The Walch Type B2 glenoid has the hallmark features of posteroinferior glenoid erosion, retroversion, and posterior humeral head subluxation. Although our understanding of the pathoanatomy of bone loss and its evolution in Type B's has improved, the etiology remains unclear. Furthermore, the morphology of the humerus in Walch B types has not been studied. The purpose of this imaging based anthropometric study was to examine the humeral torsion in Walch Type B2 shoulders. We hypothesized that there would be a compensatory decrease in humeral retroversion in Walch B2 glenoids. Three-dimensional models of the full length humerus were generated from computed tomography data of normal cadaveric (n = 59) and Walch Type B shoulders (n = 59). An anatomical coordinate system referencing the medial and lateral epicondyles was created for each model. A simulated humeral head osteotomy plane was created and used to determine humeral version relative to the epicondylar axis and the head-neck angle. Measurements were repeated by two experienced fellowship-trained shoulder surgeons to determine inter-rater reliability. Glenoid parameters (version, inclination and 2D critical shoulder angle) and posterior humeral head subluxation were calculated in the Type B group to determine the pathologic glenohumeral relationship. Two-way ANOVAs compared group and sex within humeral version and head-neck angle, and intra-class correlation coefficients (ICCs) with a 2-way random effects model and absolute agreement were used for inter-rater reliability.Introduction
Methods
A number of orthopaedic strategies have been described for limb salvage following periprosethic joint infection (PJI). However, this is often only possible with concomitant soft tissue reconstruction in the form of flap coverage. The purpose of this study was to determine the long-term clinical outcome of patients who underwent pedicled gastrocnemius flap coverage as part of their treatment for knee PJI. We performed a retrospective review of all patients undergoing gastrocnemius muscle transfer with split thickness skin grafting as part of their treatment for knee PJI at a tertiary referral centre between 1994 and 2015. Data recorded included patient characteristics, orthopaedic procedure, microbiology result and antimicrobial management. Outcome measures included flap failure, infection recurrence, amputation, functional outcome (Oxford knee score; OKS) and mortality.Aim
Method
Shoulder arthroplasty is used to treat several common pathologies of the shoulder, including osteoarthritis, post-traumatic arthritis, and avascular necrosis. In replacement of the humeral head, modular components allow for anatomical variations, including retroversion angle and head-neck angle. Surgical options include an anatomic cut or a guide-assisted cut at a fixed retroversion and head-neck angle, which can vary the dimensions of the cut humeral head (height, anteroposterior (AP), and superoinferior (SI) diameters) and lead to negative long term clinical results. This study measures the effect of guide-assisted osteotomies on humeral head dimensions compared to anatomic dimensions. Computed tomography (CT) scans from 20 cadaveric shoulder specimens (10 male, 10 female; 10 left) were converted to three-dimensional models using medical imaging software. An anatomic humeral head cut plane was placed at the anatomic head – neck junction of all shoulders by a fellowship trained shoulder surgeon. Cut planes were generated for each of the standard implant head-neck angles (125°, 130°, 135°, and 140°) and retroversion angles (20°, 30°, and 40°) in commercial cutting guides. Each cut plane was positioned to favour the anterior humeral head-neck junction while preserving the posterior cuff insertion. The humeral head height and diameter were measured in both the AP plane and the SI plane for the anatomic and guide-assisted osteotomy planes. Differences were compared using separate two-way repeated measures ANOVA for each dependent variable and deviations were shown using box plot and whisker diagrams.Introduction
Methods
Humeral version is the twist angle of the humeral head relative to the distal humerus. Pre-operatively, it is most commonly measured referencing the transepicondylar axis, although various techniques are described in literature (Matsumura et al. 2014, Edelson 1999, Boileau et al., 2008). Accurate estimation of the version angle is important for humeral head osteotomy in preparation for shoulder arthroplasty, as deviations from native version can result in prosthesis malalignment. Most humeral head osteotomy guides instruct the surgeon to reference the ulnar axis with the elbow flexed at 90°. Average version values have been reported at 17.6° relative to the transepicondylar axis and 28.8° relative to the ulnar axis (Hernigou, Duparc, and Hernigou 2014), although it is highly variable and has been reported to range from 10° to 55° (Pearl and Volk 1999). These studies used 2D CT images; however, 2D has been shown to be unreliable for many glenohumeral measurements (Terrier 2015, Jacxsens 2015, Budge 2011). Three-dimensional (3D) modeling is now widely available and may improve the accuracy of version measurements. This study evaluated the effects of sex and measurement system on 3D version measurements made using the transepicondylar and ulnar axis methods, and additionally a flexion-extension axis commonly used in biomechanics. Computed tomography (CT) scans of 51 cadaveric shoulders (26 male, 25 female; 32 left) were converted to 3D models using medical imaging software. The ulna was reduced to 90° flexion to replicate the arm position during intra-operative version measurement. Geometry was extracted to determine landmarks and co-ordinate systems for the humeral long axis, epicondylar axis, flexion-extension axis (centered through the capitellum and trochlear groove), and ulnar long axis. An anatomic humeral head cut plane was placed at the head-neck junction of all shoulders by a fellowship trained shoulder surgeon. Retroversion was measured with custom Matlab code that analysed the humeral head cut plane relative to a reference system based on the long axis of the humerus and each elbow axis. Effects of measurement systems were analyzed using separate 1-way RM ANOVAs for males and females. Sex differences were analyzed using unpaired t-tests for each measurement system.Background
Methods
Shoulder arthroplasty is used to treat osteoarthritis, post-traumatic arthritis, and avascular necrosis. Modular components allow for natural variability in shoulder anatomy, including retroversion and head-neck angles. Surgical options include anatomic or guide-assisted cut at a fixed retroversion and head-neck angle. The purpose of this study was to determine the variability between head height (HH) and anteroposterior (AP) and superoinferior (SI) diameters using anatomic and guide-assisted humeral head cuts. Computed tomography scans of 10 cadaveric shoulder specimens (5 male, 5 female) were converted to 3D models. An anatomic humeral head cut plane was placed at the anatomic head–neck junction maintaining the posterior cuff insertion for all shoulders by a fellowship trained shoulder surgeon. Cut planes were generated for standard implant head neck angles (125°,130°,135°, and 140°) and retroversion angles (20°,30°, and 40°) in commercial cutting guides, for a combination of 12 repeated cut conditions per specimen. The humeral HH and the head diameter were measured in the AP and the SI planes for anatomic and guide-assisted osteotomy planes. Differences were compared using a separate two-way repeated measures ANOVA for each dependent variable. Guide-assisted cuts showed no significant effect on HH due to head-neck (p=0.205) or retroversion angles (p=0.190). These results persisted by gender (male: head-neck p=0.659 and retroversion p=0.386; female: head-neck p=0.204 and retroversion p=0.190). SI diameter increased by 1.3 mm with increasing head-neck angle (p<0.001), but there was no effect due to retroversion (p=0.148). A head-neck angle of 125° caused the greatest decrease in SI diameter of −2.8 mm compared to the anatomic cut, averaged over the retroversion range. The greatest reduction of SI diameter, −3.4 mm compared to anatomic, occurred with 125° head-neck angle and 20° retroversion. By gender, males showed a significant effect from head-neck angle (p=0.008), but females did not (p=0.077). There was no significant difference from retroversion in either gender group (male p=0.792; female p=0.057). There was no significant difference in AP diameter by head-neck (p=0.192) or retroversion angles (p=0.168). These results persisted in the males (head-neck p=0.420 and retroversion p=0.780). In females, there was no effect from head-neck angle (p=0.232); however, retroversion angle trended toward significance (p=0.050). For patients whose natural anatomy falls outside the range of the commercial cut guides, templated resection may result in deviation from natural humeral head dimensions. Due to the large variability in anatomic retroversion and head-neck angles in the subjects of this study, further study with a larger sample size is needed to investigate observed trends. These preliminary results have implications for manufacturers to create guides to represent a larger segment of the population, and surgeons' intra-operative choice.
