Triceps brachii insertional footprint: Under-estimated complexity.

Background: The detailed complexity of triceps brachii insertional footprint continues to challenge surgeons as evidenced by continued reports of triceps-associated complications following elbow procedures. The purpose of this study is to describe the three-dimensional footprint of the triceps brachii at its olecranon insertion at the elbow. Methods: 22 cadaveric elbows were dissected leaving only the distal insertion of the triceps intact. The insertion was defined and probed with a three-dimensional digitizer to create a digital three-dimensional footprint allowing width, height, and surface area of the footprint to be recorded relative to the bare area. The insertional soft tissues of tendon versus muscle along with the shape of the footprints were qualitatively described. Results: The mean width and surface area of the lateral segment was greater in males than in females (30.07 mm vs. 24.37 mm, p = 0.0339 and 282.1 mm vs. 211. 56 mm, p = 0.0181, respectively). No other statistically significant differences between the sexes were noted. The triceps insertional footprint was "crescent-shaped" and consisted of three regions: central tendon, medial muscular extension, and lateral muscular extension. Discussion: These findings can help explain the importance of avoiding these muscular structures during triceps-off approaches and provides the framework for future clinical studies. Clinical Relevance: Basic Science, anatomy study, cadaver dissection.

Postoperative pain control for shoulder arthroplasty.

Since its inception in 1893, shoulder arthroplasty has become an increasingly common surgical procedure. Between 1998 and 2008, shoulder arthroplasty procedures increased by nearly 28,000 cases per year in the United States alone and is the fastest growing joint replacement surgery among all joint. Despite its advantages, shoulder arthroplasty is often accompanied by significant postoperative pain. Pain control continues to be a major concern in patient management, as it impacts operative costs, postoperative mobility, length of hospital stay, patient satisfaction, and overall surgical outcomes. This review aims to provide an overview of drugs such as opioids and regional anesthetics, as well as methods such as local wound infiltration, nerve block, brachial plexus infiltration, cryotherapy and multimodal approaches employed in postoperative shoulder arthroplasty pain control.

Reinforcement Ring-Augmented Hip Arthroplasty: A 35-Year Follow-up.

During the late 1980s, techniques were evolving to prevent acetabular component loosening. Inadequate acetabular bone stock further complicated this concern, which was traditionally addressed with cementation and bone grafting during this time period. However, one evolving tactic to address acetabular component loosening in the setting of inadequate acetabular bone stock was to augment bone graft with an acetabular reinforcement ring. In 1963, a 26-year-old, active male sustained a right-sided femoral neck fracture following a skiing accident. He ultimately developed a collapsed femoral head and varus deformity of the femoral neck requiring a total hip arthroplasty with a cemented monoblock femoral component and a polyethylene acetabular component cemented into a reinforcement ring. The initial procedure was performed in 1988, and this prosthesis is still functioning 35 years later and represents one of the longest follow-ups of a patient with a primary total hip arthroplasty with a reinforcement ring.

Surgeon-administered intraoperative brachial plexus block for open shoulder surgery - a novel and safe technique.

In the era of outpatient shoulder surgery, bundled payment, safe, predictable, and time-efficient pain management strategies for shoulder arthroplasty (SA) are important. Ultrasound-guided interscalene blocks (ISBs), currently the gold standard for postoperative pain management after shoulder surgery, can be highly operator dependent, time-consuming, and not without complications. We developed a new surgical technique of surgeon-administered intraoperative brachial plexus block in patients undergoing SA open shoulder surgery using the deltopectoral approach. This procedure could be performed after the exposure, either at the beginning or end of the bony work. This procedure is simple, safe, and effective. We did not notice any complications that are typically seen with ISB-like respiratory depression secondary to phrenic nerve palsy, rebound pain after the block wore off, and pain related conversion of outpatient SA to inpatient, over the period of four years (2018-2022). This technique has additional advantages over the established "gold standard" ISB in terms of time and cost savings and improved operating room efficiency.

Shoulder Anteroinferior Glenoid Labrum Reconstruction With the Long Head of the Biceps Tendon Restores Glenohumeral Stability: A Cadaveric Biomechanical Study.

PURPOSE: The purpose of this cadaveric study was to determine feasibility and assess biomechanical stability of glenoid labral reconstruction utilizing the long head of the biceps tendon (LHBT) as a local autograft for labral deficient shoulders. METHODS: Ten cadaveric shoulders underwent resection of all soft tissue structures except the labrum and LHBT. The scapula and humerus were separately attached to a custom shoulder testing apparatus allowing for 22.5 N of compressive isotonic force across the joint. An Instron (Electroplus 1000) measured the peak force (N) as the humeral head was translated over the anteroinferior glenoid rim through 10 cycles. Shoulders were tested in 3 separate scenarios: intact labrum, resected labrum from 3- to 6-o'clock (for a right shoulder), and labral reconstruction with the LHBT. Reconstruction was performed by performing LHBT tenotomy at the level of the pectoralis major insertion. The proximal LHBT tendon, left attached to the supraglenoid tubercle, was then attached to the anteroinferior glenoid rim with suture anchors. RESULTS: Mean (SD) length of the LHBT was 76.1 (12.9 mm) and the diameter was 5.9 (1.6) mm. Peak force for intact labrum was significantly greater than the deficient labrum state (14.06 vs 11.78 N; P = .012). Peak force for labral reconstruction (16.67 N) was significantly greater than both intact and deficient labral states (P < .001 and P = .011, respectively). In all specimens, the length for the LHBT to the pectoralis major insertion was sufficient for reconstruction of the labrum to the 6-o'clock position. CONCLUSIONS: Glenoid labrum reconstruction with the LHBT is a feasible option to restore glenohumeral stability, with peak force to displacement significantly greater than the labral-intact and labral-deficient states. CLINICAL RELEVANCE: This reconstruction may be an option for augmentation in the labral-deficient shoulder.

Superior Capsular Reconstruction Using the Biceps Tendon in the Treatment of Irreparable Massive Rotator Cuff Tears Improves Patient-Reported Outcome Scores: A Systematic Review.

Purpose: To systematically evaluate the clinical outcomes of superior capsular reconstruction (SCR) using the long head of the biceps tendon for irreparable massive rotator cuff tears. Methods: Multiple electronic databases were searched for studies treating massive and/or irreparable rotator cuff tears with SCR using the biceps tendon while retaining its proximal attachment to the superior glenoid. A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flowchart was created. All the included studies were assessed for quality with the Modified Coleman Methodology Score. Multiple variables including patient demographic characteristics, functional scores, visual analog scale (VAS) scores, and complications were extracted and analyzed. Results: Seven studies were included in this review, with a total of 133 patients. The age range of patients was 39 to 82 years, and the duration of follow-up ranged from 6 to 40.7 months. Various validated scoring systems were used for functional outcome evaluation in all studies; all of them showed postoperative improvement greater than the minimal clinically important difference. The VAS score improvement ranged from 3.8 to 7.1. Five studies reported improvement in shoulder forward elevation, with a range of 22° to 95°. Three studies reported retear rates of 21%, 37%, and 66% on postoperative magnetic resonance imaging scans. Two studies reported complications, with the first study reporting revision surgery in 4 of 35 patients and the second study reporting 1 infection and 1 case of deltoid detachment (open procedure) among 17 patients. Conclusions: SCR using the long head of the biceps tendon is a safe and effective procedure. VAS and patient-reported outcome scores showed significant improvement with minimal short-term complications. Level of Evidence: Level IV, systematic review of Level III and IV studies.

Allograft reconstruction of olecranon after traumatic bone loss: a case report.

Despite 2.2 million bone allografts conducted annually, their complication rate remains high, with recipients incurring infection, fracture, instability, and failure to incorporate. Nonunion rates in massive bone allografts-a bone segment ≥5 cm in length that also contains the total circumference of replaced bone-have been documented as high as 50%. However, if early complication can be avoided, a 75% success rate at 20 years postoperatively has been reported. Nonmassive allografts may yield decreased nonunion rates, as massive bone allografts must overcome a greater metaphyseal to diaphyseal incorporation rate and osteoconduction may not ensue beyond the bone periphery. The patient in this case is a 23-year-old male demonstrating absent bone in the right olecranon process of the ulna without attachment of the triceps brachii after a motorbike accident. The patient underwent olecranon allograft reconstruction with triceps brachii tendon reattachment. Four and a half years after allograft reconstruction of the right olecranon, the patient presents with minimal symptoms. However, he reports occasional aching at the site of injury. His current active arc of sagittal motion was 20°-130°, and pronation-supination was 70°-80°. His triceps strength was 4/5 Medical Research Council grade. Radiographic evaluation revealed a well-incorporated graft with a recontoured olecranon tip. Overall, this report demonstrates that operations involving a nonmassive allograft about the olecranon process may display minimal side effects in comparison to massive allografts, specifically regarding nonunion. Furthermore, this operation allows for improved range of motion after bone loss, allowing the patient to partake in activities of daily living.

Knee Implant Identification by Fine-Tuning Deep Learning Models.

BACKGROUND: Identification of implant model from primary knee arthroplasty in pre-op planning of revision surgery is a challenging task with added delay. The direct impact of this inability to identify the implants in time leads to the increase in complexity in surgery. Deep learning in the medical field for diagnosis has shown promising results in getting better with every iteration. This study aims to find an optimal solution for the problem of identification of make and model of knee arthroplasty prosthesis using automated deep learning models. METHODS: Deep learning algorithms were used to classify knee arthroplasty implant models. The training, validation and test comprised of 1078 radiographs with a total of 6 knee arthroplasty implant models with anterior-posterior (AP) and lateral views. The performance of the model was calculated using accuracy, sensitivity, and area under the receiver-operating characteristic curve (AUC), which were compared against multiple models trained for comparative in-depth analysis with saliency maps for visualization. RESULTS: After training for a total of 30 epochs on all 6 models, the model performing the best obtained an accuracy of 96.38%, the sensitivity of 97.2% and AUC of 0.985 on an external testing dataset consisting of 162 radiographs. The best performing model correctly and uniquely identified the implants which could be visualized using saliency maps. CONCLUSION: Deep learning models can be used to differentiate between 6 knee arthroplasty implant models. Saliency maps give us a better understanding of which regions the model is focusing on while predicting the results.

Using Tongue Depressors as a Technique to Aid Cord Localization During Collagenase Injection For Dupuytren Disease.

Collagenase injections are used as a minimally invasive treatment for Dupuytren contracture of the palm and fingers, with good published success. Most complications are related to injection-site swelling, pain, and ecchymosis. However, the risk of flexor tendon and digital nerve injury can occur when injecting cords that cause proximal interphalangeal joint contractures. In addition, poor localization and incorrect injection of the solution into cords may result in an incomplete correction. We describe a technique to improve visualization and isolation of Dupuytren cords using a tongue depressor.

Isolated Small Finger Distal Interphalangeal Joint Dupuytren's Contracture.

Dupuytren's contracture is a disease involving abnormal myofibroblast proliferation and collagen deposition leading to the formation of pathologic cords in the hand. Given that Dupuytren's contractures rarely extend to the distal interphalangeal joint (DIP), affecting only 5% of patients, there are few cases reported in the literature. Collagenase injection is a frequently used option for minimally invasive treatment of Dupuytren's disease with greater than a 20-degree joint contracture. Unfortunately, there is limited research on the effectiveness of these injections in isolated DIP joint deformities. We present a case of a 61-year-old right hand-dominant male with a 2-year history of isolated right small finger Dupuytren's contracture at the DIP joint who achieved significant improvement after collagenase injection.

The antibacterial effect of sonication and its potential medical application.

INTRODUCTION: Recent applications of ultrasonic probes include cataract removal and tennis elbow treatment. Early data support the use of ultrasonic probe debridement in the treatment of recalcitrant diabetic foot ulcers. No data are available concerning the potential antibacterial properties of the clinical grade, lower energy ultrasound probes. We investigated the effect of a clinically available ultrasonic debridement probe with respect to bacterial viability. METHODS: A commercially available Tenex sonication machine with a Tx1 probe was used for this study. Three bacterial strains, aerobic and anaerobic, were investigated, G-negative (Porphyromonas gingivalis) and G-positive bacteria (Staphylococcus aureus and Streptococcus gordonii). These bacteria were cultured and tested with sonication for varying lengths of time (10, 30, 60, and 120 s). The tested bacterial samples were plated, the number of colonies on each plate counted, and the anti-bacterial effect was calculated. Statistical analysis was conducted using a one-way analysis of variance. RESULTS: Sonication exhibited a significant time-dependent antibacterial effect. Statistically significant anti-bacterial effect was observed in all three species tested. When comparing the kill rate between the control and 120 s of sonication; S. gordonii had a 34% kill rate, S. aureus had a 60% kill rate, and P. gingivalis had a 64% kill rate. When comparing control to all of the time intervals tested, S. aureus kill rate was statistically significant at all times, S. gordonii was statistically significant at all times above 10 s, and P. gingivalis was only statistically significant at 120 s. CONCLUSION: This study demonstrates that a clinically available ultrasonic probe has an antibacterial effect against a wide spectrum of gram-positive, gram-negative, aerobic and anaerobic bacterial species. This may partially explain the dramatic healing of long-standing recalcitrant diabetic ulcers debrided with this device and may have a place in treating pathologies with bacterial mechanisms.

Ultrasonic debridement with stem cell therapy of suspensory branch desmitis in an equine patient.

Ultrasonic debridement as a treatment for tendinopathy and desmitis is a relatively new approach in orthopedic surgery. Previously only used in limited cases, this procedure shows promise for treating ligament-bone and tendon-bone interface injuries. We present a case study of a 2-yr-old thoroughbred male horse, unable to train due to recalcitrant symptoms after extensive conservative management of suspensory branch desmitis. It was then treated with ultrasonic debridement and concurrent manubrial stem cell autograft injection, to treat the ultrasound visualized lesion. Post-surgically, the patient recovered quickly, began training within 16 wk, and went onto win several races. Repeat ultrasound imaging reveals a complete restoration of the internal fiber architecture of the ligament. With a 3-yr follow-up, there has been consistent training and race performance with no re-injury. This study is the first to document the successful outcome of ultrasonic debridement with concurrent stem cell injection in the treatment of equine desmitis.

Aseptic loosening of an APTIS distal radioulnar joint arthroplasty - Case report.

Dysfunction of the distal radioulnar joint can cause significant pain and instability. The self-stabilizing APTIS distal radioulnar joint prosthesis is used as a solution for severe distal radioulnar joint pathologies. We present a case of a 60-year-old male, who received an APTIS distal radioulnar joint prosthesis which resulted in aseptic loosening within five years of the initial implantation. Infection, incorrect implantation, demographic differences and over-activity were all excluded as the source; therefore, mechanical aseptic loosening was concluded. Ultimately, two surgeries were required to resolve the patient's pain, which resulted in a one-bone forearm once the implant was extracted. The solution to a failed APTIS implant, a one bone forearm, is difficult and protracted, so every effort should be attempted to preserve distal ulna bone stock before resorting to the implantation of this device.

Posterior interosseous nerve localization within the proximal forearm - a patient normalized parameter.

AIM: To provide a "patient-normalized" parameter in the proximal forearm. METHODS: Sixty-three cadaveric upper extremities from thirty-five cadavers were studied. A muscle splitting approach was utilized to locate the posterior interosseous nerve (PIN) at the point where it emerges from beneath the supinator. The supinator was carefully incised to expose the midpoint length of the nerve as it passes into the forearm while preserving the associated fascial connections, thereby preserving the relationship of the nerve with the muscle. We measured the transepicondylar distance (TED), PIN distance in the forearm's neutral rotation position, pronation position, supination position, and the nerve width. Two individuals performed measurements using a digital caliper with inter-observer and intra-observer blinding. The results were analyzed with the Wilcoxon-Mann-Whitney test for paired samples. RESULTS: In pronation, the PIN was within two confidence intervals of 1.0 TED in 95% of cases (range 0.7-1.3 TED); in neutral, within two confidence intervals of 0.84 TED in 95% of cases (range 0.5-1.1 TED); in supination, within two confidence intervals of 0.72 TED in 95% of cases (range 0.5-0.9 TED). The mean PIN distance from the lateral epicondyle was 100% of TED in a pronated forearm, 84% in neutral, and 72% in supination. Predictive accuracy was highest in supination; in all cases the majority of specimens (90.47%-95.23%) are within 2 cm of the forearm position-specific percentage of TED. When comparing right to left sides for TEDs with the signed Wilcoxon-Mann-Whitney test for paired samples as well as a significance test (with normal distribution), the P-value was 0.0357 (significance - 0.05) indicating a significant difference between the two sides. CONCLUSION: This "patient normalized" parameter localizes the PIN crossing a line drawn between the lateral epicondyle and the radial styloid. Accurate PIN localization will aid in diagnosis, injections, and surgical approaches.

Ultrasound of Extensor Carpi Ulnaris Tendon Subluxation in a Tennis Player.

Wrist pain is common among competitive tennis players. Subluxation of the extensor carpi ulnaris (ECU) tendon has gained recognition as a cause of ulnar-side wrist pain in athletes. In tennis, the wrist is forcibly flexed, supinated, and ulnar deviated. These repetitive motions stress the ECU tendon stabilizers allowing tendon subluxation from the ulnar groove, especially in cases of anatomic variations such as a shallow groove. We present the presurgical and postsurgical imaging findings of recurrent ECU tendon subluxation in an elite tennis player.

Midshaft Clavicle Fractures: A Critical Review.

The clavicle is the most commonly broken bone in the human body, accounting for up to 5% to 10% of all fractures seen in hospital emergency admissions. Fractures of the middle third, or midshaft, are the most common, accounting for up to 80% of all clavicle fractures. Traditional treatment of midshaft clavicle fractures is usually nonoperative management, using a sling or figure-of-eight bandage. The majority of adults treated nonoperatively for midshaft clavicle fractures will heal completely. However, newer studies have shown that malunion, pain, and deformity rates may be higher than previously reported with traditional management. Recent evidence demonstrates that operative treatment of midshaft clavicle fractures can result in better functional results and patient satisfaction than nonoperative treatment in patients meeting certain criteria. This article provides a review of relevant anatomy, classification systems, and injury mechanisms for midshaft clavicle fractures, as well as a comparison of various treatment options. [Orthopedics.2016; 39(5):e814-e821.].

Olecranon bursitis.

BACKGROUND: Bursitis is a common medical condition, and of all the bursae in the body, the olecranon bursa is one of the most frequently affected. Bursitis at this location can be acute or chronic in timing and septic or aseptic. Distinguishing between septic and aseptic bursitis can be difficult, and the current literature is not clear on the optimum length or route of antibiotic treatment for septic cases. The current literature was reviewed to clarify these points. METHODS: The reported data for olecranon bursitis were compiled from the current literature. RESULTS: The most common physical examination findings were tenderness (88% septic, 36% aseptic), erythema/cellulitis (83% septic, 27% aseptic), warmth (84% septic, 56% aseptic), report of trauma or evidence of a skin lesion (50% septic, 25% aseptic), and fever (38% septic, 0% aseptic). General laboratory data ranges were also summarized. CONCLUSIONS: Distinguishing between septic and aseptic olecranon bursitis can be difficult because the physical and laboratory data overlap. Evidence for the optimum length and route of antibiotic treatment for septic cases also differs. In this review we have presented the current data of offending bacteria, frequency of key physical examination findings, ranges of reported laboratory data, and treatment practices so that clinicians might have a better guide for treatment.

Distal Insertional Footprint of the Brachialis Muscle: 3D Morphometric Study.

Objective. The purpose of this study is to describe the three-dimensional morphometry of the brachialis muscle at its distal attachment to the ulna. Methods. Fifty cadaveric elbows were dissected and the brachialis distal insertion was isolated on the ulna bone and probed with a three-dimensional digitizer, to create a three-dimensional model of the footprint. Measurements and analysis of each footprint shape were recorded and compared based on gender and size. Results. There was significant gender difference in the surface length (P= 0.002) and projected length (P= 0.001) of the brachialis footprint. The shapes of the footprint also differed among the specimens. Conclusion. The shape of the brachialis muscle insertion differed among all the specimens without significant variation in gender or sides. There was also a significant difference in muscle length between males and females with little difference in the width and surface area. Significance. The information obtained from this study is important for kinematic understanding and surgical procedures around the elbow joint as well as the understanding of the natural age related anatomy of the brachialis footprint morphology.