Digital analysis of external fixation area of proximal humerus fractures in elderly patients

Introduction The purpose is based on anatomical basis, combined with three-dimensional measurement, to guide the clinical repositioning of proximal humeral fractures, select the appropriate pin entry point and angle, and simulate surgery. Methods 11 fresh cadaveric specimens were collected, the distance of the marked points around the shoulder joint was measured anatomically, and the vertical distance between the inferior border of the acromion and the superior border of the axillary nerve, the vertical distance between the apex of the humeral head and the superior border of the axillary nerve, the vertical distance between the inferior border of the acromion and the superior border of the anterior rotator humeral artery, and the vertical distance between the apex of the humeral head and the superior border of the anterior rotator humeral artery were marked on the 3D model based on the anatomical data to find the relative safety zone for pin placement. Results Contralateral data can be used to guide the repositioning and fixation of that side of the proximal humerus fracture, and uniform data cannot be used between male and female patients. For lateral pining, the distance of the inferior border of the acromion from the axillary nerve (5.90 ± 0.43) cm, range (5.3-6.9) cm, was selected for pining along the medial axis of the humeral head, close to the medial cervical cortex, and the pining angle was measured in the coronal plane (42.84 ± 2.45)°, range (37.02° ~ 46.31°), and in the sagittal plane (28.24 ± 2.25)°, range (19.22° ~ 28.51°). The pin was advanced laterally in front of the same level of the lateral approach point to form a cross-fixed support with the lateral pin, and the pin angle was measured in the coronal plane (36.14 ± 1.75)°, range (30.32° ~ 39.61°), and in the sagittal plane (28.64 ± 1.37)°, range (22.82° ~ 32.11°). Two pins were taken at the greater humeral tuberosity for fixation, with the proximal pin at an angle (159.26 ± 1.98) to the coronal surface of the humeral stem, range (155.79° ~ 165.08°), and the sagittal angle (161.76 ± 2.15)°, with the pin end between the superior surface of the humeral talus and the inferior surface of the humeral talus. The distal needle of the greater humeral tuberosity was parallel to the proximal approach trajectory, and the needle end was on the inferior surface of the humeral talus. Conclusion Based on the anatomical data, we can accurately identify the corresponding bony structures of the proximal humerus and mark the location of the pin on the 3D model for pin placement, which is simple and practical to meet the relevant individual parameters.

Comparative study of cell growth and cellular adhesion on Ti-6Al-4V surfaces made by Selective Laser Melting followed by different surface post processing steps

Selective laser melting is generally considered as to improve the design of medical implants, thus supporting medical treatment and maintaining mobility of invalid and older people. In particular, medical grade titanium alloys are in favour for spinal implants, as being nowadays manufactured by, e.g., milling. Selective laser melting offers the advantage of an adapted elasticity as to avoid stress shielding within the backbone by including complex lattice structures inside the individualized implant. For the integration into the backbone, surface properties, particularly surface roughness, are crucial with respect to biocompatibility and cell growth. Opposite to conventional milling, selective laser melting, however, results in an inferior surface roughness, leading to the necessity of downstream process steps. We report on cell growth and cellular adhesion of human primary fibroblasts on medical grade Ti-6Al-4V fabricated by selective laser melting followed by combinations of milling, hot isostatic pressing, chemical surface treatment and steam-sterilization to generate different surface conditions for cell growth. For example, cell growth is studied for varying milling path spacing on SLM parts exhibiting different surface roughness. Our results reveal good cell growth for milling path spacing lower than 0.18 mm as compared to higher milling path spacing and not milled surfaces. Cell fluorescence images and SEM images show that the cell growth is additionally hampered by the edges of the milling path. Conveniently, process failures such as pores originating from the selective laser melting process do not hamper the cell growth.

Comparing the locking screw direction of three locking plates for lateral clavicle fractures: a simulation study

Background The locking plate is a useful treatment for lateral clavicle fractures, however, there are limits to the fragment size that can be fixed. The current study aimed to measure the screw angles of three locking plates for lateral clavicle fractures. In addition, to assess the number of screws that can be inserted in different fragment sizes, to elucidate the size limits for locking plate fixation. Methods The following three locking plates were analyzed: the distal clavicle plate [Acumed, LLC, Oregon, the USA], the LCP clavicle plate lateral extension [Depuy Synthes, LLC, PA, the USA], and the HAI clavicle plate [HOMS Engineering, Inc., Nagano, Japan]. We measured the angles between the most medial and lateral locking screws in the coronal plane and between the most anterior and posterior locking screws in the sagittal plane. A computer simulation was used to position the plates as laterally as possible in ten normal three-dimensional clavicle models. Lateral fragment sizes of 10, 15, 20, 25, and 30 mm were simulated in the acromioclavicular joint, and the number of screws that could be inserted in the lateral fragment was assessed. Subsequently, the area covered by the locking screws on the inferior surface of the clavicle was measured. Results The distal clavicle plate had relatively large screw angles (20° in the coronal plane and 32° in the sagittal plane). The LCP clavicle lateral extension had a large angle (38°) in the sagittal plane. However, the maximum angle of the HAI clavicle plate was 13° in either plane. The distal clavicle plate allowed most screws to be inserted in each size of bone fragment. For all locking plates, all screws could be inserted in 25 mm fragments. The screws of distal clavicle plate covered the largest area on the inferior surface of the clavicle. Conclusions Screw angles and the numbers of screws that could be inserted in the lateral fragment differed among products. Other augmented fixation procedures should be considered for fractures with fragment sizes < 25 mm that cannot be fixed with a sufficient number of screws.

Spontaneous resolution of a tentorial dural arteriovenous fistula fed by the artery of Wollschlaeger and Wollschlaeger after embolization of the main shunting point

Background: Tentorial dural arteriovenous fistula (TDAVF) is a rare intracranial vascular shunt. A TDAVF can be supplied by the Artery of Wollschlaeger and Wollschlaeger (AWW). However, a limited number of cases of TDAVF fed by the AWW have been reported to date. Case Description: A 70-year-old woman complaining of the right motor weakness underwent magnetic resonance imaging. A vascular lesion beneath the cerebellar tentorium was incidentally found with chronic infarction of the left corona radiata. Angiographically, the vascular lesion was a TDAVF supplied by the bilateral posterior meningeal arteries. No other apparent feeders were detected. The TDAVF had a shunting point on the inferior surface of the cerebellar tentorium with venous retrograde flow (Borden type III, Cognard type III). To prevent vascular events, endovascular embolization was performed using n-butyl-2-cyanoacrylate. Following embolization of the shunting point, a residual shunt fed by the AWW was identified. The shunt supplied by the AWW was not observed preoperatively. Follow-up angiography performed 1 week later revealed spontaneous disappearance of the residual shunt. The patient was followed-up in our outpatient clinic, and no recurrence of the TDAVF was confirmed postoperatively. Conclusion: Detection of mild feeding from the AWW to a TDAVF can be elusive preoperatively. Following embolization of the main shunting point, residual shunting from the AWW can resolve spontaneously.

Digital Analysis of External Fixation Area of Proximal Humerus Fractures in Elderly Patients

Background:The purpose is based on anatomical basis, combined with three-dimensional measurement, to guide the clinical repositioning of proximal humeral fractures, select the appropriate nail entry point and angle, and simulate surgery.Methods: 11 fresh cadaveric specimens were collected, the distance of the marked points around the shoulder joint was measured anatomically, and the vertical distance between the inferior border of the acromion and the superior border of the axillary nerve, the vertical distance between the apex of the humeral head and the superior border of the axillary nerve, the vertical distance between the inferior border of the acromion and the superior border of the anterior rotator humeral artery, and the vertical distance between the apex of the humeral head and the superior border of the anterior rotator humeral artery were marked on the 3D model based on the anatomical data to find the relative safety zone for nail placement.Results:Contralateral data can be used to guide the repositioning and fixation of that side of the proximal humerus fracture, and uniform data cannot be used between male and female patients. For lateral nailing, the distance of the inferior border of the acromion from the axillary nerve (5.90±0.43) cm, range (5.3-6.9) cm, was selected for nailing along the medial axis of the humeral head, close to the medial cervical cortex, and the nailing angle was measured in the coronal plane (42.84±2.45)°, range (37.02°~46.31°), and in the sagittal plane (28.24±2.25)°, range ( 19.22°~28.51°). The nail was advanced laterally in front of the same level of the lateral approach point to form a cross-fixed support with the lateral nail, and the nail angle was measured in the coronal plane (36.14±1.75)°, range (30.32°~39.61°), and in the sagittal plane (28.64±1.37)°, range (22.82°~32.11°). Two pins were taken at the greater humeral tuberosity for fixation, with the proximal pin at an angle (159.26±1.98) to the coronal surface of the humeral stem, range (155.79°~165.08°), and the sagittal angle (161.76±2.15)°, with the pin end between the superior surface of the humeral talus and the inferior surface of the humeral talus. The distal needle of the greater humeral tuberosity was parallel to the proximal approach trajectory, and the needle end was on the inferior surface of the humeral talus.Conclusion: Based on the anatomical data, we can accurately identify the corresponding bony structures of the proximal humerus and mark the location of the nail on the 3D model for nail placement, which is simple and practical to meet the relevant individual parameters.

Morphometric Study of Nutrient Foramina in Dry Human Clavicles in Central India

BACKGROUND The clavicle or collar bone is a modified long bone. It is the first bone to ossify in the membrane. The inferior surface of shaft of clavicle presents a subclavian groove. A nutrient foramen lies at the lateral end of the groove. The nutrient artery is derived from the supraclavicular or clavicular branch of thoracoacromial artery. A bone is supplied by a nutrient artery which passes through the small tunnel called as nutrient foramina. In orthopaedic procedures to preserve the circulation, the topographical knowledge of the nutrient foramen is important. The study was undertaken to analyse nutrient foramina in adult human clavicles in relation to their number, position, direction, and distribution over bone length. METHODS Our study consisted of 67 adult dry human clavicles (31 right sides and 36 left sides). The number, topography and direction of the foramina were studied. The distance of foramina from the sternal end & total length of the clavicles were measured in millimetres by using digital Vernier calipers. The foramen index was calculated by applying the Hughes formula: FI = (DNF TL) x 100. RESULTS Nutrient foramina were present in all the clavicles. Most of the clavicles have single nutrient foramen. We observed 62 (68.13 %) foramina on the posterior surface mostly in the middle 1 / 3rd region. All the nutrient foramina were directed towards acromial end and the foramina index (FI) was 50.2. CONCLUSIONS The topographical knowledge of the nutrient foramen is important in orthopaedic procedures like nail plating, K wire fixation, reduction, internal fixation devices for the treatment of fracture, coracoclavicular ligament repair and in free vascularized bone graft to preserve the circulation. KEY WORDS Clavicle, Nutrient Foramina, Nutrient Artery, Foramina Index (FI)

Transcavernous Approach to the Anteromedial Triangle for Residual Functional Pituitary Adenoma

Surgical treatment of functional pituitary adenomas is as rule performed by transsphenoidal approach. However, when then lesion invades the parasellar structures and the cavernous sinus, the transsphenoidal removal of these adenomas is usually incomplete. In this video, we present the technical nuances of a transcavernous approach to the anterio-medial triangle for the resection of a residual functional pituitary adenoma. The patient is a 40-year-old male who was diagnosed with growth hormone secreting pituitary macroadenoma. He underwent two transsphenoidal resections in 2013 and 2016 with a small residue in the left cavernous sinus. Subsequently, due to a failure of biochemical remission despite medical management, a transcranial transcavernous surgery was performed. Brain magnetic resonance imaging showed a mass in the roof of the left cavernous sinus, located at the level of the anteromedial triangle, adherent to the clinoidal segment of the internal carotid artery (ICA). The computed tomographic scan showed an osteolysis of the inferior surface of the anterior clinoidal process. After performing an extended pterional craniotomy and an extradural clinoidectomy, the cleavage plane is extended between the temporal dura and the inner layer of the lateral wall of the cavernous sinus. Intraoperative Doppler and stimulation are used to localize the clinoidal segment of the ICA and the third cranial nerve, delimiting the anteromedial triangle. The lesion is progressively dissected and removed. An optic neuropexy with the previously harvested fat is performed in case of a complementary radio surgical treatment. The patient had an uneventful postoperative course and showed a biochemical remission at the 3-month follow-up.The link to the video can be found at: https://youtu.be/oHfugVtU-Nc.

Morphometry and Morphology of Rouviere’s Sulcus of Liver for Laparoscopic Cholecystectomy - A Cadaveric Study

BACKGROUND The Rouviere’s sulcus (RS) is a horizontal sulcus on inferior surface of liver. The identification of RS may avoid bile duct injury during laparoscopic cholecystectomy and reduce the number of complications. RS is useful but often ignored anatomic landmark. The purpose of the study was to determine the presence/absence, types, and morphometry of demonstrable Rouviere’s sulcus. METHODS This observational study was conducted on 50 (cadaveric) liver specimens obtained during dissection. All the surfaces were meticulously observed, the RS was identified and photographed. The parameters like its presence/ absence, type of sulcus, length, breadth and depth were measured. Later it is classified into type 1, 2 & 3 depending on its morphology. RESULTS The Rouviere’s sulcus was present in 36 (72 %) specimens. The type 1RS in 29 (58 %), type 2 RS in 4 (8 %) and type 3 RS in 3 (6 %) specimens was observed. The RS was horizontal in 25 (50 %) specimens and oblique in 11 (22 %) specimens. The average length, breadth and depth of RS were 3.5 cm, 0.14 cm & 0.52 cm respectively. CONCLUSIONS The knowledge of presence / absence of Rouviere’s sulcus, its type and morphometry provide useful information to the surgeons to avoid bile duct injury during laparoscopic cholecystectomy and to achieve a good outcome. KEY Words Rouviere’s Sulcus, Laparoscopic Cholecystectomy, Bile Duct Injury

Traditional versus congruent-arc Latarjet anatomic and biomechanical perspective

The congruent-arc Latarjet (CAL) allows reconstruction of a greater percentage of glenoid bone deficit because the inferior surface of the coracoid is wider than the lateral edge of the coracoid used with the traditional Latarjet (TL). Biomechanical studies have shown higher initial fixation strength between the graft and the glenoid with the TL. In the TL, the undersurface of the coracoid, which is wider than the medial edge used with the CAL, remains in contact with the anterior edge of the glenoid, increasing the contact surface between both bones and thus facilitating bone consolidation. The shorter bone distance around the screw with the CAL is potentially less tolerant of screw-positioning error compared to the TL. Moreover, the wall of the screw tunnel is potentially more likely to fracture with the CAL due to the minimal space between the screw and the graft wall. CAL may be very difficult to perform in patients with very small coracoids such as small women or skeletally immature patients. Radius of curvature of the inferior face of the coracoid graft (used with the CAL) is similar to that of the native glenoid. This may potentially decrease contact pressure across the glenohumeral joint, avoiding degenerative changes in the long term. Cite this article: EFORT Open Rev 2021;6:280-287. DOI: 10.1302/2058-5241.6.200074

Morphological study of nutrient foramen in adult human clavicles

Introduction: The Clavicle is a modified long bone and only long bone which is placed horizontally and subcutaneously at the root of neck. It transmits the weight from upper limb to the axial skeleton. Nutrient foramen is the largest foramen on the long bones through which nutrient artery for the bones passes. The nutrient artery is the principal source of blood supply to a long bone, particularly important during its active growth period in the embryo and foetus, as well as during the early phase of ossification. The bone has a cylindrical part called the shaft and two ends, lateral and medial. The shaft is divisible into the lateral one-third and the medial two-thirds. The inferior surface of shaft of clavicle presents a subclavian groove. A Nutrient foramen lies at the lateral end of the groove running in a lateral direction. Aims & objectives: To note the position, number and direction of nutrient foramen Materials and Methods: The present study was performed on 100 adult human clavicles of unknown sex and age collected from the department of anatomy, Mysore medical college and research institute, Mysore. Clavicles were examined by direct observation to note the position, number and direction of nutrient foramen. A magnifying lens was used to observe the foramina. Results: The study was conducted on 100 adult human clavicles (50 right and 50 left), and we observed the following results: Nutrient foramina were present in 97 clavicles - 49 clavicles (right) and 48 clavicles (left). Single foramina was present in 80 clavicles, 41 clavicles (right) and 39 clavicles (left) Double foramina were present in 17 clavicles, 8 clavicles (right) and 9 clavicles (left). Absence of nutrient foramina were found in 3 clavicles, 1 clavicle (right) and 2 clavicles (left). All foramina were directed towards the acromial end of the clavicle. Conclusion: The knowledge of anatomical variations of nutrient foramina in clavicles are important for surgeons for performing surgical procedures like bone grafting and microsurgical vascularised bone transplantation. KEY WORDS: Clavicle, Nutrient Foramen, Bone Graft.