Percutaneous distal clavicle excision for acromioclavicular joint arthritis: our experience and early results of a novel surgical technique.

PURPOSE: Symptomatic acromioclavicular joint (ACJ) osteoarthritis causes pain and limitations in activities of daily living. Open and arthroscopic distal clavicle excision techniques have been described with good outcomes. However, both techniques have their own sets of advantages and disadvantages. This study describes a novel technique of percutaneous distal clavicle excision for symptomatic ACJ osteoarthritis and our two-year results. METHODS: Fifteen consecutive patients underwent percutaneous distal clavicle excision for ACJ arthritis. These patients had failed a trial of conservative treatment. The ACJ was confirmed as the pain generator with an intraarticular steroid/lignocaine injection, and shoulder MRI was used to exclude alternative pain generators in the shoulder. They had a minimum of two years of follow-up. RESULTS: At a mean of 26.8 months postoperatively, the mean VAS pain score was 0, and the mean Constant score for the shoulder was 87.3 points (range 50-94), which corresponded to 1 good, 1 very good and 13 excellent results. The mean SF-36 score was 94.9 points (range 65-100). There were statistically significant improvements in the VAS scores, Constant shoulder scores and SF-36 scores at one year and two years of follow-up (p < 0.05). Three unique complications, namely subcutaneous emphysema, "missing" of the distal clavicle and thermal skin injury, were encountered. Our surgical technique has since been modified to circumvent these complications. CONCLUSION: Our novel technique of percutaneous distal clavicle excision yields a 93.3% good-to-excellent results based on the Constant shoulder score and durable pain relief based on VAS at two years.

Management of the floating shoulder: Does the glenopolar angle influence outcomes? A systematic review.

INTRODUCTION: Currently there is no consensus on the optimal treatment of the "floating shoulder". We aim to perform a systematic review to determine outcomes in the management of this condition. MATERIALS AND METHODS: Studies related to the management of the "floating shoulder" were identified by a review of medline using platform Pubmed/Ovid, Scopus and Cochrane library data bases. Studies were included if they: (1) are published in the English language and (2) reported outcomes of at least 2 or more cases of floating shoulder injuries using at least one objective shoulder scoring system. Exclusion criteria were (1) non-human and biomechanical studies and (2) studies with a clear selection bias. Three treatment groups were identified. Group 1-non-operative, Group 2-fixation of clavicle only, and Group 3-fixation of clavicle and scapula neck. RESULTS: Thirteen studies gave a population of 244 subjects of which 104 had non-operative treatment, 98 had internal fixation of the clavicle only and 42 had fixation of both the clavicle and the scapula. There were no differences in the outcome scores among the 3 treatment arms as the patients with undisplaced or minimally displaced fractures had conservative treatment and those with displaced fractures were surgically stabilised. There was a positive correlation between the final glenopolar angle and the Constant score. CONCLUSIONS: The review was unable to show a difference in outcomes among the 3 treatment groups. Any treatment modality that restores the glenopolar angle is likely to result in a good outcome. LEVEL OF EVIDENCE: Therapeutic level IV.

Upper Extremity Innervation Patterns and Clinical Implications for Nerve and Tendon Transfer.

BACKGROUND: The authors previously studied the intramuscular innervation of 150 upper limb muscles and demonstrated that certain patterns of intramuscular innervation allowed muscles to be split into compartments with independent function. This study aims to determine the location, extramuscular course, and number of motor nerve branches of upper limb peripheral nerves. The authors want to combine this information with their previous work to create a blueprint of upper limb neuromuscular anatomy that would be useful in reconstructive surgery. METHODS: Ten fresh frozen cadaveric upper limbs were dissected. The origin of branches from the peripheral nerve trunk, their course, and the number of motor nerves per muscle were determined. The authors reviewed all the images of the Sihler-stained muscles from their earlier study. RESULTS: Motor nerve branches arise at the intersection of nerve trunk and muscle belly and are clustered near the origin of muscle groups. Two patterns of extramuscular innervation were noted, with one group having a single motor nerve and another group with consistently more than one motor nerve. A modified classification of muscles was proposed based on the orientation of muscle fibers to the long axis of the limb, the number of muscle compartments, and the number of heads of origin or the tendons of insertion. CONCLUSIONS: Motor nerve clusters can be located based on fixed anatomical landmarks. Muscles with multiple motor nerves have morphology that allows them to be split into individual compartments. The authors created a muscle and nerve blueprint that helps in planning nerve and split muscle transfers.

Deep branch of the radial nerve in lateral surgical approaches to the radial head - A cadaveric study.

INTRODUCTION: The traditional Kocher approach for lateral radial head exposure may be complicated by injury to the deep branch of the radial nerve (DBRN) and the radial collateral ligament. Kaplan approach is less commonly used, due to its known proximity to the DBRN. Extensor Digitorum Communis (EDC) splitting approach allows possible wide surgical exposure and low risk of radial collateral ligament injury. The comparison of the proximity of the DBRN to the surgical dissection at the level of radial head among approaches to the radial head has not previously been evaluated. We aimed to determine the anatomical proximity of the DBRN in these 3 common radial head approaches and to define a safe zone of dissection for the surgical exposure. METHODS: Cadaveric dissections of 9 pairs of fresh frozen upper extremities were performed using EDC splitting, Kaplan and Kocher approach to the radial head sequentially in a randomized order. A mark was made on the radial head upon initial exposure during dissection. Measurements from the marked point of the radial head to the DBRN were made at the level of radial head. RESULTS: The distance of DBRN to the radial head was 20 (17-22) mm in EDC splitting approach, 7 (3-11) mm in Kaplan approach and 29 (25-33) mm in Kocher approach. The EDC splitting approach was associated with a significantly lower chance of encountering the DBRN at the level of radial head as compared to the Kaplan approach (P<0.001). In all cases, lateral ligamentous complex was not exposed in Kaplan and EDC approaches, but were encountered in Kocher approach, risking injury to the radial collateral ligament. CONCLUSIONS: The EDC splitting approach provides adequate exposure without the need to elevate or retract the EDC and ECU muscle mass that could risk injuring the DBRN. The Kaplan approach should be done by experienced surgeons who are familiar with the anatomy in this region, with extreme caution due to proximity of the DBRN to the surgical dissection at the level of the radial head. Caution of the DBRN should be taken during anterior elevation and retraction of the muscle mass in Kocher approach. LEVEL OF EVIDENCE: IV.

Widely tunable LP11 cladding-mode resonance in a twisted mechanically induced long-period fiber grating.

A record tunability of 35 nm for the LP(11) cladding-mode resonance in a twisted mechanically induced long-period fiber grating using standard single-mode communication fiber is demonstrated. By forming the LP(11) resonance far away from its cut-off wavelength and modifying the grooves of the grating in the form of smooth semicircular humps, a high twist sensitivity of 8.75 nm/(rad/cm) and a controlled tunability of 35 nm is achieved. The fiber with its lacquer coating is not broken even at a severe twist rate of 5.44 rad/cm. The present design can be used as a novel variable optical selective wavelength attenuator since the bandwidth, rejection efficiency, and center wavelength can be controlled by changing the grating length, pressure over the grating, and fiber twist, respectively. Using the results, a cost-effective tunable variable optical attenuator for selective channel-blanking applications is also demonstrated. A fine tunability of 1.5 nm is achieved for a twist rate change of 0.1 rad/cm.

Ulnar fractures with bisphosphonate therapy: a systematic review of published case reports.

SUMMARY: A systematic review of eight ulnar fractures in seven patients with bisphosphonate therapy was performed to describe the characteristics and predisposing factors. The proximal ulna is likely to be fractured, especially in the dominant limb of elderly female patients using walking aids after 7 to 15 years of bisphosphonate use. INTRODUCTION: Long-term bisphosphonate use has been suggested to result in decreased bone remodelling and increased risk of atypical fractures. While the relationship between bisphosphonate use and atypical femoral fractures has been extensively studied, there is relative rarity and unawareness of these fractures in the forearm. We conducted a systematic review of existing case reports to better describe the characteristics and predisposing factors for fractures occurring in patients with bisphosphonate therapy. METHODS: The systematic review was conducted according to PRISMA guidelines. All studies with ulnar fractures in individuals with history of bisphosphonate use were included, with data extracted and analysed in totality. RESULTS: Seven patients with eight fractures are included. Predisposing factors include elderly females requiring walking aids. There is a propensity for the proximal ulna to be fractured, especially in the dominant limb used for ambulation or transfer. All patients were on bisphosphonate for 7 to 15 years. All fractures were atraumatic, non-comminuted, transverse in configuration, had localised periosteal or endosteal thickening at the fracture site and generalised cortical thickening of the diaphysis. CONCLUSION: Ulnar fractures in patients with bisphosphonate therapy demonstrate features similar to those described for atypical femoral fractures, suggesting that these fractures could also possibly be due to bisphosphonate use. However, the ulna appears to be able to tolerate longer periods of alendronate use prior to fracture development. The mechanism and characteristics of these fractures additionally suggest the presence of repetitive stress that accumulates over time due to suppressed bone remodelling in patients on bisphosphonates, eventually resulting in these fractures.

Neuroanatomical basis for the tarsal tunnel syndrome.

BACKGROUND: The results of surgical treatment for tarsal tunnel syndrome have been suboptimal, especially in the absence of space-occupying lesions. We attribute this to a poor understanding of the detailed anatomy of the `tarsal tunnel' and potential sites of nerve compression. METHODS: This study involved the dissection of 19 cadaveric feet. All findings and measurements were documented with digital photography and digital calipers. RESULTS: This study demonstrated three well-defined, tough fascial septae in the sole of the foot. In addition to the flexor retinaculum and the abductor hallucis, two of these septae represented potential sites of compression of the posterior tibial nerve and its branches. The medial plantar nerve may be entrapped under the medial septum. However, in 16 of 19 feet, the medial plantar nerve did not traverse beneath the septum. The lateral plantar nerve traversed beneath the medial septum in all specimens. The nerve to abductor digiti minimi may be trapped under the medial and intermediate septum. CONCLUSION: We detailed the anatomical relationship of the nerve branches relative to the fibrous septae and found that the medial plantar nerve did not traverse a septae in all specimens. CLINICAL RELEVANCE: We believe better understanding of the anatomical relationships of the tarsal tunnel and a clear communication system among anatomists, neuroradiologists and foot and ankle surgeons will facilitate accurate preoperative localization of the site of nerve compression possibly leading to better outcomes.

Paradoxical motion in L5-S1 adult spondylolytic spondylolisthesis.

INTRODUCTION: In patients with spondylolisthesis, it is assumed that flexion accentuates anterior displacement, whereas extension causes some reduction. Paradoxical movement-where flexion causes reduction of spondylolisthesis and extension increases the anterior translation, is rarely described. In this study, we investigate the prevalence of paradoxical motion in patients with L5-S1 spondylolytic spondylolisthesis and why this abnormal motion occurs. MATERIALS AND METHODS: Flexion and extension radiographs of 41 patients with grade I and II spondylolytic spondylolisthesis of the L5-S1 segment were analysed. Patients who had previous lumbar spine surgery, recent lumbar spine trauma, those more than 50 years of age and those with poor quality radiographs were excluded. RESULTS: There were 24 male and 17 female patients. The average age was 32.7 years. Of the 41 patients, 29 (70.7%) showed no significant instability. Six (15%) patients showed anterolisthesis, where flexion accentuated the forward displacement, while further six (15%) patients showed paradoxical motion. Statistical analyses found that patients with paradoxical motion had a significantly higher slip angle. CONCLUSION: In this study, we have demonstrated that: (1) paradoxical motion in spondylolytic spondylolisthesis is more common than previously thought. (2) Patients without anterolisthesis during flexion in dynamic radiographs may still have (paradoxical) instability. (3) Paradoxical motion may be more common in patients with a low sacral slope and increased lumbosacral lordosis.

Myofascial compartments of the hand in relation to compartment syndrome: a cadaveric study.

BACKGROUND: Acute compartment syndrome of the hand is an emergency requiring prompt surgical decompression. This cadaveric study aims to identify the myofascial compartments of the hand by detailed dissection and direct visualization, to provide an accurate anatomical basis for surgical decompression. METHODS: Fourteen fresh-frozen cadaveric hands were dissected. The findings were recorded by still digital photography. RESULTS: There was no well-defined tough fascia overlying the thenar muscles, the hypothenar muscles, or the adductor pollicis. Areolar tissue was present between the individual thenar and hypothenar muscles. A distinct band of fascia was noted over the entire length of the ulnar three dorsal interosseous muscles. A band of fascia was noted over the distal portion of the palmar interossei but not over the proximal aspect. The above findings were found in all 14 specimens. A layer of loose areolar tissue was noted over the dorsal aspect of the first web space in eight specimens, whereas a distinct band of fascia was noted overlying the first dorsal interosseous muscle in the remaining six. CONCLUSIONS: This study has shown that no distinct tough fascia surrounded any of the intrinsic muscles of the hand completely. The thin filmy fascia partially encasing some of the muscles is unlikely to contribute to development of compartment syndrome. It is postulated that the unyielding overlying skin may serve as a constricting layer in addition to the fascia and contribute to raised intracompartmental pressures.

The myofascial compartments of the foot: a cadaver study.

Compartment syndrome of the foot requires urgent surgical treatment. Currently, there is still no agreement on the number and location of the myofascial compartments of the foot. The aim of this cadaver study was to provide an anatomical basis for surgical decompression in the event of compartment syndrome. We found that there were three tough vertical fascial septae that extended from the hindfoot to the midfoot on the plantar aspect of the foot. These septae separated the posterior half of the foot into three compartments. The medial compartment containing the abductor hallucis was surrounded medially by skin and subcutaneous fat and laterally by the medial septum. The intermediate compartment, containing the flexor digitorum brevis and the quadratus plantae more deeply, was surrounded by the medial septum medially, the intermediate septum laterally and the main plantar aponeurosis on its plantar aspect. The lateral compartment containing the abductor digiti minimi was surrounded medially by the intermediate septum, laterally by the lateral septum and on its plantar aspect by the lateral band of the main plantar aponeurosis. No distinct myofascial compartments exist in the forefoot. Based on our findings, in theory, fasciotomy of the hindfoot compartments through a modified medial incision would be sufficient to decompress the foot.

Plasma proteinase inhibitory activity in ectopic and molar pregnancy.

Antitryptic, antichymotryptic and alpha 2- macroglobulin activities were measured in sera of normal nonpregnant and normal pregnant women and women with tubal ectopic pregnancy and molar pregnancies in the first 5 to 7 weeks of pregnancy calculated from the last menstrual period. While alpha 2-macroglobulin decreased in early normal pregnancy compared to nonpregnant state (p<0.001), in ectopic and molar pregnancies there was an increase in alpha 2- macroglobulin activity (p < 0.001), as compared to nonpregnant and normal pregnant women. Antitryptic activity did not increase in normal and ectopic pregnancy, however was increased in molar pregnancy (p < 0.01). Antichymotryptic activities did not show a change either in normal pregnancy or in cases of ectopic and molar pregnancy. Drop in alpha 2- macroglobulin activity to near normal levels in ectopic, 6 weeks post surgery, correlated well with the decrease in ß-hCG. However, in molar pregnancy, alpha 2- macroglobulin remained elevated even when the ß-hCG levels in serum returned to zero 10 weeks after surgery. The studies suggest a major role for circulating proteinase inhibitors especially alpha 2-macroglobulin in regulating proteinase activity in normal, ectopic and molar pregnancy.

The course of the inferior gluteal nerve in the posterior approach to the hip.

We investigated the relationship of the inferior gluteal nerve to gluteus maximus by dissecting the muscle in 12 fresh-frozen and formalin-treated cadavers. The anatomy was recorded using still digital photography. The course of the inferior gluteal nerve was carefully traced and was noted to enter the deep surface of gluteus maximus approximately 5 cm from the tip of the greater trochanter of the femur. The susceptibility of the nerve to injury during a posterior approach to the hip may be explained by its close relationship to the deep surface of gluteus maximus. It is easily damaged before it has been seen if the muscle is split and parted more than 5 cm from the tip of the greater trochanter of the femur. We suggest that a modified posterior approach be used to expose the hip to avoid damage to this nerve.

Automatic estimation of orientation and position of spine in digitized X-rays using mathematical morphology.

In this paper, we propose a method for automatic determination of position and orientation of spine in digitized spine X-rays using mathematical morphology. As the X-ray images are usually highly smeared, vertebrae segmentation is a complex process. The image is first coarsely segmented to obtain the location and orientation information of the spine. The state-of-the-art technique is based on the deformation model of a template, and as the vertebrae shape usually shows variation from case to case, accurate representation using a template is a difficult process. The proposed method makes use of the vertebrae morphometry and gray-scale profile of the spine. The top-hat transformation-based method is proposed to enhance the ridge points in the posterior boundary of the spine. For cases containing external objects such as ornaments, H-Maxima transform is used for segmentation and removal of these objects. The Radon transform is then used to estimate the location and orientation of the line joining the ridge point clusters appearing on the boundary of the vertebra body. The method was validated for 100 cervical spine X-ray images, and in all cases, the error in orientation was within the accepted tolerable limit of 15 degrees. The average error was found to be 4.6 degrees. A point on the posterior boundary was located with an accuracy of +/-5.2 mm. The accurate information about location and orientation of the spine is necessary for fine-grained segmentation of the vertebrae using techniques such as active shape modeling. Accurate vertebrae segmentation is needed in successful feature extraction for applications such as content-based image retrieval of biomedical images.

The natural history of spontaneous osteonecrosis of the medial tibial plateau.

The natural history of spontaneous osteonecrosis of the medial tibial plateau remains controversial and incomplete. We have studied 21 patients (aged between 53 and 77 years) with clinical and scintigraphic features of spontaneous osteonecrosis of the medial tibial plateau who were observed prospectively for at least three years (37 months to 8.5 years). The mean duration of follow-up was 5.6 years. The mean duration of symptoms at presentation was 4.7 weeks (3 days to 12 weeks). Radiographs of the affected knee at the first visit were normal in 15 patients and mildly arthritic in six. The characteristic radiographic lesion of osteonecrosis was noted at presentation in five of the mildly arthritic knees and during the evolution of the disease in eight of the radiographically normal knees. During the follow-up, subchondral sclerosis of the affected medial tibial plateau was noted in 16 knees. There are three distinct patterns of outcome: 1) acute extensive collapse of the medial tibial plateau in two knees within three months of onset; 2) rapid progression to varying degrees of osteoarthritis in 12 knees, in eight within a year, in all within two years and deterioration of the pre-existing osteoarthritis in three; and 3) complete resolution in four knees, two of which were normal at presentation and two mildly osteoarthritic. The two patients with acute extensive collapse and three who had rapid progression to severe osteoarthritis required total knee arthroplasty. We conclude that osteonecrosis of the medial tibial plateau progresses in most cases to significant degenerative disease of the knee.

High risk HPV types in southern Iranian patients with cervical cancer.

This study was undertaken to assess the rate of HPV infection in cervical carcinoma among southern Iranian patients. 101 archival cervical carcinoma tissue samples of a 10 year period were studied for the presence of HPV DNA in southern Iran by a polymerase chain reaction method. In addition, the presence of high risk HPV-16 and HPV-18 genotypes was investigated. In total, 88 (87.1%) of the samples were HPV DNA positive, of which 83 were squamous cell carcinomas and 5 were adenocarcinomas. HPV-16 genotype was detected in 26.7% of HPV positive cervical carcinomas; however, none of the samples were positive for the existence of HPV-18 genotype. Collectively, these results suggest that HPV-16 and HPV-18 are not the frequent high risk HPV types in our patients and circulating HPV types in southern Iranian population are different from many other populations.

Biomechanics of the shoulder.

The shoulder is a complex of 5 joints and disturbances at any of these joints are likely to interfere with the smooth rhythm observed in movements of this complex. The overall ratio of scapulothoracic to glenohumeral movement of 1:2 is made possible by a clockwork mechanism that involves movements at these 2 articulations with axial rotation of the clavicle that connects the shoulder girdle to the torso. Stability of the scapulothoracic, glenohumeral joints and acromio clavicular joints rely not only on the intrinsic capsular ligaments, bony architecture and musculature, but also on extrinsic ligaments that need to be addressed in management of instability at these joints. Of the soft tissues, premature degeneration and tears of the rotator cuff tendons pose special clinical problems by disturbance of the delicate balance between the cuff and the deltoid muscle.

Extremity osteosarcoma--a Southeast Asian experience.

INTRODUCTION: We present our experience with limb salvage emphasising the use of vascularised bone grafts in combination with autoclaved tumour bone for limb salvage in osteosarcoma. MATERIALS AND METHODS: Thirty-six cases with extremity osteosarcoma, all of which were managed at a single institution between 1980 and 1999, were reviewed at a mean follow-up of 9 years (range, 10 months to 200 months). There were 26 patients who underwent limb salvage surgery and 10 patients who had amputation. RESULTS: In the limb salvage group, 12 bone defects were bridged using vascularised bone grafts alone while autoclaved tumour bone was used for reconstruction in the remaining 14 patients. In these 14, there were 10 with autoclaved tumour bone and vascularised bone, 2 with autoclaved bone and non-vascularised bone and 2 with autoclaved bone alone. The joint was preserved in 13 of the 26 reconstructions. Of these, 11 involved preservation of the knee joint contributing to a quantum gain in function with 84% good and excellent results. The actuarial survival was 64% at 2 years and 48% at 5 years, with no significant difference between ablation and limb salvage. CONCLUSION: The use of the autoclaved bone provided yet another effective alternative for bridging large defects following resection of high grade tumours.

Qualitative and quantitative changes in acetylcholine receptor distribution at the neuromuscular junction following free muscle transfer.

The qualitative and quantitative changes in acetylcholine receptor distribution were studied in the gracilis muscle of the Wistar rat following free neurovascular transfer. Even at 30 weeks after transfer, the morphology of the neuromuscular junction failed to return to the presurgical state. The number of acetylcholine receptors at the reinnervated neuromuscular junction also remained lower than the control. The persistent weakness following free neurovascular muscle transfer may be attributed to these qualitative and quantitative changes at the neuromuscular junction.