Medial Femoral Condyle Corticoperiosteal Flap for Failed Total Wrist Fusions.

Background Recalcitrant nonunion following total wrist arthrodesis is a rare but challenging problem. Most commonly, in the setting of failed fusion after multiple attempts of refixation and cancellous bone grafting, the underlying cause for the failure is invariably multifactorial and is often associated with a range of host issues in addition to poor local soft-tissue and bony vascularity. The vascularized medial femoral condyle corticoperiosteal (MFC-CP) flap has been shown to be a viable option in a variety of similar settings, which provides vascularity and rich osteogenic progenitor cells to a nonunion site, with relatively low morbidity. While its utility has been described for many other anatomical locations throughout the body, its use for the treatment of failed total wrist fusions has not been previously described in detail in the literature. Methods In this article, we outline in detail the surgical technique for MFC-CP flap for the management of recalcitrant aseptic nonunions following failed total wrist arthrodesis. We discuss indications and contraindications, pearls and pitfalls, and potential complications of this technique. Results Two illustrative cases are presented of patients with recalcitrant nonunions following multiple failed total wrist fusions. Conclusion When all avenues have been exhausted, a free vascularized corticoperiosteal flap from the MFC is a sound alternative solution to achieve union, especially when biological healing has been compromised. We have been able to achieve good clinical outcomes and reliable fusion in this difficult patient population.

Unilateral microscopic approach for lumbar spinal stenosis decompression: a scoping review.

BACKGROUND: Microscopic unilateral laminotomy for bilateral decompression (ULBD) is a minimally invasive technique used in the treatment of lumbar spinal stenosis and could limit spinal instability and be associated with better clinical outcomes. However, there is ongoing debate regarding its utility compared to conventional laminectomy (CL). The primary objective was to collate and describe the current evidence base for ULBD, including perioperative parameters, functional outcomes, and complications. The secondary objective was to identify operative techniques. METHODS: A scoping review was conducted between January 1990 and August 2022 according to the PRISMA extension for scoping reviews (PRISMA-ScR) guidelines. Major databases were searched for full text English articles reporting on outcomes following microscopic unilateral laminotomy in patients with lumbar spinal stenosis. RESULTS: Seventeen articles met the inclusion criteria. Two studies were randomised controlled trials. Two studies were prospective data collection and the rest were retrospective analysis. Three studies compared ULBD with CL. ULBD preserves the osteoligamentous complex and may be associated with shorter operative time, less blood loss, and similar clinical outcomes when compared to CL. CONCLUSION: This review highlights that ULBD aims to minimise disruption to the normal posterior spinal anatomy and may have acceptable clinical outcomes. It also highlights that it is difficult to draw valid conclusions given there are limited data available as most studies identified were retrospective or did not have a comparator group.

Sinus arrest in a p.Arg160X-DSP-positive patient without evidence of desmoplakin-mediated cardiomyopathy: a case report.

Background: Pathogenic/Likely pathogenic variants in DSP-encoded desmoplakin are strongly associated with arrhythmogenic cardiomyopathy (ACM). However, their contribution towards sinus node dysfunction has not been well-delineated. Case summary: A 74-year-old man with a pathogenic variant of DSP-encoded desmoplakin (c.478C >T; p.Arg160X) but no evidence of ACM presented with one episode of syncope in the setting of a gastrointestinal illness. Workup including echocardiography, cardiac magnetic resonance imaging, and Holter monitor did not show evidence of ACM or significant arrhythmias. One month later, he experienced several closely-spaced episodes of syncope associated with long sinus pauses and sinus arrest documented on telemetry. He underwent urgent dual chamber pacemaker implantation, during which a ventricular programmed stimulation study was performed and was negative for sustained ventricular arrhythmias. His syncopal episodes resolved and he had no recurrent events on three-month follow-up. Discussion: As highlighted here, DSP-encoded desmoplakin pathogenic/Likely pathogenic variants may contribute to isolated sinus node dysfunction. This clinical link should be further explored in larger studies involving patients with DSP variants.

Lightning strikes as a major facilitator of prebiotic phosphorus reduction on early Earth.

When hydrated, phosphides such as the mineral schreibersite, (Fe,Ni)3P, allow for the synthesis of important phosphorus-bearing organic compounds. Such phosphides are common accessory minerals in meteorites; consequently, meteorites are proposed to be a main source of prebiotic reactive phosphorus on early Earth. Here, we propose an alternative source for widespread phosphorus reduction, arguing that lightning strikes on early Earth potentially formed 10-1000 kg of phosphide and 100-10,000 kg of phosphite and hypophosphite annually. Therefore, lightning could have been a significant source of prebiotic, reactive phosphorus which would have been concentrated on landmasses in tropical regions. Lightning strikes could likewise provide a continual source of prebiotic reactive phosphorus independent of meteorite flux on other Earth-like planets, potentially facilitating the emergence of terrestrial life indefinitely.

The Twist X-Ray: A Novel Test for Dynamic Scapholunate Instability.

Background Scapholunate instability (SLI) is the most common form of carpal instability. Early detection of SLI is imperative as early reconstructive procedures can potentially prevent the natural history of progressive degenerative arthritis. After wrist arthroscopy, magnetic resonance imaging (MRI) remains the next best noninvasive diagnostic option; however, access still remains costly and is often limited in many health care systems worldwide. In this article, we describe a novel device that allows for dynamic X-rays to be taken, accentuating the scapholunate (SL) widening. Description of Technique Twist X-ray views are generated by the patient clenching a device that combines the standard clenched fist views with ulnar deviation and supination. The test is easy to perform and functions by combining a higher grip force with the ulnar deviation and pronation effects of the extensor carpi ulnaris tendon, thus accentuating the SL gap in dynamic instability. Patients and Methods We present a series of four patients with dynamic SLI and compare the findings of the Twist X-rays with conventional wrist X-rays series, including standard anteroposterior, lateral, radial, and ulna deviation, clenched fist, and pencil grip views. Results In all the four patients, there was substantial dynamic SL widening. The SL interval increased from a mean of 1.8 mm (range: 1.5-2.8) on posteroanterior X-rays to 6.3 mm (range: 4.6-8.2) with the Twist views. Interestingly, on the pencil grip view, the mean widening was only 1.5 mm (range: 1-2.8 mm). Conclusion The authors describe a novel device that allows for improved detection of dynamic SL ligament instability when performing stress X-ray views of the wrist. Level of Evidence This is a Level IV study.

A blinded, randomized trial comparing bicolumnar arthrodesis to radioscapholunate arthrodesis in scapholunate advanced collapse II arthritis: a pilot study.

The purpose of this study was to compare the outcome of scaphoid excision with capitolunate and triquetrohamate arthrodesis (bicolumnar arthrodesis) to radioscapholunate arthrodesis in patients with scapholunate advanced collapse (SLAC) II wrist arthritis. Twelve patients with symptomatic SLAC II arthritis were recruited and randomized to receive either bicolumnar arthrodesis or radioscapholunate arthrodesis. The primary outcome was wrist function as assessed by the patient rated wrist evaluation. Secondary outcomes included range of motion, grip strength and the Mayo wrist score. A linear mixed-effects model was used to evaluate the effects of bicolumnar arthrodesis and radioscapholunate arthrodesis in treating SLAC II arthritis. Patients receiving bicolumnar arthrodesis had more improvement in their wrist function compared with patients receiving radioscapholunate arthrodesis. A high rate of re-operation was observed in patients receiving radioscapholunate arthrodesis. In SLAC II arthritis, the expected benefit of preserving the midcarpal joint was not observed. Scapholunate ligament disruption makes radioscapholunate arthrodesis a technically challenging operation. LEVEL OF EVIDENCE: I.

The dorsal horizon view: detecting screw protrusion at the distal radius.

PURPOSE: Extensor tendon injury after osteosynthesis of distal radius fractures is a well-documented complication. It has been shown to be associated with screw protrusion through the dorsal cortex, or plunging of the drill bit into the overlying tendon. It is difficult to determine screw length and protrusion using the standard anteroposterior and lateral intraoperative fluoroscopic images because of the triangular configuration of the distal radius and Lister tubercle. In fractures with a coronal split, it may be necessary to lag the dorsal fragment, necessitating longer screws and risking screw protrusion beyond the dorsal cortex. For these fractures, we use a radiographic view aimed along the long axis of the radius to detect screw protrusion. METHODS: This was a retrospective case series involving 15 distal radius fractures. To obtain the dorsal horizon view, the wrist is hyperflexed and the beam of the image intensifier is aimed along the long axis of the radius. We evaluated 15 distal radius fractures with a coronal split component, where the dorsal horizon view was used to detect dorsal cortex screw protrusion. This view was used intraoperatively following the use of the standard views. We evaluated records and imaging to ascertain whether the use of this radiograph led to a change in intraoperative screw selection. RESULTS: Of the 15 cases, we changed screw selection as a result of the additional view in 4 patients. In 3 of these cases, the screw length was long, which was not apparent on standard intraoperative fluoroscopic views. CONCLUSIONS: The use of the dorsal horizon view is a useful adjunct to prevent screw protrusion beyond the dorsal cortex when performing osteosynthesis of the distal radius.

Congenital bipartite lunate presenting as a misdiagnosed lunate fracture: a case report.

INTRODUCTION: A rare case of congenital bipartite lunate in a child is reported. Carpal variants are very uncommon as independent entities, with only three previous reports of this condition in the English literature. CASE PRESENTATION: An 11-year-old Caucasian boy presented with pain in the left wrist after a fall. Radiographs in the emergency department demonstrated a lunate that was divided into palmar and dorsal parts, causing a misdiagnosis of fractured lunate. Magnetic resonance imaging was then used to differentiate between the two diagnoses. CONCLUSION: Very few cases of bipartite lunate have been reported in the literature, and unless awareness is raised about congenital anomalies such as this variant, confusion may arise.

Vertebral artery dissection presenting with multilevel combined sensorimotor radiculopathy: a case report and literature review.

STUDY DESIGN: This study is a case report demonstrating a rare clinical presentation of vertebral artery dissection. We believe that this is the first reported case with multilevel combined sensorimotor radiculopathy. We have also included a literature review. OBJECTIVE: The purpose of this report is to inform the reader of a unique clinical presentation and to draw attention to some of the rare features of extracranial vertebral artery dissection. We believe that this condition is perhaps underrecognized and this paper may help to increase awareness, thereby encouraging prompt investigation, diagnosis, and implementing early treatment. The literature review also includes a brief anatomic and physiologic description of the underlying pathologic process. SUMMARY OF BACKGROUND DATA: Only a small number of similar cases are described in the literature, though most describe a motor deficit at a single root level. Our case included both motor and sensory deficits at more than 1 level and we describe the possible physiologic and anatomic reasons for this. METHODS: The case described is one that presented to our institution and was initially assessed by the first (corresponding) author. The literature review is based on articles identified from a PubMed search on vertebral artery dissection. RESULTS: The clinical and radiologic findings are discussed in the case report. CONCLUSIONS: Peripheral motor deficits are a rare clinical presentation of spontaneous vertebral artery dissection and tend to affect a solitary root level, typically C5. Sensation is usually preserved. We describe a case presenting with multilevel combined sensorimotor radiculopathy, which we believe has not previously been reported.

Perioperative aspects of endoscopic anterior scoliosis surgery: the learning curve for a consecutive series of 100 patients.

The reported benefits of endoscopic versus open scoliosis surgery include improved visualization, a muscle sparing approach, reduced pulmonary morbidity, reduced pain, and improved cosmesis. Some aspects of the surgical learning curve for this technically demanding method have been previously reported; however, improvements in other factors with increasing experience have not been quantified. This paper presents a series of 100 consecutive endoscopic anterior scoliosis corrections performed between April 2000 and February 2006. We report changes in the following perioperative factors with increasing experience; operative set-up time, operative time, x-ray irradiation time, number of instrumented levels, blood loss, intercostal catheter drainage, chest drain removal time, days in intensive care, days to mobilize, days in hospital, and early complications. Statistical comparisons were made between the first 20 (1 to 20), middle 20 (41 to 60), and last 20 (81 to 100) cases. Results showed statistically significant improvements and increased consistency in operative time, operative set-up time, x-ray irradiation time, blood loss, hospital stay, and mobilization time with experience. The complication rate was comparable to other recently published endoscopic studies. In the last 20 cases of the series, operative times had reduced to 35 minutes per level, x-ray irradiation times to 15 seconds per level, and blood loss to 38 mL per level. Most perioperative surgical factors therefore improve significantly with increasing experience in endoscopic anterior scoliosis correction.

Recovery of pulmonary function following endoscopic anterior scoliosis correction: evaluation at 3, 6, 12, and 24 months after surgery.

STUDY DESIGN: A series of patients with scoliosis undergoing endoscopic anterior instrumentation and fusion undertaking repeated pulmonary function assessments. OBJECTIVE: To assess recovery of pulmonary function in the 2 years following endoscopic anterior scoliosis correction. SUMMARY OF BACKGROUND DATA: Recent studies have found that pulmonary function returns to preoperative levels 12-24 months following endoscopic anterior scoliosis correction, and a small improvement in forced expiratory volume (FEV1) has also been reported. METHODS: A series of 44 patients with endoscopic anterior scoliosis correction had pulmonary function tests before surgery, and at 3, 6, 12, and 24 months after surgery. Forced vital capacity (FVC), FEV1, and total lung capacity (TLC) were measured. Nonparametric statistical analysis was used to investigate changes in pulmonary function between successive assessments. RESULTS: Pulmonary function decreased by approximately 10% at 3 months after surgery. At 24 months after surgery, FVC and FEV1 recovered to 5% to 8% higher than preoperative levels, while TLC returned to preoperative levels. Statistically significant improvements in most pulmonary function values occurred between 3 and 6, and 6-12 months. Improvements in mean FVC, FEV1, and TLC continue between 12 and 24 months, although only the increase in absolute FVC for this time is statistically significant. CONCLUSIONS: Endoscopic anterior scoliosis surgery has no lasting negative effect on pulmonary function, and with prolonged follow-up, pulmonary capacity improves beyond preoperative levels.

Variability in Cobb angle measurements using reformatted computerized tomography scans.

STUDY DESIGN: Survey of intraobserver and interobserver measurement variability. OBJECTIVE: To assess the use of reformatted computerized tomography (CT) images for manual measurement of coronal Cobb angles in idiopathic scoliosis. SUMMARY OF BACKGROUND DATA: Cobb angle measurements in idiopathic scoliosis are traditionally made from standing radiographs, whereas CT is often used for assessment of vertebral rotation. Correlating Cobb angles from standing radiographs with vertebral rotations from supine CT is problematic because the geometry of the spine changes significantly from standing to supine positions, and 2 different imaging methods are involved. METHODS: We assessed the use of reformatted thoracolumbar CT images for Cobb angle measurement. Preoperative CT of 12 patients with idiopathic scoliosis were used to generate reformatted coronal images. Five observers measured coronal Cobb angles on 3 occasions from each of the images. Intraobserver and interobserver variability associated with Cobb measurement from reformatted CT scans was assessed and compared with previous studies of measurement variability using plain radiographs. RESULTS: For major curves, 95% confidence intervals for intraobserver and interobserver variability were +/-6.6 degrees and +/-7.7 degrees, respectively. For minor curves, the intervals were +/-7.5 degrees and +/-8.2 degrees, respectively. Intraobserver and interobserver technical error of measurement was 2.4 degrees and 2.7 degrees, with reliability coefficients of 88% and 84%, respectively. There was no correlation between measurement variability and curve severity. CONCLUSIONS: Reformatted CT images may be used for manual measurement of coronal Cobb angles in idiopathic scoliosis with similar variability to manual measurement of plain radiographs.

Regional orthopaedic courses--rationale and practice.

BACKGROUND: The intensity and length of higher surgical training has changed, and with this the need for a more formalised training programme has been recognised. With limited budgets for training and the high cost of national training days, it was proposed that within the Wessex Deanery regional courses should be run to complement the existing weekly training session. METHODS: In 1998, a questionnaire was sent to all the orthopaedic consultants and specialist registrars within the region to identify the training requirements of the specialist registrars and the availability of consultants to organise and teach during these training courses. RESULTS: A regionally published report based on the questionnaire's findings identified these training requirements as indicated by both the specialist registrars and the consultants. This information has been used to organise eight 1-day training courses using the expertise of consultants within the region with more planned in the near future. CONCLUSIONS: Four years following this report, we identified the training requirements within the Wessex region and have successfully run regional courses to meet this requirement.

Preventing methicillin-resistant Staphylococcus aureus infection in joint replacements: a new problem requiring old solutions.

AIM: To analyse prospectively the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonisation and infection in wounds and surgical vacuum drains. METHODS: The study group was 100 patients undergoing primary total hip and total knee replacements in a single orthopaedic unit. RESULTS: Two patients had undergone revision joint surgery within the same unit in the year prior to the study due to confirmed MRSA infection. Following a change in the unit's infection control policy, joint replacement surgery continued within the unit even when there were cases of active MRSA present on the same ward. None of the patients undergoing joint replacement grew MRSA in their postoperative drain tips or wound cultures. CONCLUSIONS: It is safe to continue with joint replacement surgery when other patients on the same ward have active MRSA as long as strict infection control measures are followed as outlined.