The proximal humeral locking plate positioning to the pectoralis major tendon in achieving the proper calcar screw location: a cadaveric study

Background Proximal humeral fracture is the third most common of osteoporotic fracture. Most surgical cases were treated by fixation with anatomical locking plate system. The calcar screw plays a role in medial support and improving varus stability. Proximal humerus fracture in elderly patients are commonly seen with greater tuberosity (GT) fracture. The GT fragment is sometimes difficult to use as an anatomic landmark for proper plate and screw position. Therefore, the insertion of pectoralis major tendon (PMT) may be used as an alternative landmark for appropriate plate and calcar screw position. The purpose of study is going to identify the vertical distance from PMT to a definite point on the position of locking plate. Methods 30 cadaveric shoulders at the department of clinical anatomy were performed. Shoulders with osteoarthritic change (n = 5) were excluded. Finally, 25 soft cadaveric shoulders were recruited in this study. The PHILOS™ plate was placed 2 mm posterior to the bicipital groove. A humeral head (HH) was cut in the coronal plane at the level of the anterior border of the PHILOS plate with a saw. A calcar screw was inserted close to the inferior cortex of HH. Distance from the upper border of elongated combi-hole (UB-ECH) to the upper border of pectoralis major tendon (UB-PMT) was measured. The plate was then moved superiorly until the calcar screw was 12 mm superior to the inferior border of HH and the distance was repeatedly measured. Results The range of distance from UB-PMT to the UB-ECH was from − 4.50 ± 7.95 mm to 6.62 ± 7.53 mm, when calcar screw was close to inferior border of HH and when the calcar screw was 12 mm superior to the inferior border of HH, respectively. The highest probability of calcar screw in proper location was 72% when UB-ECH was 3 mm above UB-PMT. Discussion and conclusion The GT fragment is sometimes difficult to use as an anatomic landmark for proper plate and screw position. PMT can be used as an alternative anatomic reference. UB-PMT can serve as a guide for proper calcar screw insertion. UB-ECH should be 3 mm above UB-PMT and three-fourths of cases achieved proper calcar screw location.

Increase in Tibial Internal Rotation Due to Weight-bearing is a Key Feature to Diagnose Early-stage Knee Osteoarthritis: A Study with Upright Computed Tomography

Background The classification of knee osteoarthritis is an essential clinical issue, particularly in terms of diagnosing early knee osteoarthritis. However, the evaluation of three-dimensional limb alignment on two-dimensional radiographs is limited. This study evaluated the three-dimensional changes induced by weight-bearing in the alignments of lower limbs at various stages of knee osteoarthritis.Methods 45 knees of 25 patients (69.9 ± 8.9 years) with knee OA were examined in the study. CT images of the entire leg were obtained in the supine and standing positions using conventional CT and 320 low-detector upright CT, respectively. Next, the differences in the three-dimensional alignment of the entire leg in the supine and standing positions were obtained using 3D-3D surface registration technique, and those were compared for each Kellgren–Lawrence grade. Results Increased flexion, adduction, and tibial internal rotation were observed in the standing position, as opposed to the supine position. Kellgren–Lawrence grades 1 and 4 showed significant differences in flexion, adduction, and tibial internal rotation between two postures. Grades 2 and 4 showed significant differences in adduction, while grades 1 and 2, and 1 and 3 showed significant differences in tibial internal rotation between standing and supine positions.Conclusions Weight-bearing increased the three-dimensional deformities in knees with osteoarthritis. Particularly, increased tibial internal rotation was observed in patients with grades 2 and 3 compared to those with grade 1. The increase in tibial internal rotation due to weight-bearing is a key pathologic feature to detect early osteoarthritic change in knees undergoing osteoarthritis.

Characteristic Poses in Ballet in the Case of a Retired Classical Ballerina after Bilateral THA: A Case Report and Review of Literature

Background. Ballet dance involves extreme range of motion (ROM) in the hip joint. This ROM can cause injuries including labral strain, tears, and subluxation episodes. Case Presentation. A 69-year-old female classical ballet dance instructor presented bilateral hip pain. The plain radiograph showed end-stage osteoarthritic change in the bilateral hip. She could neither dance nor perform daily activities. Bilateral hybrid total hip arthroplasty (THA) was performed. After surgery, she was able to demonstrate the split position on the floor as an active classical ballerina. The plain radiograph was taken in the split position, and the radiograph did not show any characteristics of impingement or subluxation of the femoral head. Conclusion. She was able to continue working as a classical ballet instructor after bilateral THA. Additionally, any characteristics of impingement or subluxation of the femoral head were not revealed in the postoperative radiograph in the split position.

Factors affecting the onset and progression of rotator cuff tears in the general population

While previous studies have revealed factors affecting the progression of rotator cuff tear (RCT), none have yet described factors affecting its onset. The purpose of this longitudinal observational study was to analyze factors affecting the RCT onset and progression in the general population. The present study included 185 shoulders from 93 participants who completed all the examinations in both 2012 and 2017. Participants received a questionnaire with age, gender, arm dominance, and presence of pain at rest, in motion, and at night. The range of motion (ROM), simple shoulder test (SST) were also examined. Anteroposterior radiograph of the shoulder joint was performed to evaluate the degree of osteoarthritic changes by the Samilson-Prieto (S-P) classification. The degree of RCT was examined by ultrasonography. There were 132 shoulders without RCT and 53 with RCT in 2012. RCT occurred in 21 of 132 shoulders, and the factor affecting the RCT onset was S-P grade 2 osteoarthritic change in 2012 (odds ratio [OR] 10.10). RCT progressed in 22 of 53 shoulders, and the factor affecting RCT progression was the presence of motion pain in 2012 (OR 13.76). These results added new knowledge regarding the natural course of RCT onset and progression.

Comparison of clinical outcomes with and without volar lunate facet fragments in dorsal displaced distal radius fractures

Introduction: Although many clinical studies about distal radius fracture (DRF) accompanied by volar lunate facet fragments (VLFF) have recently been reported, none focus on the direction of displacement of distal fragments. Many previous cases with difficulty in treating DRF with VLFF were volar-displaced fractures. Thus, the postoperative risk for re-displacement is different between volar- and dorsal-displaced fractures with VLFF. The aim of this study is to compare the outcome of dorsal-displaced fractures treated using proximal volar locking plates (PVLP) between those with VLFF and those without, in order to reconsider the indications of distal volar locking plates (DVLP) and investigate the possibility of treating dorsal-displaced DRF with VLFF using PVLP. Methods: The subjects were 122 patients with dorsal-displaced DRFs treated using PVLP (42 males and 80 females, mean age: 59.2 years old). The patients were divided into 13 patients with VLFF group and 109 patients without VLFF group, and the clinical outcomes at 12 months after surgery were compared. Results: No significant difference was noted on any evaluation between the groups. In addition, no postoperative re-displacement of VLFF was observed and bone union was confirmed. Furthermore, no osteoarthritic change was noted in all patients. Conclusions: We confirmed that surgical treatment for dorsal-displaced DRF using PVLP is possible even in cases of DRF with VLFF. In addition, DVLP is an implant with a high complication risk; therefore, it may be necessary to reconsider the use of DVLP for dorsal-displaced DRF with VLFF treatable by PVLP.

Long-Term Survivorship and Clinical Outcomes of Osteochondral Autologous Transplantation for Steroid-Induced Osteonecrosis of the Knee

Objective Treatments for steroid-induced osteonecrosis of the knee remains challenging, and there has not been sufficient evidence to support joint preservation surgery. This study evaluated long-term outcomes of osteochondral autologous transplantation (OAT) for steroid-induced osteonecrosis of the knee. Design This retrospective case series included patients who underwent OAT for steroid-induced osteonecrosis of the knee from 1998 to 2008. The survivorship and need for secondary surgery were evaluated, and the clinical outcome was evaluated with the International Knee Documentation Committee (IKDC) subjective score. Preoperative and final Kellgren-Lawrence (KL) grade of the femorotibial and patellofemoral joints were individually evaluated. Results Fourteen knees of 10 patients whose mean age was 32.5 (95%CI 26.4-38.6) years were included and followed for 14.0 (12.4-15.7) years. The mean lesion size of 6.9 (5.3-8.5) cm2 was repaired using 4 median (minimum 2, maximum 5) osteochondral plugs. No revision surgeries were performed for transplanted osteochondral plugs. The IKDC subjective score improved from 32.9 (24.5-41.3) to 74.2 (61.9-88.5) ( P < 0.001). Knee flexion was improved at the final follow-up, and Seiza sitting was finally possible in 9 knees in 7 patients. Although the osteoarthritic change did not progress in femorotibial joint, patellofemoral joint showed early osteoarthritic changes at the final follow-up (mean KL grade: 0.8 [0.5-1.1]). Conclusions Prosthetic joint replacement was successfully avoided for at least the first decade by OAT in young patients with steroid-induced osteonecrosis of the knee. The progression of KL grade of the patellofemoral joint is of concern.

Intermediate and long-term radiographic and functional outcomes of ulnar shortening osteotomy in patients with ulnar impaction syndrome and reverse oblique sigmoid notch

Background: Ulnar shortening osteotomy (USO) is an effective treatment for the ulnar impaction syndrome. But there has been a concern of osteoarthritis developing in the distal radioulnar joint (DRUJ) if we perform the USO in patients with reverse oblique sigmoid notch. This study was to evaluate the radiographic and functional outcomes following USO in patients with reverse oblique sigmoid notch.Methods: Between 2002 and 2013, we retrospectively reviewed our patients with reverse oblique sigmoid notch underwent USO in treating the ulnar impaction syndrome. We evaluated the radiographic changes in the DRUJ and their functional outcomes.Results: We enrolled 22 patients (22 wrists) with an average age at operation of 49.6 years and mean follow-up of 93.2 months. We found that there were changes in the inclination angle of sigmoid notch, from an average of reverse oblique 14.9o preoperatively to a more parallel of 5.1o at the final follow-ups. The functional results at the final follow-ups were good with the mean VAS for pain of 0.3 at rest and 1.4 during activity, QuickDASH of 16.5, and modified Mayo Wrist Score of 91.4. There were 7 wrists (31.8%) noted to have osteoarthritic change, but they did not exhibit significantly worse function, except supination motion, pain during activity, and grip strength.Conclusions For the patients with reverse oblique sigmoid inclination following USO, the inclination angle would have a tendency to become more parallel and some would develop the osteoarthritic change in the DRUJ, but the functional outcomes could still be good in the intermediate and long-term. The reverse oblique sigmoid inclination seems not to be an absolute contraindication for USO.

Isolated first carpometacarpal joint dislocation managed with closed reduction and splinting

A 56-year-old man, right-hand-dominant office worker, complained of pain and swelling at the base of his right thumb after using his hand to press onto the front passenger seat during an emergency brake. X-ray showed a dorsal dislocation of the first carpometacarpal joint of his right hand. Closed reduction of the joint was performed. As there were no clinical signs of instability post-reduction and X-ray confirmed that the joint was congruent, the joint was immobilised in a thumb spica splint for 6 weeks. His pain subsided and the range of motion of his first carpometacarpal joint was full at 9 weeks post-injury. Two years after the injury, he was asymptomatic and X-ray revealed normal joint anatomy with no obvious subluxation or osteoarthritic change. For patients with first carpometacarpal joint dislocations, non-operative management with splinting is a good option if the joint is stable post-reduction.

Pigmented Villonodular Synovitis of the Foot and Ankle

Category: Other Introduction/Purpose: Pigmented Villonodular Synovitis (PVNS) is a benign but potentially locally aggressive condition, that results in an increased proliferation of synovium, causing villous or nodular changes of synovial-lined joints and tendon sheaths. The estimated incidence of PVNS is 1.8 new cases annually per million people, of which 2.5% occur in the foot and ankle, reflected by the limited reports of PVNS in the foot and ankle literature. We present our clinical experience of 76 patients presenting with PVNS about the foot and ankle. Methods: Patients with PVNS of the foot and ankle were identified from our tertiary referral hospital patient database from 2007 to 2017. The case notes were carefully reviewed to analyse the clinical, radiological, and histopathological features and to investigate their clinical behaviour, management and the factors influencing recurrence. Results: 76 patients were identified (32 male, 44 female) with a mean age of 39 years and mean follow-up of 5 years. The majority of cases were of localised, nodular PVNS (52%, 40/76) with the diffuse PVNS cases (48%, 36/76) presenting most commonly in the hindfoot. The most common presentation was of a swelling/lump (78%- 62/79), of which pain was an associated feature in 11% (7/62) and restricted range of motion a feature in 10% (6/62). Osteoarthritic change and cortical erosions were more commonly associated with diffuse PVNS. All patients underwent open synovectomy with a recurrence rate of 11% (7/76), all of which were the diffuse type. In those cases where synovectomy was paired with arthrodesis of the joint, there were no cases of recurrence (12%,9/76). Conclusion: We present our tertiary referral experience of PVNS in the foot and ankle as the largest series in the foot ankle ankle literature to date. A high index of suspicion is required in diagnosing PVNS. Nodular PVNS appears more common in the foot whereas diffuse PVNS more common in the ankle and hindfoot. Open synovectomy yields low recurrence rates. Although theorised, there is insufficient evidence to establish whether concurrent arthrodesis of the affected joint reduces risk of recurrence.