Axillary Artery Injuries Associated With Proximal Humerus Fractures: A Literature Review and a Proposal of a Novel Multidisciplinary Surgical Approach.

INTRODUCTION: Proximal humerus fractures (PHF) are common injuries that can lead to axillary artery injury, which carries the risk of not being identified during initial assessment. The aim of this study was to describe the management of suspected axillary artery injury associated with PHF according to our experience and to describe a new multidisciplinary surgical approach. METHODS: This was a single-center retrospective study. A database was created for patients admitted for PHF to the emergency department of the Hospital of Cannes between October 2017 and October 2019. Patients admitted with PHF associated with suspected ipsilateral upper limb ischemia, and/or massive diaphysis displacement, and/or upper limb ipsilateral neurological deficits were included in this study. RESULTS: In total, 301 patients diagnosed with PHF were admitted within these periods. Among these patients, 12 presented with suspected axillary artery lesions, of whom, 6 were included in the present study and treated according to our new approach. A description of these 6 cases, along with an extensive literature review is presented. CONCLUSION: Based on our experience, the endovascular approach proposed for the management of axillary artery injury associated with proximal humerus fractures is effective, feasible and reproducible.

A Composite Lactide-Mineral 3D-Printed Scaffold for Bone Repair and Regeneration.

Orthopedic tumor resection, trauma, or degenerative disease surgeries can result in large bone defects and often require bone grafting. However, standard autologous bone grafting has been associated with donor site morbidity and/or limited quantity. As an alternate, allografts with or without metallic or polyether-etherketone have been used as grafting substitutes. However, these may have drawbacks as well, including stress shielding, pseudarthrosis, disease-transmission, and infection. There is therefore a need for alternative bone substitutes, such as the use of mechanically compliant three-dimensional (3D)-printed scaffolds. Several off-the-shelf materials are available for low-cost fused deposition 3D printing such as polylactic acid (PLA) and polycaprolactone (PCL). We have previously described the feasibility of 3D-printed PLA scaffolds to support cell activity and extracellular matrix deposition. In this study, we investigate two medical-grade filaments consistent with specifications found in American Society for Testing and Materials (ASTM) standard for semi-crystalline polylactide polymers for surgical implants, a pure polymer (100M) and a copolymeric material (7415) for their cytocompatibility and suitability in bone tissue engineering. Moreover, we assessed the impact on osteo-inductive properties with the addition of beta-tricalcium phosphate (ß-TCP) minerals and assessed their mechanical properties. 100M and 7415 scaffolds with the additive ß-TCP demonstrated superior mesenchymal stem cells (MSCs) differentiation detected via increased alkaline phosphatase activity (6-fold and 1.5-fold, respectively) and mineralized matrix deposition (14-fold and 5-fold, respectively) in vitro. Furthermore, we evaluated in vivo compatibility, biosafety and bone repair potential in a rat femur window defect model. 100M+ß -TCP implants displayed a positive biosafety profile and showed significantly enhanced new bone formation compared to 100M implants evidenced by µCT (39 versus 25% bone volume/tissue volume ratio) and histological analysis 6 weeks post-implantation. These scaffolds are encouraging composite biomaterials for repairing bone applications with a great potential for clinical translation. Further analyses are required with appropriate evaluation in a larger critical-sized defect animal model with long-term follow-up.

Three-Dimensional Printed Polylactic Acid Scaffolds Promote Bone-like Matrix Deposition in Vitro.

Large bone defects represent a significant challenge for clinicians and surgeons. Tissue engineering for bone regeneration represents an innovative solution for this dilemma and may yield attractive alternate bone substitutes. Three-dimensional (3D) printing with inexpensive desktop printers shows promise in generating high-resolution structures mimicking native tissues using biocompatible, biodegradable, and cost-effective thermoplastics, which are already FDA-approved for food use, drug delivery, and many medical devices. Microporous 3D-printed polylactic acid scaffolds, with different pore sizes (500, 750, and 1000 µm), were designed and manufactured using an inexpensive desktop 3D printer, and the mechanical properties were assessed. The scaffolds were compared for cell growth, activity, and bone-like tissue formation using primary human osteoblasts. Osteoblasts showed high proliferation, metabolic activity, and osteogenic matrix protein production, in which 750 µm pore-size scaffolds showed superiority. Further experimentation using human mesenchymal stem cells on 750 µm pore scaffolds showed their ability in supporting osteogenic differentiation. These findings suggest that even in the absence of any surface modifications, low-cost 750 µm pore-size 3D-printed scaffolds may be suitable as a bone substitute for repair of large bone defects.

A missed traumatic atlanto-axial rotatory subluxation in an adult patient: case report.

BACKGROUND: Traumatic atlanto-axial rotatory subluxation (AARS) in an adult is a rare condition, which if left untreated can be fatal. In addition to this, many symptoms experienced such as neck pain and stiffness are non-specific which often leads to misdiagnosis, thus delaying definitive treatment. AARS can be divided into traumatic and non-traumatic causes with the latter generally encompassing congenital cervical spine abnormalities. CASE PRESENTATION: We present a case of a 66-year-old female with traumatic rotatory AARS, which was initially misdiagnosed in the emergency department. This patient was subsequently recalled to the hospital when the misdiagnosis was spotted the following day from imaging results. The patient was initially managed conservatively as an inpatient using head halter cervical traction which proved to give good clinical reduction allowing discharge with Miami J upon ambulation. Upon follow up the patient was experiencing continuous pain but remained neurovascularly intact. She thus opted for definitive management with C1-C2 stabilization with an open reduction and internal fixation. CONCLUSION: This case demonstrates the importance of having a high index of suspicion to diagnose AARS in cervical spine trauma presenting to the emergency department, until exclusion can be made using imaging and clinical examination.

Are Cephalomedullary Nail Guides Accurate? A Case Report of an Unexpected Complication After Nailing an Intertrochanteric Femoral Fracture.

Intramedullary nailing is the mainstay of treatment for unstable intertrochanteric hip fractures. Various complications have been described with the use of these nails. We report an unusual complication whereby the lag screw completely missed the nail. We hypothesize that this previously unreported complication may be related to a specific flexible carbon fiber aiming device. Surgeon awareness and thorough intraoperative imaging are crucial to avoiding this complication.

Tuberculous Dactylitis : Case Presentation and Functional outcome.

INTRODUCTION: Skeletal tuberculosis involving the small bones is less common than pulmonary tuberculosis. Tuberculous dactylitis involves the short tubular bones of the hands and feet more commonly in children. The bones of the hands are the one's more frequently affected than bones of the feet, with the proximal phalanx of the index and middle fingers as the commonest sites for infection. Spread to the skeletal system occurs during the initial infection via the lympho-haematogenous route. The radiographic features of cystic expansion have led to the name "Spina Ventosa" for tuberculous dactylitis of the short bones. We report a case of tuberculous dactylitis in the right little finger. CASE PRESENTATION: We describe a 36-year-old woman, who presented with a 12-month history of painless swelling of her right little finger associated with fever and night sweats. Her history was remarkable for persistent productive cough. On examination, her investigation reports and radiographs correlated with the symptoms of tuberculosis, suggestive of tuberculous arthritis. Magnetic resonance imaging of the hand was suggestive of osteomyelitis. Histopathological examination revealed chronic granulomatous inflammation that was consistent with osteomyelitis of the bone due to tuberculosis. However, acid-fast bacilli were not identified. Full course of anti-tuberculosis regimen was commenced. Monthly follow-up and radiographic examinations revealed improvement of the patient under this treatment. She also achieved a good functional outcome. CONCLUSION: Tuberculosis should be considered in patients with unusual soft tissue or skeletal lesions in order to make an early diagnosis and to achieve a good functional outcome. Although tuberculosis of the hand has a varied presentation, the majority of lesions respond to conservative treatment, as anti-tuberculosis chemotherapy is the cornerstone in the management of skeletal tuberculosis.