Significant differences in functional outcome between upper and lower limbs after vascular trauma of the extremities.

BACKGROUND: This study aimed to compare the functional results between upper (UE) and lower extremity (LE) following arterial reconstruction due to vascular trauma. METHODS: Patients treated for arterial injuries with vascular reconstruction at two centres between 2005 and 2014 were assessed. The physical fitness questionnaire - Fitnessfragebogen (FFB-Mot) - was evaluated. The differences between pre- and post-traumatic values were compared statistically for UE and LE. Inability to return to the preoperative workplace or postoperative loss of at least 10% of the FFB-Mot were defined as the primary outcome events. RESULTS: Twenty-seven patients could be re-evaluated. The primary outcome event occurred in 52% (14/27) without significant difference between UE (43%) and LE (62%) (p = 0.45). The difference between the pre- and post-traumatic FFB-Mot scores showed a significantly poorer functional outcome after LE vascular injury (p = 0.012). CONCLUSION: Results indicate a poorer functional outcome after vascular extremity trauma to the LE than to the UE.

Effectiveness of reverse total shoulder arthroplasty for primary and secondary fracture care: mid-term outcomes in a single-centre experience.

BACKGROUND: The introduction of reverse total shoulder arthroplasty (RSA) as a treatment option in complex proximal humeral fractures, has significantly extended the surgical armamentarium. The aim of this study was to investigate the mid-term outcome following fracture RSA in acute or sequelae, as well as salvage procedures. It was hypothesized that revision RSA (SRSA) leads to similar mid-term results as primary fracture treatment by RSA (PRSA). METHODS: This retrospective study describes the radiological and clinical mid-term outcomes in a standardized single-centre and Inlay design. Patients who underwent RSA in fracture care between 2008 and 2017 were included (minimum follow-up: 2 years, minimum age: 60 years). The assessment tools used for functional findings were range of motion (ROM), Visual Analogue Scale, absolute (CS) plus normative Constant Score, QuickDASH, and Subjective Shoulder Value. All adverse events as well as the radiological results and their clinical correlations were statistically analysed (using p < .05and 95% confidence intervals). RESULTS: Following fracture RSA, 68 patients were included (mean age: 72.5 years, mean follow-up: 46 months). Forty-two underwent primary RSA (PRSA), and 26 underwent revision RSA (SRSA). Adverse advents were observed in 13% (n = 9/68). No statistically significant results were found for the scores of the PRSA and SRSA groups, while the failed osteosynthesis SRSA subgroup obtained statistically significantly negative values for ROM subzones (flexion: p = .020, abduction: p = .020). Decreased instances of tubercle healing were observed for the in PRSA group relative to the SRSA group (p = .006). The absence of bony healing of the tubercles was related to significant negative clinical and subjective outcomes (all scores: p < .05, external rotation: p= .019). Significant postoperative improvements were evaluated in the SRSA group (CS: 23 to 56 at mean, p = .001), the time from index surgery to operative revision revealed no associations in functional findings. CONCLUSIONS: RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. Promising mid-term functional results, reasonable implant survival rates, and high patient satisfaction can be achieved. LEVEL OF EVIDENCE: Level III.

Dorsal minimally invasive plate osteosynthesis of the distal tibia with regard to adjacent anatomical characteristics.

INTRODUCTION: The aim of this study was to perform MIPO of the distal tibia from a dorsomedial and dorsolateral approach and to evaluate their feasibility and risk of injury to adjacent anatomical structures. MATERIAL & METHODS: A total of 18 extremities from 9 adult human cadavers was included in the study. In each cadaver, one lower leg underwent application of a 12-hole 3.5 LCP metaphyseal plate from the medial and the further one from the lateral approach. For the medial approach, a 4 cm skin incision was performed at the tibial border of the Achilles tendon, starting from 1 cm proximal to its insertion point at the calcaneal tuberosity. Entrance was gained between the medial border of the flexor hallucis longus tendon and the medial neurovascular bundle. Regarding the lateral approach, the skin was incised over a length of about 4 cm at the lateral border of the Achilles tendon, approximately 1 cm proximal to its insertion point. Entrance was gained between the Achilles tendon and the peroneus brevis muscle. The plates were inserted in direct bone contact in a proximal direction and the proximal and distal ends were fixed. During dissection, the proximal and distal holes beneath the crossing points of the neurovascular bundle and the plate were noted. The distal and proximal intersection points of the neurovascular bundle and the plate were measured with reference to the distal border of the plate. RESULTS: Concerning the medial approach, the neurovascular bundle was on median located between the 6th and 11th plate holes starting from distal. The bundle intersected the plate distally at a mean height of 65.8 mm and proximally at 156.8 mm on average. For the lateral approach, the neurovascular bundle was situated between the 6th and the 12th plate hole from distal. It crossed the plate distally at a mean of 61.0 mm and proximal at a mean height of 153.9 mm. In none of the cases, lacerations of the neurovascular bundle were observed. CONCLUSION: In conclusion, MIPO from the dorsomedial and dorsolateral approach are both safe procedures as indicated by our study.

Medial minimally invasive helical plate osteosynthesis of the distal femur - a new technique.

INTRODUCTION: The goal of this study was to evaluate distal femoral minimally invasive plate osteosynthesis (MIPO) from a distal medial approach by use of a pre-bent helical implant. MATERIAL & METHODS: A total of 18 lower extremities was evaluated. A 29.6 cm steel plate was constructed and pre-bent on bone specimens with a torsion of 55.7° A 5 cm incision was performed from the tip of the medial epicondyle alongside its centre in a proximal direction. The medial border of the vastus medialis was retracted anteriorly. The level of the proximal skin incision was determined using the length of the pre-bent plates. The proximal incision was performed at a length of 4 cm at the described height at a line between the lateral epicondyle and the tip of the greater trochanter. A raspatory was advanced beneath the vastus medialis in a proximal direction to create an extraperiosteal tunnel for plate insertion. The plate was fixed to the bone at its proximal and distal portion via screws. Following dissection, the distance between the nearest perforator to the proximal plate end was evaluated. The vertical distances between the medial border of the plate and the femoral artery and femoral nerve were measured at the level of the proximal plate end and at the level of the proximal margin of the vastoadductor membrane. RESULTS: The most proximal perforating artery was located at a mean distance of 20.15 mm starting from the proximal plate margin. The mean interval between the medial border of the plate at the level of its proximal tip and the femoral artery was 51.9 mm. The average distance between the femoral nerve and the medial border of the proximal part of the plate was 42.3 mm. Regarding the interval between the medial border of the plate and the femoral artery, this was at a mean of 40.5 mm at the level of the proximal margin of the vastoadductor membrane. During dissection, none of the specimens showed any lesions of the adjacent anatomical characteristics. CONCLUSION: Our results indicate MIPO of the distal femur from a medial approach as a safe technique.

The 2-2-2-20-20 concept for supraacetabular schanz screw insertion without additional radiography.

PURPOSE: Application of supraacetabular Schanz screws is usually performed under image intensifier guidance. The aim of this study was to perform it without imaging, with the hypothesis that, respecting anatomical landmarks, pre- and intraoperative fluoroscopy can be avoided. MATERIAL & METHODS: Insertion of the supra-acetabular Schanz screws was performed by two trauma surgery residents in a study sample of 14 human adult cadavers which had been embalmed by use of Thiel`s method. With cadavers placed in supine position, the anterior superior iliac spine (ASIS) was palpated. Starting from this landmark, 2 cm were measured in a distal and 2 cm in the medial direction. At this point, a 2 cm long oblique skin incision was performed. Through this approach, 150 mm Schanz screws were drilled bilaterally into the supra-acetabular corridor with an angulation of 20° to distal as well as 20° to medial. Following screw application, combined obturator oblique-outlet views (COOO) were taken bilaterally in each specimen by use of an Arcadis© Orbic 3D C-arm to prove the screw position. Six of the specimens underwent a 3D-CT-scan. Images were evaluated concerning correct screw positioning by a further traumatologist. Skin and subcutaneous tissues were removed in the ilioinguinal region and possible lesions to the lateral femoral cutaneous nerve (LFCN) or to the joint capsule were evaluated. RESULTS: The sample consisted of eight pelves from female and six pelves from male cadavers. During radiographic evaluation of the COOO-scans (14 specimens) and the 3D-scans (6 specimens), the Schanz screws were placed inside the supra-acetabular corridor in all specimens (14/14). During dissections, no intracapsular screw placements or LFCN lesions were found. CONCLUSION: According to the described anatomical data, we defined a 2-2-2-20-20 concept, starting with a 2 cm skin incision 2 cm distal and 2 cm medial to the ASIS with a drill angulation of 20° inferior and 20° lateral orientation. Using this technique, all Schanz screws could be sufficiently inserted without intraprocedural x-ray imaging.

Straight proximal humeral nailing: Risk of iatrogenic tendon injuries with respect to different entry points in anatomical specimens.

BACKGROUND: The purpose of the study was to evaluate the relationship of implant-related injuries to the adjacent anatomical structures in a newer generation straight proximal humeral nail (PHN) regarding different entry points. The proximity of the proximal lateral locking-screws of the MultiLoc proximal humeral nail (ML PHN) may cause iatrogenic tendon injuries to the lateral edge of the bicipital humeral groove (BG) as reference point for the tendon of the long head of biceps brachii (LBT) as well as the lateral insertion of the infraspinatus tendon (IST). MATERIALS AND METHODS: The study comprised n = 40 upper extremities. Nail application was performed through a deltoid approach and supraspinatus tendon (SSP) split with a ML PHN. All tests were performed in three different entry points. First nail (N1) - standard position in line with the humeral shaft axis; second nail (N2) - a more lateral entry point; third alternative (N3) - medial position, centre of the humeral head. After nail placement, each specimen was screened for potential implant-related injuries or worded differently hit rates (HR) to the BG and the IST. The distances to the anatomical structures were measured and statistically interpreted. RESULTS: The observed iatrogenic IST injury rate was 17.5% (n = 7/40) for N1, 5% (n = 2/40) for N2 and 62.5% (n = 25/40) for N3, which was statistically significantly higher (p < 0.001). Regarding the BG, the evaluated HR was 7.5% (n = 3/40) for both N1 and N2. Only the nail placed in the head centre (N3) showed an iatrogenic injury rate of 20% (n = 8/40) (p < 0.062). No statistically significant association between humeral head size and the HR could be observed (head diameter: IST: p = 0.323, BG: p = 0.621; head circumference: IST: p = 0.167; BG: p = 0.940). For the IST and BG, all distances in nail positions N1 and N2 as well as N2 and N3 differ statistically significant (p < 0.001). CONCLUSIONS: An entry point for nail placement in line or slightly laterally to the humeral shaft axis - but still at the cartilage - should be advocated.

Carpal tunnel release: Safe and simple identification of the flexor retinaculum based on superficial anatomical landmarks.

The aim of our study was to project the borders of the flexor retinaculum (FR) onto superficial landmarks since its insufficient splitting is the most common reason for persistence of symptoms after carpal tunnel release. In 60 hands the radial and ulnar styloid processes were linked by a horizontal line and a longitudinal line was laid through the ring finger's radial side. These were intersected resulting in the reference point "A" on the forearm. As the second basing point "B", the radial margin of the ring finger at the palmar digital crease was chosen. Measurement of the FR was carried out with regard to the reference points. The proximal margin of the FR was located at 4% of the reference line A-B starting from point A and extended up to 52% of this total length. Results indicate that splitting alongside the proximal half of line A-B divides the FR completely. Clin. Anat. 30:512-516, 2017. © 2017 Wiley Periodicals, Inc.

Trophic structure of coastal Antarctic food webs associated with changes in sea ice and food supply.

Predicting the dynamics of ecosystems requires an understanding of how trophic interactions respond to environmental change. In Antarctic marine ecosystems, food web dynamics are inextricably linked to sea ice conditions that affect the nature and magnitude of primary food sources available to higher trophic levels. Recent attention on the changing sea ice conditions in polar seas highlights the need to better understand how marine food webs respond to changes in such broad-scale environmental drivers. This study investigated the importance of sea ice and advected primary food sources to the structure of benthic food webs in coastal Antarctica. We compared the isotopic composition of several seafloor taxa (including primary producers and invertebrates with a variety of feeding modes) that are widely distributed in the Antarctic. We assessed shifts in the trophic role of numerically dominant benthic omnivores at five coastal Ross Sea locations. These locations vary in primary productivity and food availability, due to their different levels of sea ice cover, and proximity to polynyas and advected primary production. The delta15N signatures and isotope mixing model results for the bivalves Laternula elliptica and Adamussium colbecki and the urchin Sterechinus neumeyeri indicate a shift from consumption of a higher proportion of detritus at locations with more permanent sea ice in the south to more freshly produced algal material associated with proximity to ice-free water in the north and east. The detrital pathways utilized by many benthic species may act to dampen the impacts of large seasonal fluctuations in the availability of primary production. The limiting relationship between sea ice distribution and in situ primary productivity emphasizes the role of connectivity and spatial subsidies of organic matter in fueling the food web. Our results begin to provide a basis for predicting how benthic ecosystems will respond to changes in sea ice persistence and extent along environmental gradients in the high Antarctic.