Capitate Proximal Fragment Migration Compressing the Median Nerve in Scaphocapitate Fracture: A Case Report.

BACKGROUND Scaphocapitate syndrome is a rare clinical entity consisting of a combined scaphoid and capitate fracture along with a 90- or 180-degrees rotation of the proximal capitate fragment. The syndrome is scarcely described in the literature, with proximal migration of the capitate fragment being reported only by Mudgal et al in 1995. Concurrent compression of the median nerve is a highly unfortunate event, suggesting a unique case presented here. CASE REPORT We present a unique case of scaphocapitate fracture-dislocation in a 25-year-old man with volar dislocation of the capitate's fragment deep to the median nerve. X-rays and CT scan were performed and the patient was treated few hours after the injury by a hand specialist, in order to prevent median neuropathy and avascular necrosis of the fragment. Open reduction and internal fixation utilizing a Herbert screw for the scaphoid fracture and 3 additional K-wires was performed. Immediately post-operatively, the acute neurological symptoms had subsided and good reduction was acquired radiologically. One year post-operatively the patient had regained good hand and wrist functionality, with no extension or flexion ROM deficits. CONCLUSIONS Immediate intervention in a specialized center with reduction and fixation utilizing a Herbert screw and K-wires showed favorable 1-year results in our case of scaphocapitate syndrome. The impending complications of median neuropathy and capitate avascular necrosis were avoided despite the high-risk injury pattern.

The In Vivo Chondrotoxicity of Single Intra-articular Injection of Local Anesthetic in Rat Cartilage.

Introduction A constant infusion of local anesthetics through pain pumps has been shown to cause chondrolysis. However, there is no general consensus regarding the safety of a single intra-articular injection of local anesthetics. In this experimental study, we examined the rat cartilage for possible histological effects after a single intra-articular administration of lidocaine or ropivacaine. Material and methods Thirty-two male Sprague-Dawley rats, weighing 250-300 grams, were divided into two groups of 16 each. We injected 0.1 ml of either lidocaine 2% (20 mg/ml) or ropivacaine 0.75% (7.5 mg/ml) into the left knee of the rats. The right knee in both groups was used as a control, and an equal amount of normal saline was injected. Each group was further divided into subgroups of four, which were euthanized after one, seven, 21, and 60 days after the initial injection. Knees were excised and prepared for histopathological analysis. A modified version of the Mankin score was used for cartilage damage evaluation. Results No difference regarding cartilage damage was detected after the examination under light microscopy between lidocaine, ropivacaine, and placebo in all specimens. Time elapsed since the initial injection did not affect the results at any time point. Conclusion A single intra-articular injection of local anesthetic did not induce any histological changes in the rat cartilage. Further research is needed to demonstrate the safety of humans.

The 100 Top-Cited Articles on Medial Patellofemoral Ligament: A Bibliometric Analysis and Review.

Background: The medial patellofemoral ligament (MPFL) has been investigated widely in the past 30 years, resulting in many research achievements in this field. Purpose: To perform a comprehensive bibliometric analysis to evaluate the 100 top-cited articles on the MPFL. Study Design: Cross-sectional study. Methods: We searched the Scopus database in December 2022 using the terms "medial patellofemoral ligament" OR "MPFL." The search was confined to English-language articles, including technical notes, systematic reviews on clinical outcomes and/or complications, clinical studies, studies regarding complications, and basic science articles (either cadaveric or biomechanical); we excluded letters, case reports, personal opinions, guidelines, editorials, and narrative or other types of reviews. Analysis of the 100 top-cited articles was performed according to total number of citations, average citations per year (ACY), study type, country of origin, journal of publication, affiliated institution, and most published authors. Results: The total number of citations was 16,358 (range of citations per article, 72-692). The majority of articles were published as clinical studies (54%), with cadaveric studies being the second most common (21%). Most studies originated in the United States (32%), with Japan (15%) and Germany (13%) following. The American Journal of Sports Medicine published the majority of the 100 top-cited articles (37/100; 6304 citations) as well as the 10 top-cited articles according to ACY (7/10; mean, 285.14 citations). The most prolific authors were Nomura (8 articles); Burks (6 articles); and Inoue, Sillanpää, and Dreyhaupt (5 articles each). Conclusion: By analyzing the characteristics of the 100 top-cited articles, this study demonstrated that the MPFL is a growing and popular area of research, with the focus varying through timeline trends. Questions regarding MPFL anatomy, isometry, and biomechanics might have been answered adequately, but research regarding optimal fixation technique under various circumstances is still ongoing.

Fracture of femoral neck in modular total hip arthroplasty: a systematic review of the literature.

BACKGROUND: Modular femoral stems have the advantage of anatomic hip reconstruction by restoring the femoral offset thus minimising the bearing surface wear, implant loosening and dislocation. AIM: This study aims to investigate the existing literature on modular neck fractures, to identify predisposing factors and guide the decision-making process in the management of these difficult cases. METHODS: A systematic literature review was conducted until July 2022. PRISMA guidelines were followed, eligibility criteria were set, and methodology assessment of included studies was conducted based on MINORS criteria, size and primary outcome. Data were extracted and analysed thoroughly. RESULTS: 5657 studies were initially screened; the full texts of 124 records were assessed and finally, 32 reports were included. There were 7 clinical studies and 25 case reports. A total of 4825 patients (5204 hips) with a mean age 62.38 years and a mean BMI 29.06 kg/m2 were analysed in the 7 clinical studies. The reported overall weighted revision rate was 0.86%, while the weighted mean modular neck fracture rate was 0.26%. The usual history was sudden experience of hip pain and instability. The average time interval to neck fracture was 4.57 (range 3-4.7) years and a long modular neck was identified in 91.17% of them. Data from case reports showed a mean age and average BMI of 55.85 and 31.63 kg/m2. 82.35% of the patients were male. Necks were fractured after an average time interval of 64.5 ± 8.8 months. CONCLUSIONS: The incidence of modular neck fracture is significant. The profile of a male, obese patient with a long modular neck increased risk of neck fracture. Microstructural investigation of the retrieved implants demonstrated a higher incidence of fracture line in the base of the neck junction and at its anterolateral distal part. Surgeons should be aware of this complication while using or revising such protheses.

Terrible Triad of the Shoulder: A Case Series and Literature Review.

INTRODUCTION: The shoulder terrible triad is an underdiagnosed injury pattern consisting of anterior shoulder dislocation, rotator cuff tear, and nerve injury from the brachial plexus in its original description. The purpose of this study is to raise awareness of the condition, suggest treatment strategies, and emphasize the difficulties in treating this condition. METHODS: This case series of seven patients from the same institution. All patients underwent x-rays before and after the reduction of the dislocation, MRI to assess the musculoskeletal injuries, and EMG and clinical examination to assess the nerve lesions. Early arthroscopic repair was opted for the rotator cuff tears. A conservative approach was chosen for the nerve lesions. Active forward flexion and external rotation, Constant score, and Visual to Analogue Scale (VAS) were recorded pre- and post-operatively. RESULTS: All the patients showed an improvement in function postoperatively. However, four of the seven patients did not recover fully. The mean Constant and VAS scores were improved from 15.2 +/- 2.8 (12 to 19) to 67 +/- 16.6 (44 to 86) and from 7.5 +/- 1 (6 to 9) to 2.3 +/- 0.8 (1 to 3), respectively. The patients were followed up for a mean time of 28.2 +/- 10.1 months (18 to 43 months). Time-to-surgery shorter than four weeks showed better results, but not statistically significant. CONCLUSIONS: The diagnosis of the shoulder terrible triad requires a high level of suspicion. Early arthroscopic repair for the rotator cuff tears and waiting for the nerve recovery is suggested. Delayed time from injury to surgery might be related to worse outcomes, but higher-level research is needed in this direction.

Surgical Treatment of Monteggia-Like Lesions With a Modified Boyd Approach.

Introduction: Monteggia-like lesions are rare injuries in adults that include a wide spectrum of complex fracture-dislocations of the proximal ulna and radius. In this retrospective study, we performed a modified Boyd approach and a standard surgical protocol for the treatment of these lesions. Our aim was to evaluate the results of the operative treatment for patients with Monteggia-like lesions, using a modified Boyd approach. Materials and Methods: We present a retrospective study of 14 patients who underwent surgical treatment for Monteggia-like lesions. Preoperative clinical and radiological evaluation was performed. In 5 cases radial head prosthesis was placed, and in 3 cases the radial fracture was stabilized with the use of interfragmental screws. Regarding the proximal ulnar fracture, ORIF-anatomical plate and ORIF-straight plate was used in 12 and 2 cases, respectively. Results: Average clinical follow up was 16.9 months. Postoperatively, the mean Mayo Elbow Performance score was 83.4 points (range 70-100) and the mean visual analog scale was 1.7 (range 0-14). Mean flexion and loss of extension were 122.1° (range 80°-140°) and 21.4° (range 5°-40°), respectively. Mean supination of the forearm was 66.8° (range 50°-80°) and the mean pronation was 67.5° (range 60°-75°). Heterotopic ossification was observed in 3 patients (21.4%) and 1 patient developed stiffness (7.1%). The patient who developed stiffness underwent reoperation for plate removal and arthrolysis, with satisfactory results. Conclusions: The surgical treatment of Monteggia-like lesions in adults remains a challenge. In the present study, the use of a standard surgical protocol, with a modified Boyd approach, successfully restores the movement and stability of the elbow, with a low complication rate.

Study protocol: biomechanical testing, finite element analysis and prospective, randomized, clinical study of single screw cephalomedullary nailing versus integrated dual interlocking screw fixation for unstable (31A21-3) intertrochanteric fractures in patients > 70 years old.

BACKGROUND: Hip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. The vast majority of intertrochanteric fractures require surgical treatment to withstand early mobilization and weight bearing, which prevents complications due to prolonged bed rest and aids in fracture healing. METHODS: This study is compromised by two parts, the experimental study and the clinical part. In the first part, a standard 130° nail will be used with the appropriate lag screw(s) and dynamic distal locking in synthetic osteoporotic femurs and the transmission of forces in the proximal femur, measured by a cortical surface-strain distribution, will be evaluated using digital image correlation. Finite element parametric models of the bone, the nails and their interface will be also developed. Finite element computations of surface strains in implanted femurs, after being validated against biomechanical testing measurements, will be used to assist the comparison of the nails by deriving important data on the developed stress and strain fields, which cannot be measured through biomechanical testing. In the other part, will set up a prospective, randomized, comparative clinical study among the Gamma3 and IT cephalomedullary nailing, in order to investigate if there are any statistical important differences in the main radiological measurements and functional status in closed unstable intertrochanteric fractures (A21-3) in patients aged over 70 years old at the 24-week follow-up evaluation using patient reported disease-specific outcomes. DISCUSSION: This study will be the first to compare clinical, radiological and biomechanical measurements of the two different cephalomedullary nails. Our main hypothesis is that the IT nail would provide better radiological outcome and probably better clinical results than the Gama3 nail. Clinical trial registration International Standard Randomized Controlled Trial Number (ISRCTN): https://doi.org/10.1186/ISRCTN15588442 , registered on 19/4/2022.

From lab to mass production: a policy for enabling the licensing of mRNA vaccines.

Using the South African vaccine technology transfer hub supported by the WHO as an example, we show that the know-how needed to move mRNA vaccines from prototype to mass-production acts as an invisible barrier to market entry of mRNA vaccines. Overcoming this barrier relies on scarce human capital. In view of this scarcity and in preparation for the next pandemic, we propose broadening the scope of an existing WHO program, the WHO Academy, so that it coordinates knowledge diffusion initiatives by forming a systematized repository of know-how and a register of experts. As we explain, this proposal has an advantage in overcoming barriers to entry over current approaches of know-how acquisition.

Septic Tibial Nonunions on Proximal and Distal Metaphysis-A Systematic Narrative Review.

BACKGROUND: Infected nonunion of the tibia represents a challenging complication for orthopedic surgeons and poses a major financial burden to healthcare systems. The situation is even more compounded when the nonunion involves the metaphyseal region of long bones, a rare yet demanding complication due to the poor healing potential of infected cancellous bone; this is in addition to the increased likelihood of contamination of adjacent joints. The purpose of this study was to determine the extent and level of evidence in relation to (1) available treatment options for the management of septic tibial metaphyseal nonunions; (2) success rates and bone healing following treatment application; and (3) functional results after intervention. METHODS: We searched the MEDLINE, Embase, and CENTRAL databases for prospective and retrospective studies through to 25 January 2021. Human-only studies exploring the efficacy of various treatment options and their results in the setting of septic, quiescent, and metaphyseal (distal or proximal) tibia nonunions in the adult population were included. For infection diagnosis, we accepted definitions provided by the authors of source studies. Of note, clinical heterogeneity rendered data pooling inappropriate. RESULTS: In terms of the species implicated in septic tibial nonunions, staphylococcus aureus was found to be the most commonly isolated microorganism. Many authors implemented the Ilizarov external fixation device with a mean duration of treatment greater than one year. Exceptional or good bone and functional results were recorded in over 80% of patients, although the literature is scarce and possible losses of the follow-up were not recorded. CONCLUSION: A demanding orthopedic condition that is scarcely studied is infected metaphyseal tibial nonunion. External fixation seems promising, but further research is needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO No. CRD42020205781.

Monitoring Irrigation in Small Orchards with Cosmic-Ray Neutron Sensors.

Due to their unique characteristics, cosmic-ray neutron sensors (CRNSs) have potential in monitoring and informing irrigation management, and thus optimising the use of water resources in agriculture. However, practical methods to monitor small, irrigated fields with CRNSs are currently not available and the challenges of targeting areas smaller than the CRNS sensing volume are mostly unaddressed. In this study, CRNSs are used to continuously monitor soil moisture (SM) dynamics in two irrigated apple orchards (Agia, Greece) of ~1.2 ha. The CRNS-derived SM was compared to a reference SM obtained by weighting a dense sensor network. In the 2021 irrigation period, CRNSs could only capture the timing of irrigation events, and an ad hoc calibration resulted in improvements only in the hours before irrigation (RMSE between 0.020 and 0.035). In 2022, a correction based on neutron transport simulations, and on SM measurements from a non-irrigated location, was tested. In the nearby irrigated field, the proposed correction improved the CRNS-derived SM (from 0.052 to 0.031 RMSE) and, most importantly, allowed for monitoring the magnitude of SM dynamics that are due to irrigation. The results are a step forward in using CRNSs as a decision support system in irrigation management.

Phase separation properties of RPA combine high-affinity ssDNA binding with dynamic condensate functions at telomeres.

RPA has been shown to protect single-stranded DNA (ssDNA) intermediates from instability and breakage. RPA binds ssDNA with sub-nanomolar affinity, yet dynamic turnover is required for downstream ssDNA transactions. How ultrahigh-affinity binding and dynamic turnover are achieved simultaneously is not well understood. Here we reveal that RPA has a strong propensity to assemble into dynamic condensates. In solution, purified RPA phase separates into liquid droplets with fusion and surface wetting behavior. Phase separation is stimulated by sub-stoichiometric amounts of ssDNA, but not RNA or double-stranded DNA, and ssDNA gets selectively enriched in RPA condensates. We find the RPA2 subunit required for condensation and multi-site phosphorylation of the RPA2 N-terminal intrinsically disordered region to regulate RPA self-interaction. Functionally, quantitative proximity proteomics links RPA condensation to telomere clustering and integrity in cancer cells. Collectively, our results suggest that RPA-coated ssDNA is contained in dynamic RPA condensates whose properties are important for genome organization and stability.

Treatment of Infected Tibial Metaphyseal Nonunions Using the Ilizarov Method: Protocol for a Prospective Nonrandomized Study.

BACKGROUND: The management of infected metaphyseal nonunion of the tibia is devastating, especially when associated with significant bone loss, poor soft tissues, draining sinuses, axial deformity, knee or ankle joint stiffness, limb discrepancy, and multiresisted pathogens. A systematic review, performed recently by the primary investigators but not yet published, yielded the lack of studies in the field and the huge heterogeneity of the presented results. We found several bias and controversies such as no clear definition of the exact part of the tibia where the nonunion was located, the pathogen causing the fracture-related infection, the number of previous interventions and time to presentation, and the exact type of treatment methods including the use of muscle flaps or bone grafting. Time to final union as a functional score is another important but missing data. OBJECTIVE: The proposed study is designed to evaluate a sufficient number of patients with infected metaphyseal tibial nonunions using various general health, functional, and bone scores. METHODS: This prospective clinical trial study, with a minimum follow-up period of 36 months, focuses on the effectiveness of the Ilizarov method after radical nonunion debridement and targeted antibiotic therapy in patients with infected metaphyseal tibial nonunions. The primary outcomes would be the definite healing of nonunion and infection-free results. Secondary outcomes would be limb alignment and discrepancy, alteration in the patient's quality of life, and functional results. A power analysis calculated a minimum of 11 patients to obtain statistical power, but we aim to include at least 25 patients. Limb discrepancy, clinical validation of infection eradication and fracture healing, radiographic validation, and patient-reported outcome measures will be highlighted and correlated. Statistical analysis of the results will offer data missing from the literature so far. Measurements are scheduled at specific times for each patient: preoperatively, 3 and 6 months postoperatively, 1 month after Ilizarov frame removal, and once per semester afterward until the end of the follow-up period (minimum 36 months). Laboratory evaluation will be assessed once per month. Any complication will be reported and treated when it occurs. RESULTS: The trial has already started. It was funded in June 2020. As of May 2022, 19 participants have been recruited and no major complications have been noticed yet. Data analysis will be performed after data collection ends, and results will be published afterward. CONCLUSIONS: An infected metaphyseal tibial nonunion is a rare condition with limited treatment options and many controversies. There is no consensus in the literature about the best treatment strategy, and this lack of evidence should be fulfilled. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 30905788; https://www.isrctn.com/ISRCTN30905788. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39319.

A Review of Current Concepts of the Anterolateral Complex of the Knee.

The anterolateral complex (ALC) of the knee has gained increased interest over the last decades due to the high revision rates of anterior cruciate ligament reconstruction (ACLR). Furthermore, in patients with an ACL tear, the injury of at least one of the ALC's anatomic structures has been shown to be significantly higher, thus affecting its secondary stabilizing role at the knee joint. As such, ACLR augmentation techniques, that embrace the ALC, have been proposed recently, and indications for these procedures are still evolving. This review aims to present and discuss the most current anatomical, biomechanical, and imaging data, current reconstruction techniques, and the clinical results of ALC reconstruction.

Functional performance of the upper limb and the most common boxing-related injuries in male boxers: a retrospective, observational, comparative study with non-boxing population.

BACKGROUND: To investigate the functional status and recording the most common injuries of the upper limb in male Greek boxing squad in comparison to the general population. METHODS: A retrospective injury surveillance study using an electronic questionnaire was performed in 2021. The questionnaire was sent to male members of the Greek Boxing Federation and consisted of three parts. Demographic data, functional status scales, training conditions, hours of training, the location and description of upper limb injuries and whether the injury occurred during competition or training and also whether it was a new or a recurrent one were gathered. The same questionnaire was sent to non-boxer males (military recruits), but without asking them to report any training parameters. Inclusion criteria were age < 35 years-old for all participants and no involvement in martial arts for the control group. Also, all participants (boxers and non-boxers) completed the Patient Rated Wrist Evaluation (PRWE) scale and the Quick Disabilities of Arm, Shoulder and Hand (quick-DASH) score. RESULTS: The final study cohort was consisted of 62 elite or amateur boxers and 75 non-boxer males, less than 35 years old. The quick-DASH score was found to be significantly lower (better) in boxers in comparison to the general population (15.65 ± 10.25 vs. 12.55 ± 8.62; p = 0.020) whereas the PRWE score was similar in both groups (9.25 ± 14.96 vs. 8.61 ± 13.05; p = 0.843). Physical therapy sessions, thumb injuries and boxer's knuckle were also found to be significantly higher in the boxers group. On the other hand, upper limb surgeries were significantly less in the boxers group. Finally, the size of boxing gloves was associated to the number of finger fractures, thumb injuries and ulnar sided wrist pain in boxers. CONCLUSIONS: Although a controversial sport, boxing appears to have no long-term consequences to the upper limb function, especially regarding hand performance. The size of gloves during heavy bag training was found to be an aggravating factor for hand injuries.

Moderate COVID-19: Clinical Trajectories and Predictors of Progression and Outcomes.

BACKGROUND: Patients with COVID-19 commonly present at healthcare facilities with moderate disease, i.e., pneumonia without a need for oxygen therapy. AIM: To identify clinical/laboratory characteristics of patients with moderate COVID-19, which could predict disease progression. METHODS: 384 adult patients presented with moderate COVID-19 and admitted to two hospitals were retrospectively evaluated. In a multivariate analysis gender, age, BMI, Charlson Comorbidity Index (CCI) and National Early Weaning Score 2 were treated as co-variates. The development of hypoxemic respiratory failure, intubation rate and risk of death were considered as dependent variables. Estimated values are presented as odds-ratio (OR) with 95% confidence interval (CI). RESULTS: Most of the patients were male (63.28%) with a mean (standard deviation) age of 59 (16.04) years. Median (interquartile range) CCI was 2 (1-4). A total of 58.85% of the patients developed respiratory failure; 6.51% were intubated, and 8.85% died. The extent of pneumonia in chest X-ray (involvement of all four quartiles) [OR 3.96 (1.18-13.27), p = 0.026], respiratory rate [OR 1.17 (1.05-1.3), p = 0.004], SatO2 [OR 0.72 (0.58-0.88), p = 0.002], systolic blood pressure [OR 1.02 (1-1.04), p = 0.041] and lymphocyte count [OR 0.9993 (0.9986-0.9999), p = 0.026] at presentation were associated with the development of respiratory failure. The extent of pneumonia [OR 26.49 (1.81-387.18), p = 0.017] was associated with intubation risk. Age [OR 1.14 (1.03-1.26), p = 0.014] and the extent of pneumonia [OR 22.47 (1.59-316.97), p = 0.021] were associated with increased risk of death. CONCLUSION: Older age, the extent of pneumonia, tachypnea, lower SatO2, higher systolic blood pressure and lymphopenia are associated with dismal outcomes in patients presenting with moderate COVID-19.

Mitotic DNA synthesis is caused by transcription-replication conflicts in BRCA2-deficient cells.

Aberrant replication causes cells lacking BRCA2 to enter mitosis with under-replicated DNA, which activates a repair mechanism known as mitotic DNA synthesis (MiDAS). Here, we identify genome-wide the sites where MiDAS reactions occur when BRCA2 is abrogated. High-resolution profiling revealed that these sites are different from MiDAS at aphidicolin-induced common fragile sites in that they map to genomic regions replicating in the early S-phase, which are close to early-firing replication origins, are highly transcribed, and display R-loop-forming potential. Both transcription inhibition in early S-phase and RNaseH1 overexpression reduced MiDAS in BRCA2-deficient cells, indicating that transcription-replication conflicts (TRCs) and R-loops are the source of MiDAS. Importantly, the MiDAS sites identified in BRCA2-deficient cells also represent hotspots for genomic rearrangements in BRCA2-mutated breast tumors. Thus, our work provides a mechanism for how tumor-predisposing BRCA2 inactivation links transcription-induced DNA damage with mitotic DNA repair to fuel the genomic instability characteristic of cancer cells.

Avoiding Complications of Locking Plating for Proximal Humerus Fractures.

Proximal humeral fractures are very common, especially among elderly people with osteoporosis. The treatment methods are numerous, according to the characteristics of the patient and the fracture, as well as the surgeon's preference. These fractures can be treated either conservatively or operatively with closed or open reduction and internal fixation, or arthroplasty. During the past decades, with the advances in osteosynthesis and the establishment of locking plates, many surgeons prefer managing humeral fractures with open reduction and internal fixation with locking plates. Even though this is a widespread method of treatment, many studies report high complication rates, including perioperative and hardware complications. This article presents the most common complications a surgeon may face when managing this kind of fractures, as well as intraoperative techniques that can be used to avoid them.

Traumatic Bilateral Brachial Plexus Injury.

Traumatic brachial plexus injuries are serious, life-changing injuries that are becoming more common worldwide. A thorough physical examination, as well as radiologic and electrodiagnostic tests, are all part of the initial evaluation. Parameters such as injury patterns, the timing of intervention, patients' expectations, and pre-injury functional level should always be considered. A bilateral brachial plexus injury is a very uncommon occurrence. To our knowledge, only one case of a bilateral brachial plexus injury associated with trauma has been published in recent literature. We present a rare case of a 19-year-old man who sustained a bilateral brachial plexus injury after a motorbike accident. The patient underwent exploration of the left brachial plexus and a modified Oberlin procedure on his left arm. The right plexus injury was managed conservatively. After a follow-up period of 12 months, the patient completely returned to his previous functional level.

Reverse Shoulder Arthroplasty for Failed Operative Treatment of Proximal Humeral Fractures.

Introduction: Failure after operative treatment of complex proximal humeral fractures (PHF) can prove challenging even for experienced surgeons. Reverse shoulder arthroplasty (RSA) seems to offer a satisfactory revision procedure with good clinical outcomes. Materials and Methods: We present a case series of 14 patients, who were treated during a 3.5 years period (from 01/2016 until 06/2019). They all underwent revision surgery with RSA for failed operative treatment of PHF. Their mean age was 68 years (range, 51-84 years). 2 patients (14.3%) had been primarily treated with open reduction and internal fixation (ORIF), 5 patients (35.7%) with hemiarthroplasty, 3 patients (21.4%) with closed reduction and percutaneous fixation and 4 patients (28.6%) with transosseous suture fixation (TSF). We evaluated their absolute Constant score (CS), Visual Analogue Scale (VAS) score, and Range of Motion at their final follow-up, and we made a full clinical and radiological assessment to detect any postoperative complications. Results: The mean absolute CS, VAS score, active anterior elevation, active abduction significantly improved compared with the preoperative status. Less significant difference was found in external rotation when comparing with the preoperative status (P = .0304). No significant differences were found when comparing RSA for different failed primary techniques (P > .05). No complications were detected following the revision surgeries of all patients. Conclusion: RSA is an appropriate treatment as a revision technique for failed primary surgical treatment of PHFs. Though challenging it can offer good clinical results and pain relief.