Bony Deformities Research Articles

Arthroscopic Treatment of Subspine (Anterior-Inferior Iliac Spine) Impingement

Hip impingement can be caused by both intra- and extra-articular pathologies and may lead to significant pain and disability. Femoroacetabular impingement may present in 3 forms of intra-articular impingement: cam, pincer, or mixed. Extra-articular impingement is also common yet less recognized, but may also lead to significant functional limitations. In 1 form, the anterior-inferior iliac spine or subspine region may impinge on the femoral neck during motion. Symptoms include limited and painful hip flexion. Physical examination as well as diagnostic injections in the region can help distinguish the cause of pain. Hip arthroscopy has been reported to produce excellent results with correction of the bony deformity in the subspine region and acetabular rim. Here, we outline subspine impingment and describe our preferred surgical technique.

A Study of Factors Influencing Major and Minor Amputations in Patients of Diabetic Foot Disease in a Tertiary Care Hospital in Eastern India

Background: The factors leading to amputation in diabetic foot ulcer are diabetic neuropathy, bony deformities, inconspicuous trauma, and vascular diseases, uncontrolled diabetes for long duration, no use of foot wear, low educational status and poor nutritional state. We aimed at finding the major determinants leading to major and minor amputation in diabetic foot cases in a tertiary care institute. Methods: A prospective observational study was done in the General Surgery department of our institute from July 2018 - October 2019. The aim of our study is to determine the various factors that are influencing major and minor amputation in Diabetic foot disease. Findings: 2268 patients fulfilled the inclusion criteria of our study. 21 patients didn’t came for further follow up visits. Hence a total 2247 patients were studied. 1454(64.7%) patients were male. Uncontrolled diabetes [Random Blood Sugar (RBS)>200mg %] was the most common factor leading to amputation [Relative Risk=5.10: 95% Confidence Interval=4.73-5.47]. Bare foot walking with a Relative risk (RR) of 4.98 was the second most common cause. Neuropathy and hypoalbuminemia were the other significant predictors with RR=3.71 and RR=3.67 respectively. Interpretation: We conclude uncontrolled diabetes (RBS>200mg %), not using foot wear, neuropathy, hypoalbuminemia are the five most significant predictors leading to amputation of the limb in diabetic ulcers in the respective order. The risks of amputation are also high in patients with diabetes for more than 10 years, presence of arterial insufficiency & in patients with low educational status. Funding Statement: No funding received for the study. Declaration of Interests: We have nothing to declare and we have no conflicts of interest. Ethics Approval Statement: The study was approved by the institutional ethics committee vide IEC/IRB no: 996/14.10.2019.

Nutritional rickets & osteomalacia: A practical approach to management.

Defective mineralization of the growth plate and preformed osteoid result in rickets and osteomalacia, respectively. The leading cause of rickets worldwide is solar vitamin D deficiency and/or dietary calcium deficiency collectively termed as nutritional rickets. Vitamin D deficiency predominates in high-latitude countries in at-risk groups (dark skin, reduced sun exposure, infants and pregnant and lactating women) but is emerging in some tropical countries due to sun avoidance behaviour. Calcium deficiency predominates in tropical countries, especially in the malnourished population. Nutritional rickets can have devastating health consequences beyond bony deformities (swollen wrist and ankle joints, rachitic rosary, soft skull, stunting and bowing) and include life-threatening hypocalcaemic complications of seizures and, in infancy, heart failure due to dilated cardiomyopathy. In children, diagnosis of rickets (always associated with osteomalacia) is confirmed on radiographs (cupping and flaring of metaphyses) and should be suspected in high risk individuals with the above clinical manifestations in the presence of abnormal blood biochemistry (high alkaline phosphatase and parathyroid hormone, low 25-hydroxyvitamin D and calcium and/or low phosphate). In adults or adolescents with closed growth plates, osteomalacia presents with non-specific symptoms (fatigue, malaise and muscle weakness) and abnormal blood biochemistry, but only in extreme cases, it is associated with radiographic findings of Looser's zone fractures. Bone biopsies could confirm osteomalacia at earlier disease stages, for definitive diagnosis. Treatment includes high-dose cholecalciferol or ergocalciferol daily for a minimum of 12 wk or stoss therapy in exceptional circumstances, each followed by lifelong maintenance supplementation. In addition, adequate calcium intake through diet or supplementation should be ensured. Preventative approaches should be tailored to the population needs and incorporate multiple strategies including targeted vitamin D supplementation of at-risk groups and food fortification with vitamin D and/or calcium. Economically, food fortification is certainly the most cost-effective way forward.

Patients with primary hyperparathyroidism undergoing surgical intervention in two tertiary care hospitals in Sri Lanka

Introduction Autonomous production of parathyroid hormone results in primary hyperparathyroidism. Sri Lankan studies analyzing cases of hyperparathyroidism are scarce. Objective To describe clinical, biochemical, radiological and pathological characteristics of patients with primary hyperparathyroidism undergoing surgical intervention in two tertiary care hospitals in Sri Lanka. Design Data was collected from the available records of all patients who has undergone surgery for primary hyperparathyroidism at Teaching Hospital, Kandy and General Hospital, Badulla from 2016.10.27 to date. A total of ten patients with primary hyperparathyroidism were enrolled for analysis. Out of the ten patients, six were females. Ages ranged from 23 to 65 years (Mean- 44.2). Mode of presentation was fragility fractures in four patients, renal calculi in five patients and acute pancreatitis in one patient. Bone complications (fractures, osteoporosis) were seen in four patients and renal complications (renal calculi, nephrocalcinosis) were seen in six patients. Pre-operative total serum calcium levels ranged from 10.52 to 14.16 mg/dl (mean-12.6). Pre-operative serum phosphate levels ranged from 0.74 to 1.07 mmol/L (mean -0.868). X-ray evidence of skeletal changes of hands were seen in 6 patients (60%), of which 4 showed bony deformities and 2 showed pathological fractures. Renal calculi or nephrocalcinosis was detected by X-ray in five out of six patients and ultrasonically in all 6 patients. Ultrasound scans revealed a parathyroid adenoma in 8 patients (80%), while 2 were negative. Technetium-99-methoxyisonitrile (99m Tc-Sestamibi) scans were performed in 4 patients and three had positive images. Histological analysis revealed 8 patients with single parathyroid adenoma, 1 with parathyroid carcinoma, and one patient with four gland hyperplasia. Discussion and Conclusions All patients had symptoms at the time of diagnosis. Ultrasound scan was a useful tool for the localization.

Nasal obstruction: a common presentation in primary care.

Ear, nose, and throat (ENT) problems make up around 10% of primary care consultations,1 most of which can be managed effectively in primary care, with a small percentage of cases requiring referral to secondary care. Patients suffering from nasal obstruction often present with a feeling of fullness in the nasal cavity and reduced airflow. A detailed history of symptoms is essential (Box 1), along with its effect on the patient’s quality of life.2 | Nasal obstruction Past medical history Medications Allergy status Social history | || Box 1. History Externally, the relation of the nose with adjacent tissue and structures should be assessed, along with identification of any bony and cartilaginous nasal deformities. Two common methods have been described to assess nasal airflow: the first is occlusion of one nostril and assessing the inflow and outflow through the opposite nostril, and the second uses a metal tongue depressor, observing the misting on the metal surface and comparing the two …

Arthroscopic treatment of Cam-type femoroacetabular impingement

Femoroacetabular impingement (FAI) is a common cause of hip pain and limited range of motion among young and middle-aged active adults and athletes. The acetabular labral tear and cartilage damage secondary to FAI may increase the risk of hip osteoarthritis. FAI is characterized by pathologic impact between the femoral headneck junction and the acetabular rim secondary to bony deformity. According to the pathological anatomy leading to impingement, the FAI can be divided into the femoral cam-type deformity (Cam), the acetabular over-coverage deformity (Pincer) and a combination of both. In recent years, arthroscopic osteoplasty of the femoral head-neck junction is the main way to treat the Cam deformity; However, there still remain some controversies about how to perform an adequate and effective arthroscopic femoroplasty. Based on this problem, the present article reviewed the preoperative diagnosis, intraoperative evaluation, surgical techniques and postoperative evaluation of Cam-type FAI to explore how to adequately correct Cam deformity under arthroscopy. In the present study, a total of 1928 related articles were obtained by searching PubMed, Web of Science, Cochrane library, China Knowledge Network, Wanfang Full-text Database and Weipu Science and Technology Journal Database. According to the inclusion and exclusion criteria, 43 papers were finally included. After summarizing the above literatures, it was found that anatomical structures such as Cam deformity, femoral neck anteversion, and acetabular coverage can be evaluated preoperatively by X-ray, three-dimensional CT and MRI. X-ray fluoroscopy and arthroscopic dynamic examination are performed during the femoroplasty to locate the Cam deformity and to determine whether the femoral neck offset radio and the spherical structure of femoral head are corrected, at the same time, it is necessary to consider the overall anatomy of the hip joint to achieve an adequate resection of the Cam deformity and restore the normal mobility of the hip joint.

Predicting growth plate orientation with altered hip loading: potential cause of cam morphology.

Proximal femoral deformities can result from altered hip joint loading patterns during growth. The growth plate hyaline cartilage has low resistance to shear stress. Therefore, we hypothesized that the growth plate orients in a direction which minimizes the shear stress on its surface. A finite element model of the proximal femur was generated with a simplified flat growth plate. Hip joint forces were estimated for standing upright and standing in hip flexion. We also parametrically studied the effects of posteriorly and laterally directed loads. An algorithm was developed to predict the shape of the femoral growth plate in a plane of minimum shear (along the principal stress vectors). To characterize and compare the growth plate shapes, we represented the distance from the growth plate to a reference plane as a two-dimensional contour plot, providing information of shape and orientation across the entire surface. We also assessed the clinical measures of growth plate shape to compare our predicted growth plates with previous clinical studies data. The shape of the growth plate predicted for an upright standing load correlated closely with morphological properties of the growth plane of a typically developing child. The shape of the growth plate predicted for femoral hip flexion force was similar to the growth plate in subjects with cam morphology, a hip shape that has documented growth plate changes. The model proposed here allows for investigation of the relation between joint forces and growth plate shape, which will help predict the development of bony deformities.

What's New in the Orthopaedic Treatment of Ambulatory Children With Cerebral Palsy Using Gait Analysis.

Limb deformities in ambulatory children with cerebral palsy (CP) are common. The natural history of lower extremity deformities is variable and the impact on gait is managed with many treatment modalities. Effective interventions must consider the underlying pathophysiology, patient-specific goals, and incorporate objective outcome assessment. Evaluation and treatment include observation, tone management multilevel orthopaedic surgery to address muscle contractures and bony deformities, and the use of gait analysis for preoperative and postoperative assessment. A PubMed search of the orthopaedic literature for studies published between January 2016 and February 2019 was performed. Eligible abstracts included the use of 3-dimensional instrumented gait analysis in the evaluation and treatment of the lower extremities in ambulatory children with CP. Seven hundred twenty abstracts were reviewed, with 84 papers identified as eligible, of which 45 full manuscripts were included for detailed review. The review summarized recent advances regarding the treatment of torsional alignment, knee deformities and clinical gait evaluation with visual assessment tools compared with instrumented gait analysis. Gait analysis of ambulatory children with CP remains essential to evaluation and surgical decision-making. Promising results have been reported with the goal of maintaining or reaching a higher level of function and increased endurance. Level IV-literature review.

Clinicopathological study of Ossifying fibroma

Ossifying fibroma is a benign neoplasm of bone and often considered a type of fibro-osseous lesion. It can affect both the mandible and the maxilla, particularly the mandible. Radiologically it presents as a mixed radiodense and radiolucent lesion that is well demarcated from normal bone and histopathologically it consists of highly cellular, fibrous tissue that contains varying amounts of calcified tissue resembling bone, cementum or both. The treatment consists in completely removing the lesion with curettage, surgical excision or en-block resection, depending on the size and location of the lesion. The aim of this study is to analyse the clinicopathological characteristics of ossifying fibroma and provide a proper management system.
 Materials and methods - The prospective study was performed in the Department of Oral & Maxillofacial surgery, Dhaka Dental College and Hospital, Dhaka, Bangladesh, from a period of January 2015 to January 2019. All patients were selected for this study based on clinical, radiological and histopathological confirmation of ossifying fibroma. The management of each case and follow-up data were documented.
 Result and observations - A total number of 25 patients of ossifying fibroma were selected for this study. The mean age of ossifying fibroma were 30.35 years with an age range 12 to 57 years. Female17 (57%) represented the majority of the affected patients and more common in the mandible (60%).The radiographic appearances of ossifying fibroma presented 17(68%) mixed type and 18(72%) well-defined borders. Bone expansion 19(76%), tooth displacement 09(36%) and root resorption 10(40%) were observed in ossifying fibroma. Surgical resection, enucleation and curettage were treatment of choice in ossifying fibroma.
 Conclusion - Ossifying fibroma occurs more commonly in women in the 2nd to 4th decade of life and presents a painless bony swelling and deformity in mandible and maxilla. Frequently it shows as a mixed radiographic image that is well demarcated from normal bone. The treatment consists in completely removing the lesion with curettage, surgical excision or en-block resection, depending on the size and location of the lesion in ossifying fibroma.
 Update Dent. Coll. j: 2019; 9 (2): 7-12

Weightbearing CT and MRI findings of Stage II Flatfoot Deformity: Can We Predict Patients at High- Risk for Foot Collapse?

Category:HindfootIntroduction/Purpose:Adult acquired flatfoot deformity (AAFD) is characterized by concurrent bony deformities, tendinous and ligamentous insufficiencies. Weightbearing CT (WBCT) allows excellent dynamic evaluation of the relative three-dimensional positioning of the tarsal bones. MRI provides accurate evaluation of soft tissue integrity in the unloaded foot. Study’s objective was to evaluate the correlation between bone deformity and soft tissue insufficiency in patients with stage II AAFD, using WBCT and MR images. We hypothesized that significant correlation would be found between WBCT measurements of increased longitudinal arch collapse, hindfoot valgus, peritalar subluxation and forefoot abduction, with MRI findings demonstrating degree of soft tissue involvement.Methods:This retrospective comparative study included 55 patients (56 feet) with stage II AAFD, 20 men and 35 women, mean age of 52.5 (range, 20 to 78) years. Multiple WBCT and MRI variables related to the severity of the deformity were evaluated by four blinded and independent readers (two radiologists and two foot and ankle surgeons), including: arch collapse (navicular-floor distance and forefoot arch angle), hindfoot alignment angle (HAA), forefoot abduction (talonavicular uncoverage angle), subtalar joint subluxation, sinus tarsi and subfibular impingement, and soft tissue insufficiency (posterior tibial tendon, spring and talocalcaneal ligaments). Tendinous and ligamentous involvement on MRI were graded from zero (normal) to four (complete tear). Intra- and interobserver reliabilities were assessed by Pearson/Spearman’s and intraclass correlation coefficient, respectively. A multiple regression analysis was used to evaluate the relationship between bone alignment (WBCT variables) and soft tissue injury (MRI variables). P-values of less than 0.05 were considered significant.Results:We found overall good to excellent intra (range, 0.83-0.99) and interobserver reliability (range, 0.71-0.97) for WBCT measurements and MRI readings. Spring ligament superomedial component involvement was the only finding to correlate with medial column collapse and decreased navicular-floor distance (p=0.03). Superomedial spring ligament and PTT degeneration were also significantly correlated with increased HAA (p<0.01). Involvement of the talocalcaneal interosseous ligament significantly correlated with increased forefoot abduction as measured by the talonavicular uncoverage angle. Spring ligament degeneration, of both superomedial and inferior components, and talocalcaneal interosseous ligaments significantly correlated to subtalar joint subluxation (p<0.001). Involvement of the talocalcaneal interosseous ligament was the only one to significantly correlate to the presence of subfibular impingement (p=0.02). Degeneration of the PTT was significantly associated with sinus tarsi impingement (p=0.04).Conclusion:This study is the first to evaluate correlation between bone, tendinous and ligamentous involvement in AAFD patients, using WBCT and MR images. Our results demonstrated that progressive bone deformity in WBCT is significantly correlated to MRI involvement of the PTT and other important restraints such as the spring and talocalcaneal ligaments. The implications are that WBCT can predict ligamentous injuries and that MRI can predict dynamic bone deformity in AAFD patients. Furthermore, the correlation of bone and soft tissue involvement could impact surgical planning of flatfoot patients, decreasing thresholds for additional soft tissue procedures such as a spring ligament reconstruction.

Management Strategies of Cranial Encephaloceles: A Neurosurgical Challenge.

Background:Encephalocele is defined as herniation of cranial contents beyond the normal confines of the skull through a defect in the calvarium either along the midline or at the base of skull. These anomalies should be repaired in the first few months of life to prevent neurological deficits and facial disfigurement. The aim of the surgery is water tight dural closure at the level of internal defect, closure of skull defect, and reconstruction of external bony deformity.Materials and Methods:Fifty-four cases of encephalocoeles were studied in our hospital over a 6-year period from 2010 to 2016. Computed tomography (CT) and magnetic resonance imaging (MRI) brain were performed to delineate the bony defect and associated anomalies. Reconstruction of the bony defect was done using autologous calvarial bone graft, Osteopore polycaprolactone (PCL) bone scaffold filler and titanium mesh.Results:In our study, 54 patients (34 boys and 20 girls) whose age varied between 2 months and 14 years were evaluated. Frontoethmoidal (44.5%) and occipital encephaloceles (25.9%) were the most frequently seen varieties. Repair of the dural defect either primarily or using pericranium was done in all cases. Closure of the bony defect was done using autologous calvarial bone graft in 12 (22.22%) patients. Titanium mesh was used in eight and Osteopore PCL bone scaffold filler in four children. Cranioplasty was not done in remaining thirty children because of the small bone defect. Overall, 80% had no postoperative problem and were discharged between 7 and 10 days of surgery. Cerebrospinal fluid leak was the most frequent postoperative complication, noted in five patients. Re-exploration with repair was done in one and remaining four were managed conservatively. Overall, cosmetic results were acceptably good, with parents judging the cosmetic outcome as good to excellent in 70%, satisfactory in 18%, and poor in 3% at the last follow-up.Conclusion:Our study demonstrated that encephaloceles are associated with complex deformities and pose a technical challenge to the neurosurgeon. A multidisciplinary approach is necessary to manage these cases. MRI brain and three dimensional CT aids in evaluating the deformity better and surgical correction should be performed as soon as possible to prevent a further neurological deficit. Repair of dural defect and reconstruction of the skull defect results in a good long-term outcome. We present our experience on 54 cases of cranial encephaloceles managed surgically over a period of only 6 years which is one of the largest series reported from Asia.

Effectiveness and safety of early intramuscular botulinum toxin injections to prevent shoulder deformity in babies with brachial plexus birth injury (POPB-TOX), a randomised controlled trial: study protocol

IntroductionIn children with brachial plexus birth injury (BPBI), denervation of the shoulder muscles leads to bony deformity in the first months of life, reducing active and passive range of motion...

Arthroscopically Assisted Reduction in a Chronic Locked Posterior Shoulder Dislocation

Neglected posterior shoulder dislocation is a difficult condition in terms of decision making and surgical technique. Not only the bony deformity but also the soft tissue and patient's underlying disease are of concern. Whether the poor results are associated with a time delay or the treatment method is not clear yet. To date, there is neither a consensus nor treatment guidelines. We describe an arthroscopically assisted reduction and open McLaughlin procedure. The advantage of this procedure is preservation of the soft tissue of the anterior part of the shoulder during the surgical reduction technique for chronic neglected posterior shoulder dislocation cases.

Predictors of Failure After Surgical Treatment of Femoroacetabular Impingement: Results of a Multicenter Prospective Cohort of 621 Hips

Objectives: Surgical treatment of femoroacetabular impingement attempts to improve patients’ symptoms through treatment of intra-articular labrochondral pathology and correction of underlying bony deformity. The purpose of the current study was to determine independent predictors of failure after surgical treatment of femoroacetabular impingement in a large prospective multicenter cohort study. Methods: A prospective cohort study of the surgical treatment of FAI was performed. A total of 760 hips undergoing primary surgical treatment of FAI were enrolled across seven surgeons. Patient characteristics, baseline patient reported outcomes (PROs), imaging findings, intraoperative pathology, and surgical treatments were prospectively recorded. A total of 621 hips (81.6%) with minimum one year follow-up were included in the current study (mean 4.3 years). The mHHS was assessed relative to the minimally clinically important difference (MCID, 8 points) and patient acceptable symptom state (PASS, 74 points). Univariate analyses were performed to identify factors significantly associated with failure. Multivariate logistic regression was performed to identify independent predictors of failure. Results: A total of 621 hips undergoing surgical treatment of FAI were assessed at a mean 4.2 years postoperatively. This cohort had a mean age of 29.8 and included 56.8% females. Multivariate logistic regression identified independent predictors of each failure definition. Failure A (THA) was independently associated with increasing age, acetabular microfracture (both p&lt;0.001), and femoral head chondroplasty (p=0.02). Failure B (THA or revision surgery) was independently associated only with lower preoperative mHHS (p&lt;0.001) (p=0.01). A lower failure C (clinical failure) was independently associated with participation in competitive athletics (p=0.01), BMI (p&lt;0.001), and male gender (p&lt;0.001). Conclusion: This large multicenter cohort demonstrates the outcomes of FAI treatment at a mean of 4.3 years postoperative. Rates of THA and revision surgery were 4.0% and 6.9%. An additional 14.8% of patients demonstrates clinical failure based on patient-reported outcomes.

Analysis of Pelvic Fracture Healing Status in 198 Cases.

Objective To analyze the relationship between the number of pelvic ring fractures, the location of fracture and Tile type of pelvic fracture and pelvic fracture healing status. To discuss how to understand the pelvic malunion, severe pelvic malunion and bony pelvis deformity （destruction） in Classification of the Impairment Related to Injury. Methods One hundred and ninety-eight cases of evaluation of body impairment class of pelvic fracture caused by traffic accident accepted by Zhongcheng Institute of Forensic Science in 2016 were collected. The cases were statistically analyzed in terms of the distribution of the number of pelvic ring fracture, the location of pelvic ring fracture and Tile type of pelvic fracture in various healing statuses. Results There were 16 cases without pelvic ring fracture, 18 cases of single pelvic ring fracture, 91 cases of 2 pelvic ring fractures, 73 cases of 3 or more pelvic ring fractures, 136 cases of anterior or posterior pelvic ring fractures, 46 cases of simultaneous anterior and posterior ring fractures. There were 34 cases of Tile A type, 130 cases of Tile B type and 24 cases of Tile C type. Statistical analysis results showed that, the differences in distribution of the number of pelvic ring fracture, the location of pelvic ring fracture and Tile type of pelvic ring fracture in various healing statuses had statistical significance （P<0.05）. Conclusion In determination of the healing status of pelvic fracture, preliminary judgment can be made by using the number of pelvic ring fracture, status of pelvic ring fracture and Tile type of pelvic fracture. Caution is required when dealing with single pelvic fractures （including dislocations）, and determining the destruction of bony pelvis.

Intracranial abscess formation in an adult alpaca: a case report

BackgroundIntracranial abscess formation is an extremely rare and sporadically documented disease in South American Camelids (SACs). Herein we report the first case of otogenic brain abscess formation in this species.Case presentationA 4 years old female alpaca was presented to our veterinary hospital with a 6 month history of neurologic disorder symptoms, mainly head tilt to the right and emaciation. A comprehensive workup (ultrasound and computed tomography) revealed irreversible cranial nerve abnormalities, extensive lesions in the region of external, middle and internal right ear including destruction of bony structures (tympanic bulla, parts of temporal bone) and severe brain deformation caused by an intracranial abscess. The lesion was up to 6x7x4 cm and occupying almost 40% of the cranial cavity. No pathological findings were evident in other organs or structures. The late referral of the alpaca at this advanced stage of destructive disease precluded surgical intervention.ConclusionsThis case report describes the clinical signs, diagnostic procedures and pathological findings in an adult female alpaca suffering from cranial nerve abnormalities caused by a massive otogenic brain abscess. Camelids suffering from otitis may not present with clinical signs until the pathology is severe. The importance of considering intracranial abscess formation as differential diagnosis in SACs showing the merest hint of nerve deficits cannot be emphasized enough in order to diagnose such pathological processes at an early and treatable stage.

Radiographic Remodeling of the Proximal Phalangeal Head Using a Stretching Exercise in Patients With Camptodactyly

The aims of this study were to verify proximal phalangeal head normalization after a stretching exercise in patients with infantile-type camptodactyly and to propose radiographic indices for quantifying bony deformities. Forty-eight fingers of 20 patients with camptodactyly were enrolled in this study. All patients and their parents received instruction on how to perform the stretching exercise. The qualitative assessments of proximal phalangeal head remodeling were conducted by consensus of 2 hand surgeons. Two radiographic parameters, head triangle ratio (HTR) and head angle (HA), were measured on finger lateral radiographs taken at the initial visit and at 12-month follow-up. The intra- and interobserver reliability of both parameters was assessed. Those parameters of the patients were compared with those of 177 fingers of 80 children without camptodactyly. The extent of proximal interphalangeal (PIP) joint flexion contracture was used to evaluate clinical outcomes resulting from nonsurgical treatment. Qualitative assessments of proximal phalangeal head remodeling exhibited meaningful improvements. Both radiographic parameters showed significant change between their status before and after intervention and had excellent intra- and interobserver reliability. Average PIP joint flexion contracture significantly improved. In the noncamptodactyly group, neither parameter showed significant differences in accordance with finger types and age ranges. Stretching improved movement within the proximal phalangeal joint and helped to restore proximal phalangeal head roundness and concentricity in patients with infantile-type camptodactyly. The HTR and HA would be useful indices for objectively assessing the degree of bony deformity in patients with camptodactyly. Therapeutic IV.

Pre-operative planning for reverse shoulder replacement: the surgical benefits and their clinical translation

With the increasing use of reverse shoulder arthroplasty and its expanding indications, surgeons today are facing tougher reconstructive challenges while still providing the patient with a good clinical outcome. There are a greater number of primary and revision cases where glenoid vault deformity is encountered. This presents a challenge to the surgeon during glenoid component positioning. He or she must place the implants in a location and orientation that optimizes range of motion and stability while minimizing impingement. In order to address this, surgeons can look to the use of 3D imaging in order to better understand each patient’s pathology. With the use of virtual planning the surgeon has the ability to arrive in the operating room with an established surgical plan in order to better address the deformity present. This can help in determining if glenoid bone grafting, eccentric reaming, or the use of augmented/lateralized components is the best choice in addressing bony deformity and maximizing impingement-free range-of-motion. Furthermore, with the advent of patient specific instrumentation and navigation the surgeon has the means to translate the preoperative plan into the operating room with increased accuracy, thus, decreasing the likelihood of component malposition and its associated complications. In the future, custom implants may grant the surgeon the means to address severe glenoid bone loss that would otherwise not be reconstructable and potentially give the patient improved function.

Preoperative multislice computed tomography evaluation of shoulder deformities in brachial plexus birth palsy patients undergoing tendon transfer

BackgroundBrachial plexus birth palsy (BPBP) refers to a birth related paralysis of the upper extremity. The current study was designed to evaluate the efficacy of computed tomography (CT) in the assessment of humeral head posterior subluxation and glenoid retroversion preoperatively and to evaluate whether or not bony deformity correlates with functional improvement (based on Modified Mallet Score) following tendon transfer in brachial plexus birth palsy patients. Patients and methodsThis prospective study included 30 patients, 15 below 4 years and 15 above 4 years old, with a mean age 3.65 ± 1.39 (range 2–8) years old. Thirteen patients were males (43.3%) and 17 were females (56.6%). The left side was affected in 13 patients (43.3%), while the right in 17 (56.7%). The Modified Mallet Score was used for clinical assessment of the shoulder function. A multislice CT scan with 3D reconstruction was used as a preoperative radiological assessment of the shoulder. An electromyography (EMG) of the muscles around the shoulder was performed. All patients were operated upon by anterior release of the internal rotators to improve the external rotation range of motion and by transfer of teres major and latissimus dorsi to improve the abduction motion through one anterior deltopectoral incision and a small posterosuperior incision. Postoperatively, the range of shoulder abduction and external rotation had been assessed after shoulder spica removal and till the end of follow up. ResultsFourteen patients (46.7%) had a normal glenoid version angle (normal range from −12° to 2°) and normal range of articulation with the glenoid (42.3%–71.4%) and 16 patients (53.3%) had an abnormal glenoid version angle and abnormal range of articulation with the glenoid. According to the Modified Mallet Score, there was a statistically significant difference in the mean value of global abduction (P = 0.04), external rotation (P = 0.03), hand to mouth (P = 0.02), hand to neck (P = 0.03) and hand to spine (P = 0.02) between the pre- and post-operative assessment of all patients. There was a statistically significant difference in the mean value of postoperative Modified Mallet Score between the patients under the age of 4 years and those above the age of 4 years. There was no statistically significant difference between the patients with normal CT angles and those with abnormal CT angles. There was no statistically significant difference in the mean value of glenoid version angle and percentage of humeral head articulation between the patients below the age of 4 years and those above 4 years (P = 0.845). ConclusionThe study concluded that the glenoid version angle and humeral head articulation percentage do not negatively affect results of the tendon transfer around the shoulder in patients of upper brachial plexus birth palsy. Level of evidenceIV.

THE EVALUATION OF SUPRATROCHLEAR OSSEOUS MORPHOLOGY: AN EPIDEMIOLOGIC STUDY

Introduction: Patellar instability can impede activities of daily life. The morphology of the femoral trochlea has significant involvement in maintaining patellofemoral joint stability. Trochlear dysplasia, or a shallow trochlear groove, has been implicated as a risk factor for recurrent patellar dislocation. A supratrochlear spur in the setting of existing trochlear dysplasia can generate further patellar instability. Trochleoplasty has been popularized by some surgeons for the treatment of recurrent patellar instability in the setting of significant trochlear dysplasia. Despite recommendation of trochleoplasty in treatment of patellar instability in the setting of trochlear dysplasia, much is unknown about the prevalence of trochlear dysplasia and supratrochlear spurs in the general population. The purpose of this study is to investigate the prevalence of supratrochlear spurs and trochlear dysplasia in the population and investigate the relationship between supratrochlear spurs and dysplastic femoral trochleae. Methods: This study was performed at the Cleveland Museum of Natural History, the Hamann Todd Human Osteological Collection. With over 4,000 complete human skeletons, the Hamann Todd osteological collection at the Cleveland Museum of Natural History is the largest collection of osteological specimens with documented demographic data in the Western Hemisphere. We evaluated femora from over 1,000 individuals aged 16-40 years. Each specimen was evaluated for the presence of trochlear dysplasia and supratrochlear spurs. We excluded skeletally immature specimens as well as specimens with visible signs of osteoarthritis or abnormal, bony deformity. The presence or absence of supratrochlear spurs was documented. Abnormal femoral trochleae were photographed in A/P, axial, and lateral views. The width and length of supratrochlear spurs were measured using digital calipers. Results: Of the 1,148 specimens studied, 135 femora from 93 individuals were found to be dysplastic. Amongst these, 9 femora with trochlear dysplasia had supratrochlear spurs. The average age of individuals with dysplastic trochleae in this study was 32.86. Of the 93 specimens identified, 24 were female (25.8%). Additionally, 52% of individuals with dysplastic trochleae were white while 48% were black. Conclusions: There may be an association of supratrochlear spurs with trochlear dysplasia. Though 25.8% of individuals with dysplastic trochleae were female, it is important to note that the Hamann Todd Collection as a whole is 19% female.