Management of Locked Posterior Shoulder Dislocation with Reverse Hill-Sachs Lesions via Anatomical Reconstructions.

OBJECTIVE: To evaluate the outcomes of locked posterior shoulder dislocation with reverse Hill-Sachs lesions in patients treated with anatomical reconstructions. METHODS: Patients who were treated at our institution between January 2016 and June 2020 were retrospectively reviewed. The demographics of the patients including gender, age, occupation, and dominant arm were recorded. Eleven cases from 10 patients qualified in this study. Nine males and one female were included. The mean age of the patients was 44.8 years (range, 33-54 years). Mechanism of injury, duration between injuries and definitive diagnosis, misdiagnosis, size of humeral head impaction, treatment maneuver, and details of operation performed were reviewed. Plain radiographs and computed tomography (CT) scan were taken to determine the size of defects preoperatively and fracture healing during follow-up. During surgery, the deltopectoral approach was employed. Anatomical reconstruction procedure including reduction, disimpaction, bone grafting, and fixation were sequentially performed. Either cancellous autograft from iliac crest or allograft were used and the fractures were anatomically reduced and stabilized by screws or plates. Visual Analog Scale (VAS) and Constant-Murley score were recorded to determine the functional outcomes preoperatively, at 3 months and 6 months postoperatively, and at the last follow-up. The range of motion in forward flexion was recorded at 6 months follow-up postoperatively. RESULTS: Causes of injuries included epileptic seizure in four cases, fall in three cases, and road traffic accident in three cases. Misdiagnoses occurred in five out of 10 patients. The mean time between injury and definitive treatment among those misdiagnosed was 112 days. The mean size of the impacted reverse Hill-Sachs lesions was 33.95% (range, 19.1%-42.6%). All patients received surgical management with anatomical reconstruction approach, including open reduction, disimpaction, bone grafting, and internal fixation. The mean amount of bleeding during operation was 450 mL. The mean follow-up period was 22.6 months. Fracture healing was observed by 8 weeks in all cases postoperatively and evidence of bone grafting could not be further detected on CT scan at 6 month during follow-up. VAS was significantly lower at the last follow-up (0.68 ± 0.21) in comparison to preoperative scores (4.96 ± 0.97) (P < 0.05). Constant-Murley was improved significantly at the last follow-up (91.7 ± 8.3) in comparison to that preoperatively (40.6 ± 10.3) (P < 0.05). The mean range of motion in forward flexion was 38.25° ± 9.36° preoperatively and significantly improved to 162.48° ± 12.68° at 6-month follow-up (P < 0.05). CONCLUSION: The anatomical reconstruction procedure by open reduction and bone augmentation for the treatment of locked posterior shoulder dislocation with reverse Hill-Sachs lesion was promising in both fracture healing and functional outcomes.

Pelvic resection: current concepts.

Pelvic resection is a technique that involves surgical resection of portions of the pelvic girdle. Historically, this procedure was known as internal hemipelvectomy. Hemipelvectomy is a resection that includes the ipsilateral limb. The main indication for these procedures is primary malignant tumors of the pelvis, but in rare cases they are indicated for metastatic lesions, infection, or trauma. Reconstruction is dictated by the extent of the resection and the remaining structures. Surgical technique is dictated by histology of the tumor and location of the lesion. A multidisciplinary team is required. The patient and family should undergo counseling preoperatively to discuss morbidity and mortality, the extensive rehabilitation process, and life expectancy.

Selection of massive bone allografts using shape-matching 3-dimensional registration.

BACKGROUND AND PURPOSE: Massive bone allografts are used when surgery causes large segmental defects. Shape-matching is the primary criterion for selection of an allograft. The current selection method, based on 2-dimensional template comparison, is inefficient for 3-dimensional complex bones. We have analyzed a 3-dimensional (3-D) registration method to match the anatomy of the allograft with that of the recipient. METHODS: 3-D CT-based registration was performed to match the shapes of both bones. We used the registration to align the allograft volume onto the recipient's bone. Hemipelvic allograft selection was tested in 10 virtual recipients with a panel of 10 potential allografts, including one from the recipient himself (trap graft). 4 observers were asked to visually inspect the superposition of allograft over the recipient, to classify the allografts into 4 categories according to the matching of anatomic zones, and to select the 3 best matching allografts. The results obtained using the registration method were compared with those from a previous study on the template method. RESULTS: Using the registration method, the observers systematically detected the trap graft. Selections of the 3 best matching allografts performed using registration and template methods were different. Selection of the 3 best matching allografts was improved by the registration method. Finally, reproducibility of the selection was improved when using the registration method. INTERPRETATION: 3-D CT registration provides more useful information than the template method but the final decision lies with the surgeon, who should select the optimal allograft according to his or her own preferences and the needs of the recipient.

Inaccuracy in selection of massive bone allograft using template comparison method.

The use of massive bone allografts is increasing year by year and selection method remains unchanged. Superposition of patient's radiograph over allograft image and comparison of distances is the gold standard. Experiment was led to test selection procedure of a major european tissue bank. Four observers were asked to select an allograft for 10 fictive recipients. Nine allografts were provided. To simulate a perfect allograft, recipient himself was inserted in the pool of allografts (trap graft). The 10 potential bone transplants were classified in four categories (from adequate to unacceptable). In addition, observers were asked to choose the three best grafts for a given recipient. Quadratic kappa measuring agreement on classification between two observers ranged between 0.74 (substantial) and 0.47 (moderate). Trap graft was quoted by observers as adequate four times (10%) and was cited eight times (20%) among the three best matching allografts. None of the observers discovered that recipient was among allograft panel. This study demonstrates that current selection method is inaccurate for hemipelvic allograft selection. New methods should be developed and tested to assist tissue banks in bone allograft selection.

Free-tissue transfers for reconstruction of oromandibular area in children.

INTRODUCTION: Currently, free-tissue transfers are commonly used for various reconstructive purposes in adults. However, there is a lack of large series of free flap reconstruction in children, especially for reconstruction of oromandibular defects. Our study aims to share our experience in free-flap reconstruction of some challenging pediatric cases. MATERIALS AND METHODS: Pediatric free-flap interventions (<18-year-old) that were performed between 2000 and 2006 in our clinic were retrospectively evaluated. Eighteen free-tissue transfers were performed in 17 pediatric cases. Epidemiologic data, etiology, defects, preferred free flaps, and results have been compared and analyzed. RESULTS: A total of 17 patients (18 free flaps) were analyzed. Mean age was 10.4 years. The etiology was tumor in 11 cases, traffic accident in 5 cases, and gunshot in 1 case. Double-flap transfer was performed to one patient with a devastating shotgun wound and single flap transfers to others. A total of 8 osseous flaps, 7 osteocutaneous flaps, and 3 septocutaneous flaps were transferred. Total superficial flap necrosis was encountered in one flap (5.8%) while partial superficial necrosis was seen on two flaps (11.7%). Sixteen of the 17 cases reconstructed, including the three cases with complications, resulted in good functional and cosmetic outcome. One case was lost in the sixth postoperative month due to septisemia during chemotherapy. All the surviving 16 cases acquired bony fusion, mastication, and speech in addition to good cosmetic results. CONCLUSION: Pediatric free-tissue transfers are increasing due to the development of better equipment, finer surgical technique, and a better understanding of the unique characteristics of pediatric cases. In our opinion, high success rates with good cosmetic and functional results can be obtained if the specific requirements of the pediatric procedures are met.

Congenital sternal cleft.

A cleft of the sternum is a rare congenital anomaly. We present a case of a sternal cleft in a 7-year-old boy. A split iliac bone graft covered with the sternocostal portion of a pectoralis major flap was used to reconstruct the defect.

Quantitative analysis of cancellous bone graft available from the greater trochanter.

To quantify the amount of cancellous bone graft available from the greater trochanteric region, 20 paired iliac crest-proximal femur specimens were harvested and compared in 10 adult pelvises. A 1.3 x 1.3-cm cortical window was made in the lateral aspect of the proximal femur 2 cm distal from the tip of the greater trochanter. Cancellous bone evacuation was performed by curettage. The extent of harvest was mechanically limited by the medial wall of the trochanter and by curette impingement on the margins of the cortical window. The graft was quantitated after maximal digital compression in a 10-ml syringe and compared with cancellous graft obtained from the paired anterior iliac crest. The average compressed volume of cancellous bone harvested from the greater trochanter was 6.5 ml (range, 4.2-9.6 ml). The average iliac crest cancellous bone volume was 6.0 ml (range, 2.7-8.8 ml). Differences in graft volume between the anterior iliac crest and the trochanter were not statistically significant. The resulting defect in the proximal femur remained isolated to the trochanteric region. In this study, we demonstrate that cancellous bone is available from the greater trochanteric region in an amount similar to that available from the anterior iliac crest. We also show that it is obtainable in a reproducible manner. Our clinical experience of over 100 cases has demonstrated acceptable morbidity associated with this technique. The greater trochanteric region may be used as a secondary source of autogenous cancellous bone graft when specific procedures demand more bone graft than available from the iliac crest alone, or in patients who have had previous iliac crest graft harvest.

[Massive allografts of the pelvis. Possibilities and limitations in oncologic and reconstructive surgery]. / Allogreffes massives de bassin. Possibilités et limites en chirurgie oncologique et réparatrice.

Nine massive hemipelvic allografts were used to reconstruct the pelvic ring and the hip articulation after resection of malignant tumors. At follow up of 3 to 10 years, six patients were free of oncologic disease. In the 3 acetabular massive allografts, functional results were close from those standard THR. After resection of hemipelvis and adjacent muscles, patients resume a normal family life (painless hip, poor active motion, walking with a crutch) with a functional result much better than after amputation. Considering these encouraging results in oncologic surgery, we used similar technics for reconstruction of very severe bone loss after iterative failures of THR revisions: some examples are reported at medium follow up.

Manejo de la columna cervical traumática con la técnica de Caspar: experiencia del Hospital Ramón y Cajal / Caspar's procedure for treatment of traumatic cervical spine: experience of Ramon y Cajal of Spain Hospital

Los autores revisaron una serie de 22 pacientes en los que se ha practicado una artrodesis cervical anterior con la técnica de Caspar de 1987 a 1992. La etiología original fue traumática, con un seguimiento medio de 23.5 meses. Se discuten las diferentes técnicas, comentando en profundidad de descrita por Caspar y su empleo en nuestros pacientes; se estudian los resultados encontrando una mejoría clínica en la escala de Frankel y de Toledo de más de un grado y una satisfacción subjetiva de un 80 por ciento excelente, 10 por ciento de resultados buenos y 10 por ciento de resultados regulares. Fueron escasas las complicaciones intraoperatorias. En conclusión, reseñamos que es una muy buena técnica por su estabilidad inmediata, ausencia de complicaciones y recuperación precoz de los pacientes.

Uso de implantes biológicos de hueso esponjoso: sustituto de injerto de hueso autólogo / Use of biological spongeal bone graft: an autologous bone graft substitute

Se presenta una revisión sobre el uso del injerto óseo homólogo considerado como implante biológico de hueso esponjoso, como sustituto del injerto óseo autólogo. El estudio se hizo en el Hospital de Ortopedia Lomas Verdes del IMSS entre agostos de 1987 y agosto de 1989. El material se obtuvo de enfermos operados de artroplastia total de la cadera o de la rodilla, siempre que no tuvieran padecimientos agregados. El hueso se almacenó en bolsas de polietileno, en simple refrigeración a temperaturas bajo cero. De acuerdo con la necesidad de su uso, se fragmentó; los fragmentos se agitaron dentro de peróxido de hidrógeno durante 30 minutos, después se la varon con jabón quirúrgico y solución salina hasta que quedaron sin detritus; se colocaron en frascos de vidrio con tapa metálica fenestrada y con doble cubierta de tela. Se calcinaron mediante esterilización en autoclave en un ciclo de 45 minutos a 250 grados centígrados. Se almacenaron en vitrinas a temperatura ambiente durante 14 días y después se sometieron a nuevo proceso de esterilización hasta por tres ciclos. Estos implantes se utilizaron considerándolos como sustitutos de injerto óseo autólogo. De 40 enfermos en quienes se usó el implante, solamente se pudieron seguir 24 a un plazo de 16 a 28 meses después de haber recibido el injerto. Fueron pacientes de uno y otro sexo, con edad promedio de 36.7 años. Se obtuvo integración del implante en 85.4 por ciento de los casos. En todos los injertos pricesados, los cultivos para pacterias aerobias, anaerobias y hongos fueron negativos.

The use of hemipelvic allografts or autoclaved grafts for reconstruction after wide resections of malignant tumors of the pelvis.

Fourteen patients who had a malignant tumor of the pelvic bone, adjacent to the acetabulum, were managed with a wide en bloc resection that included most of the hemipelvis as well as the hip. Reconstruction was done with either a massive allograft or replacement of the resected bone after it had been autoclaved. The duration of follow-up ranged from four to eleven years, with a mean of seven years. One osteosarcoma recurred locally, and a repeat excision was done. Two patients who had had a solitary supra-acetabular metastasis preoperatively had systemic metastases much later, but no local recurrence. At the most recent follow-up examination, twelve patients had no evidence of tumor, and all had a functioning lower limb. After a minimum of two years, all grafts had healed and were structurally normal as seen roentgenographically. Later, however, three of the fourteen grafts had failed by fracture, and numerous other complications were evident. The described regimens offer superior functional results compared with other options for management, despite the complications.

[Superselective intra-arterial DSA in femur head necrosis and femoral neck fractures]. / Superselektive intraarterielle DSA bei Hüftkopfnekrose und Schenkelhalsfraktur.

The prospective study includes 25 patients without pathology of the femoral head for the evaluation of the normal femoral head perfusion. In addition 34 patients with femoral head necrosis underwent i.a. DSA preoperatively before pedicled pelvic bone grafting. 15 patients after pelvic bone graft operation and 7 patients with medial femoral head fracture were also examined via superselective DSA. In cases with femoral head necrosis a rarefaction or interruption of the rami nutricii proximales, or an occlusion of the medial circumflex femoral artery were observed. Patients with medial femoral neck fracture showed an interruption of the rami nutricii proximales of the femoral head. Postoperative DSA--after pedicled pelvic bone graft--revealed a regular arterial graft perfusion in 82%.

Pelvic allograft. A case report with a follow-up evaluation of 5.5 years.

A 23-year-old man with a large chondrosarcoma of the right bony pelvis was successfully treated by limb-saving internal hemipelvectomy and anatomic reconstruction of the pelvis by a pelvic osteoarticular allograft including the acetabulum. Optimum anatomic fit was achieved at the hip joint as well as at the iliac and pubic host-graft junctions, which were fixed with plates and screws. This reconstruction restored stability, leg length, hip motion, and cosmesis. Five and one-half years postoperatively, the patient remained asymptomatic with good functional and roentgenographic results.

[Enlargement of the transverse diameter of the pelvis in a cat]. / Elargissement du diamètre transversal pelvien chez un chat.

By symphysiotomy and inserting of a homograft, the pelvic transverse diameter of a cat, suffering from pelvic fracture complication, has been improved. Chronic obstipation has been suppressed; gait and muscular atrophy have been ameliorated.

A technique for obtaining bone graft.

A technique is described for obtaining large amounts of morselized cancellous graft to fill significant bony defects. This method uses an acetabular reamer placed against the outer wall of the posterior pelvis. Advantages of this technique include the procurement of copious amounts of homogeneous cancellous bone graft, ease of performance, little postoperative pain, and minimal bleeding. This technique should not be performed in elderly or osteopenic patients.

Osteoplastía autógena del cráneo / Cranial autogenous osteoplastic

Se realiza un estudio sobre craneoplastia con autotrasplante de hueso ilíaco en el Hospital Provincial clinicoquirúrgico Docente "Saturnino Lora" y en el Hospital Militar "Castillo Duany", de Santiago de Cuba, por un grupo multidisciplinario formado por cirujanos maxilofaciales y neurocirujanos, en el período comprendido desde junio de 1980 hasta julio de 1982. Se presenta una síntesis bibliográfica de la literatura médica internacional sobre los distintos métodos y materiales utilizados en al plastia de los defectos craneales. Se describe el método empleado en 9 pacientes con defectos en dicha región, y se muestran los resutlados mediante ilustraciones fotográficas de los pacientes tratados, después de 6 meses (AU)

Osteoplastía autógena del cráneo / Cranial autogenous osteoplastic

Se realiza un estudio sobre craneoplastia con autotrasplante de hueso ilíaco en el Hospital Provincial clinicoquirúrgico Docente "Saturnino Lora" y en el Hospital Militar "Castillo Duany", de Santiago de Cuba, por un grupo multidisciplinario formado por cirujanos maxilofaciales y neurocirujanos, en el período comprendido desde junio de 1980 hasta julio de 1982. Se presenta una síntesis bibliográfica de la literatura médica internacional sobre los distintos métodos y materiales utilizados en al plastia de los defectos craneales. Se describe el método empleado en 9 pacientes con defectos en dicha región, y se muestran los resutlados mediante ilustraciones fotográficas de los pacientes tratados, después de 6 meses

[Angiographic control of treatment of femur head necrosis with a pedicled pelvic bone graft]. / Angiographische Therapiekontrolle der mit einem gefässgestielten Beckenspan versorgten Hüftkopfnekrose.

A new operative method is introduced in the therapy of the idiopathic necrosis of the femoral head. This operation is based on the idea, that ischaemic processes play an important role in the origin of the idiopathic necrosis of the femoral head. The transplantation of a pedicle bone graft should provide a good arterial supply. 28 Preoperative superselective angiographies of the A. circumflexa femoris medialis showed pathological findings in 17 cases. A good supply of the bone graft was found in 4 from a total of 7 postoperative angiographies of the reset A. circumflexa ilium profunda.