Approaching the Humerus, Elbow, and Proximal Forearm Using the Trimano Arm Holder.

Upper limb surgeons frequently encounter complex cases involving the proximal humerus, elbow joint, and proximal forearm, both in trauma and elective practice. Given the diverse pathology in these areas, various surgical approaches have been described, each with its advantages, limitations, and specific patient positioning requirements. We describe an operative technique that modifies the use of an existing, commercially available, dynamic pneumatic limb positioner, the TRIMANO FORTIS® (Arthrex, Maquet GmbH), for open and arthroscopic procedures of the elbow, proximal forearm, midshaft, and distal humerus. This technique offers simplicity, reproducibility, and enhanced surgical efficiency.

How to Deal With an Unreconstructable Distal Radius Fracture.

The most prevalent long bone fracture is that of the distal radius, and it affects all age groups. These fractures can present after low-energy or high-energy trauma, and their configuration often varies depending on the mechanism of injury. Their management can be operative or non-operative, and the scientific literature is abundant in studies comparing these two treatment modalities. There is also a healthy scientific debate as to the indications that should guide surgery for these injuries. A male patient sustained a high-energy fracture to his distal radius and presented to our unit soon after the injury. His fracture presented significant surgical challenges due to its complexity. It was stabilised surgically, and the patient recovered good function after rehabilitation. This case aims to demonstrate a surgical treatment protocol and the relevant surgical considerations when dealing with significant injuries, such as the one presented in this paper, where traditional fixation techniques may not yield a satisfactory outcome.

Strategies for the planning of complex shoulder arthroplasty: Use of a custom-made glenoid component in reverse shoulder arthroplasty for a neglected posterior fracture dislocation of the shoulder with malunited scapula fractures and severe eccentric glenoid bone loss.

Glenoid bone loss associated with abnormal glenoid morphology can be encountered in complex primary and revision reverse shoulder arthroplasty. Strategies to deal with this include allografts, augments and custom-made prostheses. We describe a unique case of a long-standing neglected posterior fracture dislocation of the shoulder with severe glenoid bone loss and retroversion. The patient also had malunited acromial and scapula fractures and an associated rotator cuff tear. The primary challenges were access to the shoulder joint due to the malunited fractures, reconstruction of the dysplastic glenoid and providing joint stability. A reverse shoulder replacement was planned using a custom-made glenoid component and patient-specific instrumentation (PSI). The custom base plate was manufactured based on the pre-operative computerised tomography (CT) scan and conformed to the native glenoid. A post-operative CT scan confirmed adequate positioning of the implants. 30 months following surgery, there was a significant improvement in pain and range of motion with an Oxford Shoulder Score (OSS) of 39/48, compared to a pre-operative score of 12/48. Plain radiographs did not show any evidence of loosening or osteolysis. This case report highlights the approach for planning a complex reverse shoulder arthroplasty and the use of custom-made prostheses and PSI in such scenarios.

A Unique Presentation of the Glenoid, Coracoid, and Proximal Humerus Fractures.

Fractures of the proximal humerus are common injuries with a bimodal age distribution. They usually present in younger patients after high-energy trauma and in elderly patients after lower-energy trauma. Fractures of the proximal humerus are rarely associated with concomitant fractures of the glenoid, and this is a complex injury pattern that indicates the presence of significant instability. Such injuries are usually treated surgically. Even more rarely, patients may present with proximal humerus fractures and fractures of the coracoid process. A male patient presented to our emergency department (ED) after a fall off the loading platform of his heavy goods vehicle (HGV), resulting in a right shoulder injury. During his initial assessment in ED, a computerised tomography (CT) scan demonstrated the presence of a comminuted proximal humerus fracture, a comminuted anterior glenoid wall fracture, and a coracoid process displaced fracture. Surgical fixation of all three fractures was undertaken in the same sitting. This is the first case described in the literature with a combination of the above injuries and serves as a reminder that as trauma complexity and incidence continue to increase, we should maintain a high index of diagnostic suspicion when dealing with such patients. Furthermore, we present our treatment approach for this case and the rationale behind it.

Proximal Humerus Fracture/Dislocation: Look for the Greater Tuberosity.

The shoulder is the commonest major joint involved in dislocations. These are often associated with fractures of the surgical neck and/or of the greater tuberosity of the proximal humerus. A good functional recovery is associated with a successful union of the tuberosity fragment, as this carries the insertion of the superior and posterior rotator cuff tendons. A 29-year-old male patient presented to our Emergency Department (ED) after a fall off his motorbike, resulting in a left shoulder fracture dislocation and an axillary nerve injury. His shoulder was reduced under sedation in the ED, with post-reduction radiographs demonstrating a seemingly satisfactory fracture position. Later on, a computerized tomography (CT) scan was arranged which actually confirmed significant displacement of his greater tuberosity, which was not picked up on initial post-reduction radiographs. As a result of identifying the displacement, surgical fixation with a locking plate and suture construct was undertaken. This case demonstrates the ease with which greater tuberosity fractures can mistakenly be presumed as reduced on post-reduction films, whilst in fact they can be significantly displaced. This risk is especially great when only one radiographic view is obtained. The sign of the 'disappearing tuberosity' on a plain radiograph should prompt the clinician to seek further imaging by way of CT, to uncover the true position of the greater tuberosity.

Distal biceps repair through a single incision with the use of a knotless cortical button device: Mid-term results.

Background: Distal biceps rupture presents with an increasing incidence and evidence suggests that although a surgical repair is not mandatory, it results in superior functional outcomes when compared to non-operative management. As implant technology has advanced, several devices have been utilised and studied in managing this pathology. We present our single-centre experience with the use of the ToggleLoc Ziploop reattachment device, a knotless cortical button implant, using a single-incision technique. Methods: Retrospective series of 70 consecutive distal biceps tendon repairs, at a mean follow-up of 45.6 months after surgery, using a standardised single implant, single-incision technique, and post-operative rehabilitation programme. Results: There was one (1.4%) re-rupture in our patient cohort. The range of motion was complete in all patients except for one patient who had symptomatic heterotopic ossification, causing limitation in pronation. Complications were minor with the commonest being transient neuropraxia of the lateral cutaneous nerve of the forearm. The mean Oxford elbow score was 46.9 out of 48, and the patient global impression of change scale was 7 out of 7 in 77% of cases. Conclusion: Our data support this technique and implant combination when dealing with acute and chronic distal biceps tendon rupture.

Reverse Shoulder Arthroplasty Humeral Lateralisation: A Systematic Review.

Different studies on reverse shoulder arthroplasty (RSA) have proposed changes to the humeral design to lateralise the humeral centre of rotation (COR), with humeral inclination to 135 or 145 from 155 degrees or to switch to onlay humeral trays from inlay design; with both having also been used in combination. There have been many studies and systematic reviews to show the difference in outcomes and complications to the variations in glenoid design but to date, there have been no systematic studies to compare different humeral inclinations for RSA implants. Searches using keywords were used in common medical search engines in a systematic fashion. The article was reviewed for the class of evidence and bias, summarised and compared in meta-analysis. Inclusion criteria included studies on adults with RSA that compared lateralised humeral implants to medialised. The search produced 349 articles; of these, we identified nine studies that met the inclusion criteria. Our review identified a total of 562 patients who had been included in studies directly comparing lateralised humerus to a more medial design. Meta-analysis showed a significantly reduced risk of scapular notching in lateralised humerus compared to the standard medialised component. The external rotation range of motion in the lateralised group was statistically significant. The improvement in scapular notching and gain in the range of motion without any apparent downside in the form of reduced patient-reported outcome measures or complications suggest a lateralised humeral component is superior to the more medialised design in RSA. A large RCT with a longer-term follow-up is needed to confirm whether there is clinically significant benefit from the lateralisation of the humerus.

Shoulder examination: a systematic approach.

The shoulder is a complex joint with static and dynamic stabilising structures working synchronously. These allow a full range of movement while preserving stability of the joint. Patients may present with pain, stiffness, weakness, deformity or instability. The authors suggest a systematic examination sequence to ensure that important pathology is not overlooked. Adopting this approach allows common pathologies, including tears of the rotator cuff, impingement and tendinopathy, to be easily identified. This shoulder examination sequence may be used by all healthcare professionals and can also act as a revision aid for those undergoing exams in this field, at different levels of training.

Use of Surgical Adhesive Tape to Maintain Tension on Intrafocal K-Wires for Easy Reduction and Fixation of Complex Intra-Articular Distal Radius Fractures.

Maintaining reduction during fixation of complex intra-articular distal radius fractures with dorsal comminution can be challenging. We describe an operative technique where reduction is achieved with temporary intrafocal Kirschner wires (K-wires), and held using surgical adhesive tape wrapped around the hand, whilst a volar plate is applied to achieve rigid fixation. This is a simple, inexpensive method used at our institutions which allows fixation of these fractures without the need for an operative assistant.

Rotatory subluxation of the proximal interphalangeal joint: an easily missed diagnosis.

We present a case of volar rotatory subluxation of index finger proximal interphalangeal joint (PIPJ) following a skiing accident. The injury was initially perceived to be a central slip rupture and treatment was directed as such. After the initial delay in the diagnosis, the patient underwent surgery during which his radial collateral ligament was found to be avulsed from the proximal origin, the radial lateral band palmarly subluxed and was interposed in the joint space. This structure was also adhered to the uninjured volar plate.PIPJ volar rotatory subluxation could be readily missed in the acute setting. Without surgery, the functional outcome could be mediocre and to the patient's detriment.

Cutibacterium (Propionibacterium) acnes Infection of the Native Wrist Joint.

Cutibacterium (Propionibacterium) acnes (C. acnes, previously known as P. acnes) is an anaerobic organism that commonly colonizes the human skin. After Staphylococcus spp. and Streptococcus spp., it is a common organism associated with deep prosthetic shoulder joint infections. We describe the case of rapidly progressive arthropathy of the native wrist secondary to infection with C. acnes. Diagnosis was made on prolonged enrichment cultures. The patient went on to complete a long-term course of oral sulfamethoxazole-trimethoprim with clinical improvement. To the best of our knowledge, this is the first report in the literature that C. acnes has been the main causative organism implicated in infection of the native wrist joint. It is imperative to request and wait for results of prolonged enrichment cultures to aid microbiological diagnosis in such cases.

The effects of knee meniscectomy on the development of osteoarthritis in the patellofemoral joint 40 years following meniscectomy.

Most knee osteoarthritis and meniscectomy studies focus on osteoarthritis in the tibiofemoral joint and ignore the patellofemoral joint. This study aims to assess the long-term effects of total meniscectomy on the patellofemoral joint. To our knowledge, this is the only study of osteoarthritis in the patellofemoral joint following meniscectomy that extends to a 40-year follow-up period. Twenty-two patients with osteoarthritis were evaluated at a mean of 40 years post-meniscectomy using standardised weight-bearing radiographs of the operated and non-operated knees. Patellofemoral joint osteoarthritis was diagnosed by the presence of osteophytes and joint space narrowing to less than 5 mm. Kellgren and Lawrence scores were calculated from the radiographs. Patellofemoral joint osteoarthritis and tibiofemoral joint osteoarthritis were correlated with International Knee Documentation Committee scores and range of movement measurements. A significant difference was observed between the operated and non-operated knees in terms of patellofemoral joint osteophyte formation. There was a significant difference in tibiofemoral joint Kellgren and Lawrence scores, International Knee Documentation Committee scores and range of movement measurements between knees with lateral facet patellofemoral joint space of < 5 mm and > 5 mm. This study shows an association between open total meniscectomy and patellofemoral joint osteoarthritis at 40 years following surgery. There was also an association between patellofemoral joint space narrowing in the lateral facet and tibiofemoral joint osteoarthritis. Possible causes include altered biomechanical loading patterns following meniscectomy as well as global processes within the knee.

Patellar complications following total knee arthroplasty: a review of the current literature.

Total knee arthroplasty is a common operation for treating patients with end-stage knee osteoarthritis and generally has a good outcome. There are several complications that may necessitate revision of the implants. Patella-related complications are difficult to treat, and their consequences impact the longevity of the implanted joint and functional outcomes. In this review, we explore the current literature on patellar complications in total knee arthroplasty and identify risk factors as well as strategies that can help in preventing these complications. We present pertinent findings relating to patellar complications. They can be classified into bony or soft tissue complications and include bone loss, aseptic loosening, periprosthetic fractures, patella fracture, patellar clunk syndrome, patellofemoral instability, extensor mechanism complications, maltracking, patella baja and malrotation. We conclude that patellar complications in total knee arthroplasty are common and have significant implications for the functional outcome of total knee arthroplasty. A high index of suspicion should be maintained in order to avoid them. Implant malpositioning and other forms of intraoperative technical error are the main cause of these complications, and therefore, primary prevention is crucial. When dealing with these established problems, a clear plan of action should be formulated in advance to allow appropriate management as well as anticipation of adverse outcomes.

Trapeziumectomy And Mini Tightrope Stabilization Of The First Metacarpal For Thumb Carpometacarpal Osteoarthritis : A Prospective Case Series.

Our purpose was to investigate the short-term results of trapeziumectomy and stabilization of the first metacarpal by using the TightRope© device, at a maximum follow-up of 1 year post-op. This is a novel method in treating first carpometacarpal joint osteoarthritis and an alternative to the variety of other methods that have been previously reported. We recruited 21 patients and assessed them at regular intervals, comparing pre-operative and postoperative variables. We recorded all complications during the study period. There was a statistically significant improvement in pain, hand grip and tip pinch power and functional outcome scores. Patients were very satisfied at 12 months after surgery. No significant change in thumb opposition was noted. There was subsidence of the first metacarpal at 1 year after surgery. Despite the existence of a significant number of alternative procedures, we feel that the procedure described in this paper has promising short-term results and is safe.

A novel freehand method for patellar resurfacing in total knee replacement.

Patellar resurfacing in the context of primary total knee replacement (TKR) and in the presence of patella-femoral osteoarthritis is common and widespread practice, as it reduces the rate of re-operation and anterior knee pain. There are several measuring devices and cutting jigs available in the market, which aim to aid with accurately resecting the patellar articular surface. A common characteristic of these jigs is that the patella needs to be everted at some stage to apply them and use them. The senior author of this paper has developed a method of performing patellar resection with the use of simple instruments with no need to evert it and while it engages the trochlea in a physiological position. We propose that this method is reproducible and produces cuts that are parallel to the trochlea.

Knee Osteochondritis Dissecans Treated by the AO Hook Fixation System: A Four Year Follow-Up of an Alternative Technique.

Surgical fixation is recommended for stable osteochondritis dissecans (OCD) lesions that have failed nonoperative management and for all unstable lesions. In this study we set out to describe and evaluate an alternative method of surgical fixation for such lesions. Five knees with unstable OCD lesions in four male adolescent patients with open physes were treated with the AO Hook Fixation System. The outcome was evaluated both clinically and with three separate outcome systems (IKDC 2000, KOOS, Lysholm) at one and a mean four year follow-up. We demonstrated excellent clinical results in all patients. At four years, all scoring systems demonstrated statistically significant improvement when compared to the preoperative status. Our study suggests that the AO Hook Fixation System is an alternative method of surgical intervention with comparable medium term results with other existing modes of fixation and the added biomechanical advantage of the absence of distracting forces during hardware removal.

Idiopathic hypertrophic pachymeningitis responsive to mycophenolate.

Idiopathic hypertrophic pachymeningitis (IHP) represents a rare inflammatory condition that affects the central nervous system, often difficult to treat. We report the case of a patient who presented with difficulty in swallowing, slurred speech and ataxia associated with headache, vomiting and weight loss. He was diagnosed with IHP. He deteriorated despite treatment with high dose steroids and other immunosuppressants, including pulsed cyclophosphamide. Mycophenolate mofetil was therefore administered resulting in improvement and stabilization. This is the first report in English literature of the use of mycophenolate mofetil in the treatment of IHP and could stimulate further research in its efficacy in managing this condition.