10MWT. Gait and functional mobility parameters during 10MWT and TUG tests were assessed using the BTS G-Walk sensor (G-Sensor 2). One-way ANOVA for repeated measures was conducted to detect the effects of SAB on gait parameters and functional mobility over time. Statistical analysis was performed with IBM®SPSS statistics software version 23.0 (SPSS Inc., Chicago, IL, USA), with the significant level set at p<0.05. 83% of the participants had surgery on the right upper limb. A main effect of time for the time of execution (duration) (p=0.01, η2=0.148), speed (p<0.01, η2=0.136), cadence (p<0.01, η2=0.129) and propulsion-right (R) (p<0.05, η2=0.105) and left (L) (p<0.01, η2=0.155) in the 10MWT was found. In the 10MWT, the running time at T1 (9.6±1.6s) was found to be significantly longer than at T2 (9.1±1.3s, p<0.05) and at T3 (9.0±1.3s, p=0.02). Cadence at T1 (109.7±10.9steps/min) was significantly lower than at T2 (114.3 ±9.3steps/min, p<0.01) and T3 (114.3±9.3steps/min, p=0.02). Velocity at T1 (1.1±0.31m/s) was significantly lower than at T2 (1.2± 0.21m/s, p<0.05). No difference was found in the pelvis symmetry index. No significant differences were found during the TUG test except for the final rotation phase with T2 value significantly greater than T3 (1.6±0.4s vs 1.4±0.3s, p<0.05). No statistically significant differences were found between T0 and T2 and between T0 and T3 in any of the parameters analyzed. Propulsion-R was significantly higher at T3 than T1 (p<0.01), whereas propulsion-L was significantly lower at T1 than T0 (p<0.05) and significantly higher at T2 and T3 than T1 (p<0.01). Specifically, the final turning phase was significantly higher at T2 than T3 (p<0.01); no significant differences were found for the duration, sit to stand, mid-turning and stand to sit phases. The results demonstrated that the use of the abduction brace affects functional mobility 24 hours after shoulder surgery but no effects were reported at longer term observations

In a consecutive retrospective analysis of 190 patients treated with the Masquelet technique at the BG Klinikum Hamburg from January 2012 to January 2022, defect-specific features such as the extent and morphology of the defect were recorded, and their influence on the time to reach full weight-bearing of the affected limb was investigated. A total of 217 defects were treated in 190 patients using the Masquelet technique. 70% of all defects were located in the tibia, followed by 22% in the femur and only about 7% in the upper extremity. The average length of all defects was 58 mm (+/−31 mm), with the largest defect measuring 180 mm and the smallest measuring 20 mm. 89% of the patients achieved full weight-bearing at the end of therapy. The average time from initiation of therapy to reaching safe full weight-bearing was 589 days. There was a significant correlation between defect length and time to reach full weight-bearing (p = 0.0134). These results could serve as a basis for creating a score for prognostics and evaluation of bone healing after treatment with the Masquelet technique. Additionally, the results could help guide indications for secondary stabilization using internal fixation

To analyse bone stresses in humerus-megaprosthesis construct in response to axial loading under varying implant lengths in proximal humeral replacement following tumour excision. CT scans of 10 cadaveric humeri were processed in 3D Slicer to obtain three-dimensional (3D) models of the cortical and cancellous bone. Megaprostheses of varying body lengths (L) were modelled in FreeCAD to obtain the 3D geometry. Four FE models: group A consisting of intact bone; groups B (L=40mm), C (L=100mm) and D (L=120mm) comprising of humerus-megaprosthesis constructs were created. Isotropic linear elastic behaviour was assigned for all materials. A tensile load of 200N was applied to the elbow joint surface with the glenohumeral joint fixed with fully bonded contact interfaces. Static analysis was performed in Abaqus. The bone was divided at every 5% bone length beginning distally. Statistical analysis was performed on maximum von Mises stresses in cortical and cancellous bone across each slice using one-way ANOVA (0-45% bone length) and paired t-tests (45-70% bone length). To quantify extent of stress shielding, average percentage change in stress from intact bone was also computed. Maximum stress was seen to occur distally and anteriorly above the coronoid fossa. Results indicated statistically significant differences between intact state and shorter megaprostheses relative to longer megaprostheses and proximally between intact and implanted bones. Varying levels of stress shielding were recorded across multiple slices for all megaprosthesis lengths. The degree of stress shielding increased with implant lengthening being 2-4 times in C and D compared to B. Axial loading of the humerus can occur with direct loading on outstretched upper limbs or indirectly through the elbow. Resultant stress shielding effect predicted in longer megaprosthesis models may become clinically relevant in repetitive axial loading during activities of daily living. It is recommended to use shorter megaprosthesis to prevent failure

The COVID-19 pandemic necessitated a pivot to online learning for many traditional, hands-on subjects such as anatomy. This, coupled with the increase in online education programmes, and the reduction of time students spend in anatomy dissection rooms, has highlighted a real need for innovative and accessible learning tools. This study describes the development of a novel 3-dimensional (3D), interactive anatomy teaching tool using structured light scanning (SLS) technology. This technique allows the 3D shape and texture of an object to be captured and displayed online, where it can be viewed and manipulated in real-time. Human bones of the upper limb, vertebrae and whole skulls were digitised using SLS using Einscan Pro2X/H scanners. The resulting meshes were then post-processed to add the captured textures and to remove any extraneous information. The final models were uploaded into Sketchfab where they were orientated, lit and annotated. To gather opinion on these models as effective teaching tools, surveys were completed by anatomy students (n=35) and anatomy educators (n=8). Data was collected using a Likert scale response, as well as free text answers to gather qualitative information. 3D scans of the scapula, humerus, radius, ulna, vertebrae and skull were successfully produced by SLS. Interactive models were produced via scan data in Sketchfab and successfully annotated to provide labelled 3D models for examination. 94% of survey respondents agreed that the interactive models were easy to use (n=35, 31% agree and 63% strongly agree) and 97% agreed that the 3D interactive models were more useful than 2D images for learning bony anatomy (n=35; 26% agree and 71% strongly agree). This initial study has demonstrated a suitable proof-of-concept for SLS technology as a useful technique for producing 3D interactive online tools for learning and teaching bony anatomy. Current studies are focussed on determining the SLS accuracy and the ability of SLS to capture soft tissue/joints. We believe that this tool will be a useful technique for generating online 3D interactive models to study orthopaedic anatomy

Distal radius fractures are common, particularly in post-menopausal women. Several factors have been identified such as osteopenia and an increased risk of falling. We hypothesised that increased soft tissue padding from muscle and fat in the volar hand may confer an element of protection against fractures more in men than women and more in younger than older patients. The aim of the study was to assess for thenar and hypothenar thickness and assess whether it varies between sexes and changes with age. We retrospectively evaluated hand MRI scans performed for non-acute conditions in adults without previous injury or surgery. Using the Patient Archiving and Communication System (PACS) we measured the distance (mm) from the volar surface of the trapezium to the skin, the hook of the hamate to skin and the pisiform to skin as measures of thenar and hypothenar thickness. We also recorded the sex and age of the subjects. Soft tissue thickness was corrected for hand size by dividing by capitate length which we measured; we have already established this as a surrogate measure of hand size. The scans of 51 men (mean age 35, range 19–66) years and 27 women (mean age 49, range 19–79) years were reviewed. Men had significantly thicker soft tissues compared to women over both the thenar and hypothenar eminences (p=0.0001). Soft tissue thickness did not change significantly with age (p> 0.05). The study confirms a significant difference in volar hand soft tissue thickness between men and women accounting for differences in hand size. Our previous research has shown how we fall onto our outstretched hands in the upper limb falling reflex and we have shown that padding the thenar and hypothenar eminences reduces force transmission to the forearm bones. In theory thicker thenar and hypothenar musculature would help protect against distal radius fractures following a fall on an outstretched hand. The thinner musculature on women may further predispose them to an increased risk of distal radius fractures. Further research is needed to assess for any loss of volar hand soft tissue thickness beyond age 75 years

Biomedical imaging is essential in the diagnosis of musculoskeletal pathologies and postoperative evaluations. In this context, Cone-Beam technology-based Computed Tomography (CBCT) can make important contributions in orthopaedics. CBCT relies on divergent cone X-rays on the whole field of view and a rotating source-detector element to generate three-dimensional (3D) volumes. For the lower limb, they can allow acquisitions under real loading conditions, taking the name Weight-Bearing CBCT (WB-CBCT). Assessments at the foot, ankle, knee, and at the upper limb, can benefit from it in situations where loading is critical to understanding the interactions between anatomical structures. The present study reports 4 recent applications using WB-CBCT in an orthopaedic centre. Patient scans by WB-CBCT were collected for examinations of the lower limb in monopodal standing position. An initial volumetric reconstruction is obtained, and the DICOM file is segmented to obtain 3D bone models. A reference frame is then established on each bone model by virtual landmark palpation or principal component analysis. Based on the variance of the model point cloud, this analysis automatically calculates longitudinal, vertical and mid-lateral axes. Using the defined references, absolute or relative orientations of the bones can be calculated in 3D. In 19 diabetic patients, 3D reconstructed bone models of the foot under load were combined with plantar pressure measurement. Significant correlations were found between bone orientations, heights above the ground, and pressure values, revealing anatomic areas potentially prone to ulceration. In 4 patients enrolled for total ankle arthroplasty, preoperative 3D reconstructions were used for prosthetic design customization, allowing prosthesis-bone mismatch to be minimized. 20 knees with femoral ligament reconstruction were acquired with WB-CBCT and standard CT (in unloading). Bone reconstructions were used to assess congruency angle and patellar tilt and TT-TG. The values obtained show differences between loading and unloading, questioning what has been observed so far. Twenty flat feet were scanned before and after Grice surgery. WB-CBCT allowed characterization of the deformity and bone realignment after surgery, demonstrating the complexity and multi-planarity of the pathology. These applications show how a more complete and realistic 3D geometric characterization of the of lower limb bones is now possible in loading using WB-CBCT. This allows for more accurate diagnoses, surgical planning, and postoperative evaluations, even by automatisms. Other applications are in progress

Abstract. Objective. There is no specific framework for the clinical management of sports related brachial plexus injuries. Necessarily, rehabilitation is based on injury presentation and clinical diagnostics but it is unclear what the underlying evidence base to inform rehabilitative management. Methods. A systematic review of the literature was undertaken in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We applied the PEO criteria to inform our search strategy to find articles that reported the rehabilitative management of brachial plexus injuries sustained while playing contact sports. An electronic search of Medline, CINAHL, SPORTDiscus and Web of Science from inception to 3rd November 2022 was conducted. MESH terms and Boolean operators were employed. We applied an English language restriction but no other filters. Manual searches of Google Scholar and citation searching of included manuscripts were also completed. All study types were considered for inclusion provided they were published as peer-reviewed primary research articles and contained relevant information. Two investigators independently carried out the searches, screened by title, abstract and full text. Two researchers independently extracted the data from included articles. Data was cross-checked by a third researcher to ensure consistency. To assess internal validity and risk of bias, the Joanna Briggs Institute (JBI) critical appraisal tools were utilised. Results. The search generated 88 articles. Following removal of duplicates, 43 papers were evaluated against the eligibility criteria. Nine were eligible for full text review, with the majority of exclusions being expert opinion articles. Eight case reports were included. One article reported three individuals, resulting in data for ten athletes. The mean age was 19.8 years (±4.09). Injuries occurred in five American football players, two wrestlers, two rugby players, and a basketball player. No two studies applied the same diagnostic terminology and the severity of injury varied widely. Burning pain and altered sensation was the most commonly reported symptom, alongside motor weakness in the upper limb. Clinical presentation and management differed by injury pattern. Traction injuries caused biceps motor weakness and atrophy of the deltoid region, whereas compression injuries led to rotator cuff weakness. In all cases treatment was separated into acute and rehabilitative management phases, however the time frames related to these differed. Acute interventions varied but essentially entailed soft tissue inflammation management. Rehabilitation approaches variously included strengthening of shoulder complex and cervical musculature. Return-to-play criteria was opaque. The methodological quality of the case reports was acceptable. Four met all nine of the JBI evaluation criteria, and a further three met at least 75% of items. Conclusion(s). There is a distinct lack of evidence supporting rehabilitation management of sports related brachial plexus injury. Through systematic review we found only eight reports, representing ten individual case studies. No trials, cohort studies, or even retrospective registry-based studies are available to inform clinical management, which, necessarily, is driven by expert opinion and application of basic rehabilitation principles. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

The function of the upper extremity is highly dependent on correlated motion of the shoulder. The shoulder can be affected by several diseases. The most common are: rotator cuff tear (RCT), shoulder instability, shoulder osteoarthritis and fractures. Rotator cuff disease is a common disorder. It has a high prevalence rate, causing high direct and indirect costs. The appropriate treatment for RCT is debated. The American Academy Orthopaedic Surgeons guidelines state that surgical repair is an option for patients with chronic, symptomatic full-thickness RCT, but the quality of evidence is unconvincing. Thus, the AAOS recommendations are inconclusive. We are performing a randomized controlled trial to compare surgical and conservative treatment of RCT, in term of functional outcomes, rotator cuff integrity, muscle atrophy and fatty degeneration. Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. Shoulder instabilities have been classified according to the etiology, the direction of instability, or on combinations thereof. The Thomas and Matsen classification, which is currently the most commonly utilized classification, divides shoulder instability events into the traumatic, unidirectional, Bankart lesion, and surgery (TUBS) and the atraumatic, multidirectional, bilateral, rehabilitation, and capsular shift (AMBRI) categories. The acquired instability overstress surgery (AIOS) category was then added. Surgical procedures for shoulder instability includes arthroscopic capsuloplasty, remplissage, bone block procedure or Latarjet procedure. Reverse total shoulder arthroplasty (RTSA) represents a good solution for the management of patients with osteoarthritis or fracture of the proximal humerus, with associated severe osteoporosis and RC dysfunction

Treatment of large bone defects represents a great challenge for orthopedic surgeons. The main causes are congenital abnormalities, traumas, osteomyelitis and bone resection due to cancer. Each surgical method for bone reconstruction leads its own burden of complications. The gold standard is considered the autologous bone graft, either of cancellous or cortical origin, but due to graft resorption and a limitation for large defect, allograft techniques have been identified. In the bone defect, these include the placement of cadaver bone or cement spacer to create the ‘Biological Chamber’ to restore bone regeneration, according to the Masquelet technique. We report eight patients, with large bone defect (for various etiologies and with an average size defect of 13.3 cm) in the lower and upper limbs, who underwent surgery at our Traumatology Department, between January 2019 and October 2020. Three patients were treated with both cortical and cancellous autologous bone grafts, while five received cortical or cement spacer allografts from donors. They underwent pre and postoperative radiographs and complete osseointegration was observed in all patients already undergoing monthly radiographic checks, with a restoration of length and range of motion. In our study, both the two stage-Masquelet and the cortical bone graft from a cadaver donor proved to be valid techniques in patients with very extensive defects to reconstruct the defect, restore the length, minimize implant left in situ and achieve complete functional recovery

Abstract. Background. Benign osteolytic lesions of bone represent a diverse group of pathological and clinical entities. The aim of this study is to highlight the importance of intraoperative endoscopic assessment of intramedullary osteolytic lesions in view of the rate of complications during the postoperative follow up period. Methods. 69 patients (median age 27 years) with benign osteolytic lesion had been prospectively followed up from December 2017 to December 2018 in a university hospital in Cairo, Egypt and in a level-1 trauma center in United Kingdom. All patients had been treated by curettage with the aid of endoscopy through a standard incision and 2 portals. Histological analysis was confirmed from intraoperative samples analysis. All patients had received bone allografts from different donor sites (iliac crest, fibula, olecranon, etc). None of them received chemo or radiotherapy. Results. Most of lesions were enchondroma (n=29), followed by Aneurysmal bone cyst (ABC) (n=16), Fibrodysplasia (n=13), Chondromyxoid fibroma (n=3), simple bone cyst (n= 3), non-ossifying fibroma (n= 3), giant cell tumour (n= 1) and chondromyxoid fibroma (n = 1). Site of lesion varied from metacarpals (n = 29), femur (n= 1), lower leg (n= 31), and upper limb (n=18). Complications happened only in 9 cases (pathological fractures (n=2), infection (n= 1), recurrence (n=3, all aneurysmal bone cyst), residual pain (n= 3, all in tibia). None of cases developed malignant transformation. Conclusion. Endoscopy is recommended in management of benign osteolytic bone lesions; as it aids in better visualization of the hidden lesions that are missed even after doing apparently satisfactory blind curettage. From our study the recurrence rate is 2% compared to the known 12–18% recurrence rate in the blind technique from literature

Introduction and Objective. In recent years, along with the extending longevity of patients and the increase in their functional demands, the number of annually performed RSA and the incidence of complications are also increasing. When a complication occurs, the patient often needs multiple surgeries to restore the function of the upper limb. Revision implants are directly responsible for the critical reduction of the bone stock, especially in the shoulder. The purpose of this paper is to report the use of allograft bone to restore the bone stock of the glenoid in the treatment of an aseptic glenoid component loosening after a reverse shoulder arthroplasty (RSA). Materials and Methods. An 86-years-old man came to our attention for aseptic glenoid component loosening after RSA. Plain radiographs showed a complete dislocation of the glenoid component with 2 broken screws in the neck of glenoid. CT scans confirmed the severe reduction of the glenoid bone stock and critical bone resorption and were used for the preoperative planning. To our opinion, given the critical bone defect, the only viable option was revision surgery with restoration of bone stock. We planned to use a bone graft harvested from distal bone bank femur as component augmentation. During the revision procedure the baseplate with a long central peg was implanted “on table” on the allograft and an appropriate osteotomy was made to customize the allograft on the glenoid defect according to the CT-based preoperative planning. The Bio-component was implanted with stable screws fixation on residual scapula. We decided not to replace the humeral component since it was stable and showed no signs of mobilization. Results. The new bio-implant was stable, and the patient gained a complete functional recovery of the shoulder. The scheduled radiological assessments up to 12 months showed no signs of bone resorption or mobilization of the glenoid component. Conclusions. The use of bone allograft in revision surgery after a RSA is a versatile and effective technique to treat severe glenoid bone loss and to improve the global stability of the implant. Furthermore, it represents a viable alternative to autologous graft since it requires shorter operative times and reduces graft site complications. There are very few data available regarding the use of allografts and, although the first studies are encouraging, further investigation is needed to determine the biological capabilities of the transplant and its validity in complex revisions after RSA

Introduction and Objective. Zone 2 flexor tendon injuries are still one of the challenges for hand surgeons. It is not always possible to achieve perfect results in hand functions after these injuries. There is no consensus in the literature regarding the treatment of zone 2 flexor tendon injuries, tendon repair and surgical technique to be applied to the A2 pulley. The narrow fibro-osseous canal structure in zone 2 can cause adhesions and loss of motion due to the increase in tendon volume due to surgical repair. Different surgical techniques have been defined to prevent this situation. In our study, in the treatment of zone 2 flexor tendon injuries; Among the surgical techniques to be performed in addition to FDP tendon repair; We aimed to compare the biomechanical results of single FDS slip repair, A2 pulley release and two different pulley plasty methods (Kapandji and V-Y pulley plasty). Materials and Methods. In our study, 12 human upper extremity cadavers preserved with modified Larssen solution (MLS) and amputated at the mid ½ level of the arm were used. A total of 36 fingers (second, third and the fourth fingers were used for each cadaver) were divided into four groups and 9 fingers were used for each group. With the finger fully flexed, the FDS and FDP tendons were cut right in the middle of the A2 pulley and repaired with the cruciate four-strand technique. The surgical techniques described above were applied to the groups. Photographs of fingers with different loads (50 – 700 gr) were taken before and after the application. Proximal interphalangeal (PIP) joint angle, PIP joint maximum flexion angle and bowstring distance were measured. The gliding coefficient was calculated by applying the PIP joint angle to the single-phase exponential association equation. Results. Gliding coefficient after repair increased by %21.46 ± 44.41, %62.71 ± 116.9, %26.8 ± 35.35 and %20.39 ± 28.78 in single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. The gliding coefficient increased significantly in all groups after surgical applications (p<0.05). PIP joint maximum flexion angle decreased by %3.17 ± 7.92, %12.82 ± 10.94, %8.33 ± 3.29 and %7.35 ± 5.02 in single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. PIP joint maximum flexion angle decreased significantly after surgery in all groups (p<0.05). However, there was no statistically significant difference between surgical techniques for gliding coefficient and PIP joint maximum flexion angle. Bowstring distance between single FDS slip repair, kapandji pulley plasty and V-Y pulley plasty showed no significant difference in most loads (p>0.05). Bowstring distance was significantly increased in the A2 pulley release group compared to the other three groups (p<0.05). Conclusion. Digital motion was negatively affected after flexor tendon repair. Similar results were found in terms of gliding coefficient and maximum flexion angle among different surgical methods. As single FDS slipe repair preserves the anatomical structure of the A2 pulley therefore we prefer it as an ideal method for zone 2 flexor tendon repair. However, resection of FDS slip may jeopardizes nutrition to the flexor digitorum profundus tendon which weakens the repair site. Therefore the results must be confirmed by an in vivo study before a clinical recommendation can be made. Keywords: Flexor tendon; injury; pulley plasty; cadaver;