Contralateral Extremity Research Articles

Soft Tissue Complications of Dorsal Versus Volar Plating for Ulnar Shortening Osteotomy

To compare the results and complications of fixed-angle dorsal locking plate fixation for ulnar shortening osteotomy (USO) with the conventional technique of volar plating. We performed a retrospective review of 32 patients undergoing USO on 34 wrists and compared the outcomes of 16 consecutive cases with dorsal 2.4/2.7-mm fixed-angle plating and 18 consecutive cases with volar 3.5-mm plating. A minimum of 12 months' follow-up was used to assess outcomes. Primary outcomes were painful hardware and removal of symptomatic implants. Secondary outcomes were pain, Patient-Rated Wrist Evaluation, range of motion, time to union, grip strength, and complications. There were no significant differences in Patient-Rated Wrist Evaluation, pain score, range of motion, or time to union. Relative grip strength compared with the contralateral upper extremity in the dorsal group was higher than the volar group. After adjusting for hand dominance, dorsal plating was significantly associated with higher relative grip strength. There were 2 complications in the dorsal group, including one case with painful hardware. This was significantly lower than in the volar group, which had 10 complications including 2 nonunions and 6 cases of hardware-related soft tissue irritation. Both volar and dorsal plating techniques for USO yielded good functional outcomes. There was a higher incidence of painful hardware requiring removal of implants in the volar group. Based on these findings, we advocate dorsal plate position using a smaller fixed-angle plate for USO in ulnar impaction syndrome. Therapeutic III.

Patient-related factors influencing ulnar-shortening osteotomy outcomes using the trimed dynamic compression plate.

Ulnocarpal impingement can be surgically managed with various shortening osteotomy techniques. The purpose of this study was to retrospectively examine the outcomes of the ulnar-shortening osteotomy technique using the Trimed dynamic compression plate (Valencia, California) and to determine whether results vary among patient-related factors, including smoking status, occupation, preoperative diagnosis, and workers' compensation status. Twenty-seven patients (28 wrists) operated by a single surgeon underwent ulnar shortening over a 4-year span. Radiographic analysis was obtained preoperatively and at an average 24-month follow-up. A subset of 12 patients completed the Disabilities of the Arm, Shoulder and Hand (DASH) inventory; the Patient-Rated Wrist Evaluation (PRWE); and the visual analog scale for pain and underwent clinical evaluation for range of motion and strength. Ulnar variance improved in all cases between pre- and postoperative imaging (P<.05). Grip strength and range of motion were found to be 79% and 90% of the contralateral extremity, respectively. Among the examined patient-related factors, patients involved in a workers' compensation claim demonstrated significantly different DASH (average, 56.8 claim vs 26.8 no claim; P=.037) and PRWE (average, 66.0 claim vs 32.8 no claim; P=.008) scores while also showing a trend toward nonunion (3/10 claim vs 1/18 no claim; P=.105). Results of ulnar-shortening osteotomy using the Trimed system at 2-year follow-up show consistent objective improvements in radiographic ulnar variance. Workers' compensation claims may negatively influence outcomes of ulnar shortening, and this factor should be considered in preoperative patient selection and counseling.

Inflammation in cold complex regional pain syndrome.

In patients with complex regional pain syndrome (CRPS), the temperature of the affected side often differs from that of the contralateral side. In the acute phase, the affected side is usually warmer than the contralateral side, the so-called 'warm' CRPS. This thermal asymmetry can develop into a colder affected side, the so-called 'cold' CRPS. In contrast to cold CRPS, in warm CRPS, inflammation is generally assumed to be present. However, there are reports of cold CRPS patients, successfully treated with vasodilatation therapy, who subsequently displayed warm CRPS. It seems that inflammation could be 'hidden' behind vasomotor disturbance. This study was designed to test this hypothesis. A retrospective analysis was made of patients in our CRPS database. We defined three types of CRPS: cold CRPS, neither cold nor warm (intermediate) CRPS, and warm CRPS. Of these patients, the difference between the level of the pro-inflammatory cytokines interleukin (IL)-6 (Δ IL-6) and tumor necrosis factor (TNF)-α (Δ TNF-α) in the affected extremity and that in the contralateral extremity was determined. The bilateral difference of the level of these cytokines did not differ among patients with cold CRPS, intermediate CRPS, or those with warm CRPS. Inflammation may be involved in cold CRPS.

Redo off-pump coronary artery bypass grafting via a left thoracotomy

SummaryBackgroundIn this study, we retrospectively reviewed our experience in a meticulously selected group of patients undergoing redo off-pump coronary artery bypass graft (CABG) surgery from the descending aorta to the circumflex artery (Cx) and its branches.MethodsBetween January 2001 and October 2013, 32 patients at our hospital underwent redo off-pump CABG from the descending aorta to the Cx and its branches via a left posterolateral thoracotomy. Of these patients, 27 were male (84.3%) and five were female (15.7%), with a mean age of 61.66 ± 8.63 years. All patients had a patent left internal thoracic artery-to-left anterior descending coronary artery (LITA–LAD) anastomosis. Thoracotomy was performed through the fifth intercostal space. The saphenous vein or radial artery was prepared as a graft at the same time as the left posterolateral thoracotomy from the contralateral extremity, without any positional problem.ResultsThe main reasons for surgery in this group of patients were new lesion formation in 19, graft occlusion in six, and both in seven patients. The average operating time was 143.90 ± 36.93 minutes, respiratory assist time was 5.08 ± 1.88 hours, intensive care unit (ICU) stay was 21.3 ± 4.41 hours and hospital stay was 5.06 ± 2.74 days. Thirty-eight bypasses were performed. The follow-up period was 56.17 ± 39.2 months. Six patients were lost in the follow-up period and four patients died. Twenty-two were alive and free of cardiac problems.ConclusionRedo off-pump CABG via a left posterolateral thoracotomy provided a safe and effective surgical approach with lower rates of postoperative morbidity and mortality in patients who required revascularisation of the Cx and its branches.

Activation of the gluteus medius according to load during horizontal hip abduction in a one-leg stance.

[Purpose] This study researched the influences of different loads on muscle activity of the posterior fibers of the gluteus medius in a one-leg standing position. [Subjects] Twenty-four healthy adult men participated in this study. [Methods] All participants performed the one-leg standing position under four conditions: the standard no-load condition, in which the non-weight-bearing leg was lifted and kept parallel to the back and then pelvic or lumbar rotation was performed without thorax rotation, and the 0 kg, 1 kg, and 3 kg load conditions, in which horizontal shoulder abduction was performed with a load of 0 kg, 1 kg, or 3 kg added to the hand. The electromyographic activity of the posterior fibers of the gluteus medius was measured using a wireless surface electromyography under all conditions. The electromyographic activity of each muscle under the four conditions during the one-leg stance was analyzed using one-way analysis of variance. [Results] The electromyographic activity of the posterior fiber of the gluteus medius was significantly increased under the 3 kg load condition compared with the no-load, 0 kg load, and 1 kg load conditions. [Conclusion] These findings indicated that muscle activation is affected by increases in load in the one-leg standing position. The load on the upper extremity influences the muscle activity of the contralateral lower extremity.

Shoulder arthroscopy and complications: Can we afford to relax?

Shoulder arthroscopy and complications: Can we afford to relax?

MRI Guided Focused Ultrasound Thalamotomy for Moderate-to-Severe Tremor in Parkinson's Disease.

Background. Thalamotomy is effective in alleviating tremor in Parkinson's disease (PD). Methods. Seven PD patients, mean age 59.4 ± 9.8 years (range, 46–74) with a mean disease duration of 5.4 ± 2.8 years (range, 2–10) suffering from severe refractory tremor, underwent ventral intermediate nucleus thalamotomy using MRI guided focused ultrasound (MRgFUS), an innovative technology that enables noninvasive surgery. Results. Tremor stopped in the contralateral upper extremity in all patients immediately following treatment. Total UPDRS decreased from 37.4 ± 12.2 to 18.8 ± 11.1 (p = 0.007) and PDQ-39 decreased from 42.3 ± 16.4 to 21.6 ± 10.8 (p = 0.008) following MRgFUS. These effects were sustained (mean follow-up 7.3 months). Adverse events during MRgFUS included headache (n = 3), dizziness (n = 2), vertigo (n = 4), and lip paresthesia (n = 1) and following MRgFUS were hypogeusia (n = 1), unsteady feeling when walking (n = 1, resolved), and disturbance when walking tandem (n = 1, resolved). Conclusions. Thalamotomy using MRgFUS is safe and effective in PD patients. Large randomized studies are needed to assess prolonged efficacy and safety.

Reliability of ultrasound imaging for the assessment of lumbar multifidi thickness in older adults with chronic low back pain.

Ultrasound imaging (USI) has been shown to be a reliable measure for direct assessment of the lumbar multifidi among younger adults. However, given age- and chronic low back pain (CLBP)-related spinal changes, similar studies are needed before clinical use of USI among older adults with CLBP. The goals of this study were to evaluate intra- and interexaminer reliability for USI assessment of multifidi thickness at rest and during a contraction and to determine standard error of measurement values (SEMs) and minimal detectable change values (MDCs) among older adults with CLBP. Thirty-one adults, aged 60 to 85 years, with CLBP were recruited. Two examiners performed USI assessments of multifidus thickness at rest and during a contralateral lower extremity lift. Intraclass correlation coefficients (ICCs) were used to estimate inter- and intraexaminer reliability. Additionally, SEMs and MDCs were calculated. All USI measurement techniques demonstrated excellent within-day, interexaminer procedural reliability (ICCs: 0.82-0.85) and good-to-excellent between-day, interexaminer procedural reliability (ICCs: 0.72-0.79). The SEMs ranged from 0.36 to 0.46 cm; MDCs ranged from 1.01 to 1.26 cm. Regardless of the measurement technique, examiner 1, the more experienced examiner, demonstrated lower SEMs and MDCs than examiner 2. Lower ICCs, greater SEMs, and greater MDCs for USI multifidus thickness assessment in older adults with CLBP, when compared with previously published, procedural reliability results for younger adults with and without low back pain, may indicate that imaging is more challenging in this patient population. Factors, such as examiner training and participant anthropometrics, may impact reliability. Good-to-excellent intra- and interexaminer USI procedural reliability may provide clinicians a direct assessment technique for clinical evaluation of the lumbar multifidi in older adults with CLBP. SEMs and MDCs may allow for accurate interpretation of USI assessments in this population.

Church Pew Exercise Integrated With Conventional Physical Therapy Following Total Knee Arthroplasty (TKA): Case Report

Background and Purpose: Physical therapy treatment following Total knee Arthroplasty (TKA) consists of a combination of strengthening and range of motion exercises. The exercise technique, church pew exercise (CPE), has been proposed to enhance quadriceps facilitation and improve function. This is a technique that has the patient standing and rocking forward/back. The backward motion is arrested by engagement of the upper calf against a solid object, creating a sudden flexion torque at the knee and a sudden extension torque at the hip. The combination of CPE with standard physical therapy is claimed to provide better quadriceps control and faster walking post TKA. In this case study, a 51-year-old female with decreased knee active and passive range of motion (ROM), decreased lower extremity (LE) muscle strength, and limited ambulation post left knee TKA, received conventional physical therapy treatment plus CPE. Methods: The patient received 11 physical therapy home sessions. The first 8 sessions were used to strengthen her knee and increase active and passive ROM. The CPE intervention was performed 3 weeks post-surgery, during the last 3 physical therapy sessions. At these three sessions the patient performed the Timed Up and Go (TUG) before and after CPE. Outcomes: At initial evaluation, 4 days post left knee TKA, this patient’s left knee active ROM was only 15 to 76 degrees, and manual muscle testing at her hip and knee indicated strengths of 2- (hip flexors), 3- (hamstrings and quadriceps), and 3+ (hip abductors), all out of 5, and her times on two trials of the TUG were 30.31 and 30.65 sec, indicating impaired functional ability. At all CPE sessions (3 weeks post-surgery) the patient demonstrated increased gait speeds (i.e. shorter times) on the TUG after the CPE (pre CPE mean = 13.2 sec; post CPE mean = 11.2), increased stance time on her affected lower extremity, and increased step length on her contra-lateral lower extremity. The patient reported increased knee stability. Clinical Relevance: Rationale for CPE is based on neurological facilitation of quadriceps and other lower extremity muscles. However, to engage in this exercise the patient must have the ability to balance and to control the hip and knee joints. This patient required several weeks of strengthening and active and passive ROM exercises before she could perform the CPE. Once able to perform the CPE, she demonstrated improvements in her walking ability, and she expressed greater confidence. Conclusion: Provided a minimal level of strength and active and passive ROM has been attained, CPE may be a valuable short-term supplement to current strengthening regimens addressing quadriceps functional deficits following TKA. Other conditions that involve gait problems related to quadriceps insufficiency might also benefit. The long-term efficacy of CPE remains to be determined.

Bilateral Vocal Cord Dysfunction in the Setting of Lateral Medullary Infarction: A Case Report and Review of Neuro-Anatomical Correlate

Background: Lateral medullary (Wallenberg) syndrome is the most common stroke syndrome related to vertebral artery disease. The hallmark of this syndrome is crossed sensory findings affecting the contralateral trunk and extremities and the ipsilateral side of the face. This is in addition to dysarthria, dysphagia, vertigo, and Horner's syndrome. Unilateral vocal cord dysfunction is frequently seen, but bilateral vocal cord paralysis is an extremely rare and potentially life threatening complication. Case Presentation: We present the case of a 75 year-old man who presented with the diagnosis of acute lateral medullary (Wallenberg) syndrome, and experienced bilateral vocal cord paresis leading to acute airway obstruction. Conclusion: We report a rare manifestation of acute ischemic stroke: bilateral vocal cord paresis. We propose an underlying neuroanatomical mechanism for bilateral vocal cord involvement.

Vascularized proximal fibular epiphyseal transfer for Bayne and Klug type III radial longitudinal deficiency in children.

Treatment of Bayne and Klug type III radial longitudinal deficiency with fibular epiphyseal transplantation in children has had limited success to date. The purpose of this investigation was to review the authors' results of microvascular epiphyseal transplantation for radial longitudinal deficiency. Between 2007 and 2009, four children with a mean age of 4.3 years (range, 3.3 to 5.8 years) who had a type III radial longitudinal deficiency underwent microsurgical reconstruction of the distal radius with vascularized proximal fibular transplantation, including the physis, partial superior tibiofibular joint, and a variable length of the diaphysis. All of the grafts were supplied by the inferior lateral genicular artery. In all patients, the range of motion of the digits, wrist, forearm, and elbow; the length of the forearm; and the deviation of the wrist were evaluated. The mean duration of follow-up was 42 months (range, 24 to 65 months). All four transfers survived and united with the host bone within 3 months postoperatively. An average correction of 28 degrees in the hand-forearm angle was obtained. Forearm length was 67.9 percent that of the normal side on average at the final follow-up. The overall range of wrist motion was approximately 55 percent that of the contralateral extremity. No major complications were observed. Vascularized proximal fibular epiphyseal transfer, based on the inferior lateral genicular artery, is a technically feasible method for treatment of type III radial longitudinal deficiency, which maintains hand-forearm alignment, provides excellent function, and minimizes the length discrepancy between the distal radius and ulna. Therapeutic, IV.

Functional Outcomes of Replantation Following Radiocarpal Amputation

To assess the long-term functional and clinical outcomes of patients who have undergone replantation after radiocarpal amputation. We performed a retrospective review of radiocarpal joint amputations at a level 1 trauma center over a 13-year period. Medical records of patients treated with replantation were queried for injury data, operative reports, complications, and clinical progress. Patients who met inclusion criteria were contacted for long-term follow-up. We measured total active motion of each digit, strength (grip and pinch), and 2-point discrimination. Functional outcomes were assessed with Disabilities of Arm, Shoulder, and Hand score, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. Six patients met the inclusion criteria. The mean age was 36 years (range, 26-50 y). Five patients were available at a mean follow-up of 3.9 years (range, 1.0-6.9 y). Compared with the contralateral uninjured extremity, total active motion of the hand was 38% (range, 26% to 59%) and grip strength was 9% (range, 0% to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (range, 8-12 mm). All mean outcome scores indicated moderate disability, including Disabilities of Arm, Shoulder, and Hand (76; range, 45-82), Mayo Wrist Score (23; range, 5-50), Patient-Rated Wrist Evaluation (86; range, 56-98), and Michigan Hand Questionnaire (27; range, 15-55). Two patients were able to return to work and 3 were permanently disabled. All patients were satisfied with the hand function. Successful replantation for a radiocarpal joint amputation is associated with major restriction of motion, decreased strength, and moderate disability on functional outcome assessments. Therapeutic IV.

A comparison of function after limb salvage with non-invasive expandable or modular prostheses in children

BackgroundModular and non-invasive expandable prostheses have been developed to provide a functional knee joint that allows future expansion as growth occurs in the contralateral extremity in children with bone sarcomas that require removal of the growth plate. This study aimed to evaluate the functional outcomes of paediatric patients who received either a non-invasive expandable or modular prosthesis for bone sarcomas arising around the knee. MethodsWe evaluated clinician-reported, patient-reported and measured function in 42 paediatric patients at least one year (median age at assessment 19.1years) after limb salvage surgery, and compared patients who received modular system prostheses (N=29, median age 15.5), who did not require lengthening procedures to those who received non-invasive expandable prostheses (N=13, median age 11.1) requiring lengthening procedures (median 5). ResultsThe number of revisions and time to first revision did not differ between the two groups. There were no differences between the two groups in total scores on the Enneking Musculoskeletal Tumor Society Scale, the Toronto Extremity Salvage Scale, and the Functional Mobility Assessment. Children with non-invasive expandable prostheses climbed stairs (11.93±4.83 versus 16.73±7.24s, p=0.02) in less time than those with modular prostheses. ConclusionOur results suggest that the non-invasive expandable prosthesis produces similar functional results to the more traditional modular prosthesis.

Impact of joint status on contraction steadiness of m. quadriceps femoris in people with severe haemophilia.

Impaired contraction steadiness of lower limb muscles affects functional performance and may increase injury risk. We hypothesize that haemophilic arthropathy of the knee and the strength status of quadriceps are relevant factors which compromise a steady contraction. This study addresses the questions if impaired steadiness of the quadriceps is verifiable in people with haemophilia (PWH) and whether a connection between the status of the knee joint and quadriceps strength exists. A total of 157 PWH and 85 controls (C) performed a strength test with a knee extensor device to evaluate their bilateral and unilateral maximal quadriceps strength and steadiness. Isometric steadiness was measured by the coefficient of variation of maximum peak torque (CV-MVIC in %). For classification of the knee joint status the World Federation of Haemophilia (WFH) score was used. Lower steadiness (higher CV values) was found in PWH compared with C during bilateral [PWH vs. C; 0.63 (0.36/1.13) vs. 0.35 (0.15/0.72), median (Q25/Q75) P<0.001] and unilateral trials [left leg: 0.70 (0.32/1.64) vs. 0.50 (0.23/1.04), P<0.05; right leg: 0.68 (0.29/1.51) vs. 0.39 (0.18/0.68), P<0.001]. PWH with a WFH score difference (≥1) between their extremities showed a less steady contraction in the more affected extremity (P<0.05). More unsteady contractions have also been found in extremities with lower quadriceps strength compared with the contralateral stronger extremities (P<0.001), whereby the weaker extremities were associated with a worse joint status (P<0.001). The results of this study verify an impaired ability to realize a steady contraction of quadriceps in PWH and the influence of joint damage and strength on its manifestation.

Case Scenario: Postoperative Brachial Plexopathy Associated with Infraclavicular Brachial Plexus Blockade

Case Scenario: Postoperative Brachial Plexopathy Associated with Infraclavicular Brachial Plexus Blockade

Ulnar shortening osteotomy for ulnar impaction syndrome.

Background Ulnar impaction syndrome is a condition in which the ulna impacts on the ulnar carpus. This most commonly occurs when the ulna is longer than the radius, but it can also occur in wrists with ulnar neutral and ulnar negative variance. Materials and Methods In this paper we outline our surgical technique for ulnar shortening osteotomy. A previously published retrospective case series of 28 patients treated at our center is presented. Fifty consecutive patients who underwent ulnar shortening osteotomy (USO) for ulnar impaction syndrome were approached for study, and 28 consented to review. Mean preoperative ulnar variance was +2.3 mm, and mean postoperative ulnar variance was -0.8 mm. Mean follow-up time was 21.2 months (8 to 41 months) and ten of 28 were receiving workers' compensation. Mean preoperative pain score (visual analog scale; VAS) was 7.9. Univariate analysis was performed to assess clinical and demographic data. In addition, subgroup analysis of workers' compensation patients and smokers was performed. Description of Technique A longitudinal incision over the subcutaneous border of the ulna is used to expose the ulna between the distal and middle third of the ulna from the ulna styloid. Preoperative posteroanterior (PA) X-rays are reviewed to determine the amount of shortening required, with a goal of creating -2 mm variance postoperatively. A 6-hole dynamic compression plate is predrilled distally prior to performing two oblique osteotomies separated by the desired shortening length. The fragments are reduced, controlling for rotation, and plated using compression. In some cases, a lag screw is employed across the oblique osteotomy site. Results Mean pain scores were significantly reduced postoperatively (VAS 7.9 versus 3.1, P < 0.0001). The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 37.2 postoperatively. Flexion, extension, and supination were reduced compared with the contralateral unaffected extremity (84.6%, 85.3%, and 86.9% of normal). Patients receiving workers' compensation and smokers had significantly more pain postoperatively (VAS 5.2 vs. 2.0, P = 0.0002 and VAS 4.4 vs 2.4, P < 0.05, respectively). Eleven of 28 patients required hardware removal for plate irritation, and five of 28 patients had a nonunion. Conclusion We present our surgical technique for ulnar shortening osteotomy. Pain was significantly improved in our population; however, patients receiving workers' compensation and smokers had less improvement in pain and higher disability scores.

Abstract T P226: Novel Technique of Minimally Invasive Image Guided Catheter Evacuation of Spontaneous Basal Ganglia Hemorrhages Results in Improved Hemorrhage Evacuation and Outcome

Introduction: Minimally invasive surgical (MIS) therapies demonstrate promising results in the treatment of intracerebral hemorrhages (ICH). We applied a novel technique of image guided catheter placement and evacuation, followed by recombinant tissue plasminogen activator (rtPA) thrombolysis, to treat spontaneous basal ganglia hemorrhages. We hypothesized that MIS ICH evacuation would result in decreased clot size, improved survival, and improved functional outcome. We predicted that the corticospinal tracts would be preserved, as quantified with diffusion tensor imaging (DTI). Methods: We reviewed a prospective series of 19 patients, selected from 655 ICHs evaluated from 2009-2013. We chose patients with an ICH volume of 10 to 80cc, age less than 80, and admission GCS greater than 5 for this procedure. Patients with aneurysms, malformations, or traumatic hemorrhages were excluded. Using frameless stereotaxy (StealthStation® AxiEM™) a 14 French, urethral rubber catheter (Bard Inc.) was guided to the clot and it was evacuated. A drainage catheter placed in the hemorrhage allowed for rtPA thrombolysis and drainage post-operatively. Results: Reduction in average hematoma volume from 44 +/- 16 to 26 +/- 16 cc was achieved at surgery (p&lt;0.05). This volume was reduced to 13 +/- 8 cc after rtPA lysis and drainage (p&lt;0.05). 30 day mortality was 10.5%, better than the 40% mortality predicted by the calculated individual ICH scores. The mean discharge GCS of 12.1 +/- 2.2 improved from the admission GCS of 9.8 +/- 2.2 (p=0.0053). DTI of 13 patients before and after surgical evacuation demonstrated less of a decrease in the mean fractional anisotropy ratio of the ipsilateral over the contralateral corticospinal tract to the hemorrhage for those patients with discharge GCS&gt;12 (-0.09 vs. -0.40, p=0.083). This trend did not correlate with a significant improvement of the contralateral upper extremity NIH motor score from admission to discharge for these patients (+0.6 vs. -0.40, p=0.10). Conclusions: Our innovative MIS technique for ICH evacuation is safe and effective. DTI demonstrates a trend towards preservation of the corticospinal tract, which may contribute to the benefits of MIS techniques over traditional craniotomy.

A Randomized, Controlled Animal Trial Demonstrating the Feasibility and Safety of the Magellan™ Endovascular Robotic System

The success of remotely steerable catheters designed for cardiac ablation procedures in the peripheral vasculature (in the laboratory and in highly select live cases) has led to the development of a vascular robotic system designed specifically for use in the arterial and venous systems. Limited bench-top and animal testing has been successful, but no randomized, controlled study of the system's safety has been performed. In a 3-phase study, we performed a randomized, controlled trial comparing standard manual catheterization and balloon angioplasty of visceral, renal, and contralateral lower extremity vessels in a porcine model. We also demonstrated feasibility of standard device deployment through the system. There was 100% technical success in test (robotic) and control (manual) arm cannulation and balloon angioplasty of all target vessels, without complications. Pathologic analysis at 7 days revealed significantly fewer traumatic lesions in the test animal arm as compared with the control arm (P < 0.001) and, by 30 days, all lesions had healed in both groups. There was 100% success in delivery of standard devices (balloons and stents) without complications. Remotely steerable robotic catheters are at least as safe as manual catheter techniques, and may prove less traumatic to peripheral vessels. Standard devices can be deployed through the system, and the stability of the platform may aid in ease of device delivery in difficult vascular segments.

Monomelic Amyotrophy Involving Contralateral Upper and Lower Extremities with an Atypical Involvement of Lower Limb Muscles in a North-American Hispanic Female: Case Report and Review of Literature

Monomelic Amyotrophy Involving Contralateral Upper and Lower Extremities with an Atypical Involvement of Lower Limb Muscles in a North-American Hispanic Female: Case Report and Review of Literature

Management of Acromioclavicular Joint Injuries

Acromioclavicular joint injuries are among the most common shoulder girdle injuries in athletes and most commonly result from a direct force to the acromion with the arm in an adducted position. Acromioclavicular joint injuries often present with associated injuries to the glenohumeral joint, including an increased incidence of superior labrum anterior posterior (SLAP) tears that may warrant further evaluation and treatment. Anteroposterior stability of the acromioclavicular joint is conferred by the capsule and acromioclavicular ligaments, of which the posterior and superior ligaments are the strongest. Superior-inferior stability is maintained by the coracoclavicular (conoid and trapezoid) ligaments. Type-I or type-II acromioclavicular joint injuries have been treated with sling immobilization, early shoulder motion, and physical therapy, with favorable outcomes. Return to activity can occur when normal shoulder motion and strength are obtained and the shoulder is asymptomatic as compared with the contralateral normal extremity. The management of type-III injuries remains controversial and is individualized. While a return to the previous level of functional activity with nonsurgical treatment has been documented in a number of case series, surgical reduction and coracoclavicular ligament reconstruction has been associated with a favorable outcome and can be considered in patients who place high functional demands on their shoulders or in athletes who participate in overhead sports. Surgical management is indicated for high-grade (≥type IV) acromioclavicular joint injuries to achieve anatomic reduction of the acromioclavicular joint, reconstruction of the coracoclavicular ligaments, and repair of the deltotrapezial fascia. Outcomes after surgical reconstruction of the coracoclavicular ligaments have been satisfactory with regard to achieving pain relief and return to functional activities, but further improvements in the biomechanical strength of these constructs are necessary to avoid loss of reduction and creep with cyclic loading.