Degrees Of Flexion Research Articles

Single-Strand “Short Isometric Construct” Medial Collateral Ligament Reconstruction Restores Valgus and Rotational Stability While Isolated Deep MCL and Superficial MCL Reconstruction Do Not

Background: Historical MCL (medial collateral ligament) reconstruction (MCLR) techniques have focused on the superficial MCL (sMCL) to restore valgus stability while frequently ignoring the importance of the deep MCL (dMCL) in controlling tibial external rotation. The recent recognition of the medial ligament complex importance has multiple studies revisiting medial anatomy and questioning contemporary MCLR techniques. Purpose: To assess whether (1) an isolated sMCL reconstruction (sMCLR), (2) an isolated dMCL reconstruction (dMCLR), or (3) a novel single-strand short isometric construct (SIC) would restore translational and rotational stability to a knee with a dMCL and sMCL injury. Study Design: Controlled laboratory study. Methods: Biomechanical testing was performed on 14 fresh-frozen cadaveric knee specimens using a custom multiaxial knee activity simulator. The specimens were divided into 2 groups. The first group was tested in 4 states: intact, after sectioning the sMCL and dMCL, isolated sMCLR, and isolated dMCLR. The second group was tested in 3 states: intact, after sectioning the sMCL and dMCL, and after single-strand SIC reconstruction (SICR). In each state, 4 loading conditions were applied at 0°, 20°, 40°, 60°, and 90° of knee flexion: 8-N·m valgus torque, 5-N·m external rotation torque, 90-N anterior drawer, and combined 90-N anterior drawer plus 5-N·m tibial external rotation torque. Anterior translation, valgus rotation, and external rotation of the knee were measured for each state and loading condition using an optical motion capture system. Results: sMCL and dMCL transection resulted in increased laxity for all loading conditions at all flexion angles. Isolated dMCLR restored external rotation stability to intact levels throughout all degrees of flexion, yet valgus stability was restored only at 0° of flexion. Isolated sMCLR restored valgus and external rotation stability at 0°, 20°, and 40° of flexion but not at 60° or 90° of flexion. Single-strand SICR restored valgus and external rotation stability at all flexion angles. In the combined anterior drawer plus external rotation test, isolated dMCL and single-strand SICR restored stability to the intact level at all flexion angles, while the isolated sMCL restored stability at 20° and 40° of flexion but not at 60° or 90° of flexion. Conclusion: In the cadaveric model, single-strand SICR restored valgus and rotational stability throughout the range of motion. dMCLR restored rotational stability to the knee throughout the range of motion but did not restore valgus stability. Isolated sMCLR restored external rotation and valgus stability in early flexion. Clinical Relevance: In patients with anteromedial rotatory instability in the knee, neither an sMCLR nor a dMCLR is sufficient to restore stability.

Time to surgical management of distal radius fractures: effects on health care utilization and functional outcomes.

Distal radius fractures are common injuries. Open reduction and internal fixation with volar locking plates is the most common approach for surgical fixation. This study investigated the association between time to surgery and health care utilization, income, and functional outcomes among patients undergoing open reduction and internal fixation for distal radius fracture. We conducted a retrospective review of patients who underwent open reduction and internal fixation for isolated acute distal radius fracture between 2009 and 2019. Time to surgery was grouped as early (≤ 14 d) and delayed (> 14 d). We performed χ2 (or Fisher exact) and Wilcoxon rank sum (or Kruskal-Wallis) tests to provide statistical comparison of time to surgery by health care utilization and functional outcomes. Univariable and multivariable logistic regression analyses were performed to identify factors significantly associated with time to surgery. We included all significant univariables in the multivariable logistic regression model, which identified factors based on significant adjusted odds ratios (95% confidence intervals excluding the null) after we adjusted for confounding variables. We included 106 patients, with 36 (34.0%) in the group receiving early treatment and 70 (66.0%) in the group receiving delayed treatment. Patients in the delayed-treatment group attended significantly more clinic visits and postoperative hand therapy sessions. The group with delayed treatment demonstrated significantly lower degrees of wrist flexion at the first follow-up, but this difference did not persist. Patients with higher estimated income (> $39 405 per annum) had lower odds of delayed surgery than those with lower estimated income (≤ $39 405). Delayed time to surgery was associated with greater health care utilization and lower degrees of early wrist flexion. Access to care for lower-income patients warrants further evaluation.

Navigation and robotics-current status and future implications

Both navigation systems and robotics enable greater precision in the implantation of an artificial knee joint. However, they do not improve clinical outcomes. We hypothesized that although implantation of atotal knee arthroplasty results in reconstruction of the alignment in the coronal plane, the variable rotational tibial and variable translational femoral and tibial component positioning lead to achange in the remaining alignment parameters of the lower extremity. However, these parameters could be determined using anavigation system or robot and could represent future implications for these systems. The kinematics and the position between femur and tibia before and after implantation of atotal knee arthroplasty were determined using anavigation system in nine healthy knee joints of Thiel-fixed whole-body cadavers. After arthroplasty, there was no change in the natural coronal alignment. In extension and the early degrees of flexion, the rotational position of the femur relative to the tibia was altered. This also led to achange in the positioning of the medial and lateral epicondyle in relation to the tibia; while both epicondyles were positioned more laterally in relation to the tibia after arthroplasty, the lateral epicondyle was significantly more lateral in relation to the tibia up to 20° of flexion. Following arthroplasty of aknee joint using the established technique, agood reconstruction of the coronal alignment was achieved with simultaneous changes in the alignment in both the rotational and translational directions between the femur and tibia. Using navigation as well as robotics, we would be able to quantify all alignment parameters and could achieve an alignment of the components or areconstruction of the overall alignment in all six degrees of freedom. We might also be able to achieve aclinical advantage or increase the service life even further.

Acute effects of an instructional movie on drop jump performance and lower limb kinematic and kinetic variables

Objectives: Drop jump (DJ) is a typical exercise of plyometric training in which the state before takeoff (pre-set phase) influences the force exertion of the lower limbs during takeoff, as well as performance variables. This study aimed to examine the effects of watching an instructional movie during the pre-set phase on the performance and lower limb kinematic and kinetic variables during plyometric training.Methods: Fourteen participants (age, 21.9 ± 2.1 years; height, 175.6 ± 2.6 cm; weight, 70.7 ± 4.9 kg) were enrolled in this study. Seven participants with a high rebound jump (RJ) index under normal conditions were classified into the high RJ-index group. Seven participants with a low RJ-index were classified into the low RJ-index group. DJs were performed under normal conditions and under the movie condition (DJ immediately after watching the instructional movie during the pre-set phase). Performance and kinematic and kinetic variables of the lower limb joints were measured.Results: Compared with the normal condition, the movie condition was associated with a significantly high RJ-index, lesser degree of knee flexion (p < 0.011), and significantly larger concentric torque (p < 0.018) of the ankle. An interaction effect was observed for the eccentric torque (p < 0.025) and positive power (p < 0.004) of the ankle, which were significantly greater in the high RJ-index group under the movie condition.Conclusion: Watching an instructional movie during the pre-set phase improves the movement and force production of the ankle and knee joint, which, in turn, improves the DJ performance. However, the effects may be more pronounced in participants with a high RJ-index.

Effects of Adding Extracorporeal Shockwave Therapy (ESWT) to Platelet-Rich Plasma (PRP) among Patients with Rotator Cuff Partial Tear: A Prospective Randomized Comparative Study.

A rotator cuff tear is a prevalent ailment affecting the shoulder joint. The clinical efficacy of combined therapy remains uncertain for partial rotator cuff tears. In this study, we integrated extracorporeal shockwave therapy (ESWT) with platelet-rich plasma (PRP) injection, juxtaposed with PRP in isolation. Both cohorts exhibited significant improvements in visual analogue scale (VAS), Constant-Murley score (CMS), degrees of forward flexion, abduction, internal rotation, and external rotation, and the sum of range of motion (SROM) over the six-month assessment period. The application of ESWT in conjunction with PRP exhibited notable additional enhancements in both forward flexion (p = 0.033) and abduction (p = 0.015) after one month. Furthermore, a substantial augmentation in the range of shoulder motion (SROM) (p < 0.001) was observed after six months. We employed isobaric tag for relative and absolute quantitation (iTRAQ) to analyze the differential plasma protein expression in serum samples procured from the two groups after one month. The concentrations of S100A8 (p = 0.042) and S100A9 (p = 0.034), known to modulate local inflammation, were both lower in the ESWT + PRP cohort. These findings not only underscore the advantages of combined therapy but also illuminate the associated molecular changes.

The Impact of Complex Loadings on the Structure of the L2-L3 Intervertebral Disc in a Sheep Spine Cadaver Model: A Biomechanical and Histological Evaluation.

Background The human vertebral column generates movements under versatile, dynamic loads. Understanding how the spine reacts to these movements and loads is crucial for developing new spine implants and surgical treatments for intervertebral disc injuries. Mechanically uni-axial compression models have been extensively studied. However, the spine's daily loading is not limited to compression, so it is crucial to measure its behavior in allmovements (flexion-extension, rotation, and axial compression). Methods This study utilized L1-L5 segments from 19 healthy adult sheep spines. The L2-L3 disc of the first spine underwent only histological evaluation without biomechanical testing to define basic histological parameters. The remaining 18 were divided into three groups of six and subjected to biomechanical tests. Different mechanisms for three groups of spinal segments were prepared, and tests were performed on Shimadzu AG-IS 10 KN (Universal Drawing Press, Kyoto, Japan). An axial load (800 N) was applied to the first group, an axial load with 15 degrees of flexion to the second group, and an axial load with 10 degrees of rotation plus 15 degrees of flexion to the third group. A biomechanical evaluation of the maximum elongation amounts (MEAs) was performed and compared between the groups. Then, the L2-L3 discs were removed from the sheep spines, and a histological examination of the discs was conducted usingHematoxylin-Eosin (HE), Alcian Blue (AB), and Masson's Trichrome (MT) staining. Results The mean MEA ± Standard Deviation (Range) was 1.39 ± 0.38 (0.91-1.94) for Group 1, 2.02 ± 0.75 (0.91-3.01) for Group 2, and 2.47 ± 1.09 (0.64-3.9) for Group 3. Biomechanically, although MEAs increased from Group 1 to Group 3 (meaning that the mean MEAs increased as the number of types of applied force increased), there was no statistically significant difference between the groups regarding the MEAs (P = 0.092). Histologically, no significant differences were observed between all groups after HE staining. In all groups, hypercellularity, edema in the connective tissue, separation between tissue layers, delamination, and signs of swelling and necrosis in the cells were observed similarly. For the AB staining, there was a decrease in the glycosaminoglycan (GAG) structure in the tissue samples compared to the control tissue, but no significant differences were observed between the groups. However, it was observed that the stratification in Group 3 was slightly more deteriorated than in the other groups. For the MT staining, collagen structure deterioration was observed in all groups. It was observed that the amount of collagen was significantly reduced compared to the control tissue. Conclusion As a result, when the axial load is applied biomechanically, there is more displacement of the vertebral discsin Group 3 with multidimensional movements. Furthermore, histological studies revealed deterioration between tissue layers when exposed to complex movements, and the degradation of stratification in group 3 compared to other loading combinations in groups 2 and 3 may indicate the role of complex loads in the formation of disc herniation.

Evaluation of Remodeling and Extrusion of Polyurethane Meniscal Implants after Meniscus Reconstruction using Ultrasonography.

Meniscal tears are among the most common indications for knee arthroscopy. Artificial polyurethane scaffolds have demonstrated efficacy in reducing pain and promoting the growth of normal meniscal tissue, with high absorption rates facilitating full tissue regeneration. This study aimed to evaluate the remodeling of polyurethane meniscal implants post-reconstruction using ultrasonography. This imaging technique not only assesses changes in implant properties, such as echogenicity, but also the shape changes during functional examination. The assessment of meniscal extrusion, comparing size at rest and under weight-bearing, is an indirect parameter that provides insight into the physical properties of the remodeling implant, with greater extrusion indicating reduced stiffness and inferior physical properties of the meniscus. Ultrasonography has the valuable advantage of allowing for assessment of the blood supply to the meniscus through Power Doppler imaging. The presence of vessels within the meniscal implants serves as evidence of ongoing remodeling. The study included 35 patients (13 female, 22 male; mean age 41.6 years, range 18-66) who underwent arthroscopic meniscal reconstruction with polyurethane implants, with an average time from surgery of 2.8 years (range 0.3-4.5 years). Results showed complete (29.7%), significant (45.9%), or moderate (16.2%) remodeling into natural meniscal tissue in 91.8% of the implants. The mean values of extrusion in the supine position and during 90-degree flexion were significantly greater in the operated limb (2.603) compared to the contralateral limb (1.978; t(35) = 2.442; P < 0.05). No significant differences in extrusion were found between the limbs in a standing position, indicating favorable physical properties of the polyurethane meniscal implants. Further ultrasonography studies of meniscal scaffolds are deemed relevant.

Participants with restricted dominant shoulder internal rotation range of motion demonstrate no side-to-side difference in humeral head translation; and no difference before and after joint mobilization: a pilot study.

[Purpose] To compare humeral head translation (HHT) during shoulder elevation between dominant and non-dominant shoulders in participants with limited dominant shoulder internal rotation range of motion (ROM). To determine if joint mobilization alters HHT, and if relationships exist between the bicipital forearm angle and HHT. [Participants and Methods] Fifteen (9 female) participants (age 25.7 ± 6.8 years) with a minimum 15-degree dominant shoulder internal rotation ROM deficit compared to the opposite shoulder participated. All participants underwent bicipital forearm angle (BFA) measurements and ultrasound imaging to measure acromiohumeral and posterior glenohumeral distances in 3 positions: Resting, 90 degrees of shoulder flexion, and 60 degrees of shoulder abduction with full external rotation. Ultrasound images were used to calculate HHT. Participants' dominant shoulders underwent posterior glide mobilization, followed immediately by repeated ultrasound images and ROM measures. [Results] There was no dominant to non-dominant shoulder, or before and after mobilization HHT differences. No correlations existed between bicipital forearm angles and HHT or ROM gains after mobilization. [Conclusion] Participants with internal rotation ROM loss demonstrated symmetrical HHT. Joint mobilization increased ROM, but HHT was unchanged. No relationships existed between BFA and HHT.

Design and Development of Portable Wrist Rehabilitation Device for Post-Stroke Subjects: A Pilot Study

Wrist mobility is vital for post-stroke patients to carry out their daily activities. The use of robotic devices in hand rehabilitation has increased significantly in recent years, allowing patients to get training at home and effectively compensating for the therapist-to-patient ratio. Nevertheless, rehabilitation devices are expensive, cumbersome, immobile, and difficult to wear and operate. This work proposes a new method for designing a wrist rehabilitation device that uses airbag technology to minimize device weight and size. A triangular prism-shaped Neoprene (synthetic rubber) airbag is utilized in the experiment; which is inflated and deflated using a DC motorized air pump. An accelerometer sensor serves as the control input for the wrist rehabilitation exercise device. The proposed device trains the impaired hand of ten hemiplegic post-stroke patients. A goniometer and Fugl-Meyer Assessment (FMA) are used to measure wrist motion before and after the training regimen to evaluate the results. The mean angle (in degree) of wrist flexion increases from 8.6 ± 2.59 to 18.4 ± 5.19 (p = 0.005). Likewise, an increase in the wrist extension angle from 12.3 ± 3.62 to 17.7 ± 6.2 (p = 0.008) is noted. The wrist rehabilitation device is lightweight, portable, and simple to use, producing good results for hemiplegic individuals with hand disability. The suggested invention enables the user to extend their wrist’s range of motion.

Osteochondral Fragment Fixation in Transient Patellar Dislocation of an Adolescent: A Case Report

Osteochondral Fractures (OCFs) of the patella are common in adolescents due to ligament laxity and weak osteochondral junctions. OCFs following patellar dislocation are particularly challenging in this age group. Magnetic Resonance Imaging (MRI) aids in comprehensive evaluation, and surgical fixation with bioabsorbable sutures is a reliable treatment option. Early intervention and proper rehabilitation are essential to ensure optimal outcomes and prevent long-term complications. The present case report details the presentation, diagnosis, surgical intervention and outcome of a 16-year-old male with an OCF following patellar dislocation. Examination revealed significant ligament laxity and patellar hypermobility, along with patella alta (Insall-Salvati ratio of 2.1) on the affected side. The neurovascular examination was normal. Initial X-rays showed no abnormalities; however, Computed Tomography (CT) and MRI scans revealed a displaced OCF fragment in the anterior intercondylar region, along with lateral patellar tilt, marrow contusion, chondral delamination and partial thickness tearing of the Medial Patellofemoral Ligament (MPFL). Surgical intervention involved open reduction and internal fixation using absorbable Vicryl sutures. Postoperatively, the patient was immobilised for six weeks, followed by a structured rehabilitation program. The patient achieved a full range of motion and restored knee function within six months, with satisfactory radiographic and functional outcomes. At the latest follow-up, the knee range of motion was from 0 degrees of extension to 130 degrees of flexion, with complete pain alleviation. OCFs of the patella in adolescents require timely diagnosis and intervention to prevent degenerative changes. MRI is essential for evaluating soft tissue injuries. Surgical fixation using bioabsorbable sutures provides effective treatment, offering strong fixation without the need for implant removal. Addressing associated injuries, such as MPFL tears, is crucial to prevent recurrent dislocation.

Severe rigid hip flexion-abduction contracture in cerebral palsy: a case report and review of the literature.

severe, rigid hip abduction deformity in individuals with cerebral palsy (CP) is an exceptionally uncommon condition. This posture hinders the positioning in the wheelchair and the completion of basic activities of daily living (ADL). Addressing such severe deformities can be quite challenging. a 14-year-old male, with spastic-dystonic quadriplegic CP, developed rigid and severe flexion-abduction contractures in both hips, characterized by 90 degrees of flexion and 100 degrees of abduction. These contractures severely impeded his ability to comfortably use a wheelchair and even pass through doorways. Performing basic ADLs became a significant challenge for both the patient and his caregivers. the treatment approach involved a two-stage surgical procedure, one for each hip, with a two-month interval between them. An extensive release of the fascia latae, gluteus maximus, external rotators, and hip flexors; in combination with a proximal femur osteotomy were performed. To maintain the corrections achieved, long-leg casts connected with two bars were employed, followed by orthotic support and physiotherapy. Following the procedure, lower limb adduction was achieved, and the patient and caregivers were highly satisfied, as ADLs and basic caregiving had been greatly facilitated. while the available literature on the management of severe rigid abduction hip contractures in non-ambulatory CP patients is limited, and treatment options are often complex, the present case underscores the effectiveness of a comprehensive approach involving soft tissue release and bone surgery. Achieving a more favorable wheelchair positioning and facilitating basic ADLs and care represents a significant success for patients and families.

Control of Tibial Advancement by the Plantar Flexors during the Stance Phase of Gait Depends on Knee Flexion with Respect to the Ground Reaction Force.

During the stance phase of a normal gait, the triceps surae muscle controls the advancement of the tibia, which contributes to knee extension. Plantar flexor weakness results in excessive dorsiflexion, and consequently, the knee loses this contribution. However, increasing knee flexion is also seen in patients with cerebral palsy who do not have plantar flexor weakness. We aimed to understand this mechanism through the use of a musculoskeletal dynamic model. The model consists of solid segments connected with rotatory joints and springs to represent individual muscles. It was positioned at different degrees of ankle plantarflexion, knee flexion, and hip flexion. The soleus muscle was activated concentrically to produce plantarflexion and push the foot against the ground. The resulting knee extension was analyzed. The principal determinant of knee flexion or extension associated with ankle plantarflexion was the position of the knee joint center. When this was anterior to the line of action of the ground reaction force (GRF), the soleus contraction resulted in increased knee flexion. The knee extension was obtained when the knee was flexed less than approximately 25°. The relation between joint angles, anthropometric parameters, and the position of the GRF was expressed in a mathematical formulation. The clinical relevance of this model is that it explains the failure of plantar flexor control on knee extension in patients with cerebral palsy, when increased knee flexion can occur even if there is a normal or plantarflexed foot position.

FUNCTIONAL OUTCOME OF INTRAARTICULAR DISTAL RADIUS FRACTURE TREATED WITH OPEN REDUCTION AND INTERNAL FIXATION WITH DORSAL PLATE

Background: Distal radius fractures are among the most common fractures and there is considerable disparity among surgeons regarding the best way to treat these patients. Intraarticular fractures are treated with open reduction and internal fixation with either dorsal or volar plates. Dorsal plating is not much popular due to its reported complications of extensor tendon irritation and rupture. We conducted this study to assess the functional outcome of dorsal plating in intraarticular distal radius fractures. Methods: A clinical prospective observational study was conducted at Kathmandu Medical College,Sinamangal. A total of 26 patients (male: 14; female: 12) of intraarticular distal radius fractures were enrolled and underwent open reduction and internal fixation using the dorsal plate. The functional outcome of dorsal plating was measured at 3 weeks,3 months and 6 months follow up. Results: All patients achieved a functional range of motion, with greater than 50 degrees of wrist flexion, 25 degrees of wrist extension, and 60 degree arc of pronation and supination. The functional outcome measured was found to be good to excellent with a mean Mayo Wrist score of 89.23(75-100) and Quick Dash-9 score of 9.20(2.75 to 22). There were 3 cases of extensor tendon irritation, which completely resolved and no cases of extensor tendon irritation at final follow up. Conclusions: Dorsal plating is a safe and effective way of treating intra articular distal radius fracture with good functional outcome.

MRI sequences at different degrees of flexion to investigate knee popping: an unusual way to diagnose an isolated pigmented villonodular synovitis lesion.

Knee popping is a frequent symptom among knee disorders which requires further investigation in case of a recent evolution of the symptom or pathological associated ones. This article reports a rare presentation of pigmented villonodular synovitis (PVNS), identified as the cause of knee popping symptoms, by performing MRI sequences at various degrees of knee flexion for a patient complaining from a gradual onset of knee popping, occurring when bending the knee over 120° of flexion. MRI sequences were performed just before the popping occurs (flexion 90°) and right after it had occurred (flexion 120°). The latter confirmed the origin of the symptom as the lesion moved forward, passing brutally through the interstice between the PCL and the ACL at 120° of flexion, explaining the popping. Treatment decision was to perform an arthroscopic resection of the lesion. Diagnosis of isolated PVNS was confirmed after anatomopathological analysis.

Reverse total shoulder arthroplasty for proximal humerus fractures: Primary or delayed after failed treatment?

BackgroundReverse total shoulder arthroplasty (RTSA) has recently become an option for the treatment of proximal humerus fractures (PHFs) or as a salvage procedure after failure of another treatment. The purpose of this study was to compare primary RTSA with delayed RTSA in the treatment of displaced PHFs. Study design & MethodsA retrospective cohort study was conducted on patients with PHFs who were treated between May 2013 and December 2021 with primary or delayed RTSA after failure of conservative treatment or osteosynthesis. Clinical data were withdrawn from our local computerized database. Complications, active range of motion, as well as the functional outcome were recorded at the end of the follow-up period. Differences between clinical outcomes were analyzed using a logistic regression analysis. ResultsA total of 70 individuals were included in this study (41 primary RTSA and 29 delayed RTSA). The mean of follow-up time was of 112 and 60 months, respectively. There were no differences between groups regarding fracture type according Neer Classification, ASA score or the presence of complications. Q-DASH and Oxford Shoulder scores were significantly better when patients underwent a primary RTSA (49.8 vs 31.4, p = 0.006 and 37.2 vs 27.5, p = 0.004 respectively). In addition, primary RTSA achieved more degrees of flexion and abduction than delayed RTSA (96.8 vs 72.9, p < 0.001 and 94.1 vs 69.3, p < 0.001 respectively). ConclusionPrimary RTSA for PHFs achieved better functional outcomes and a wider range of motion when compared with delayed RTSA. However, primary and delayed RTSA have similar complication and reintervention rates. Level of Clinical Evidence3

Anterior transposition of the radial nerve to achieve primary suture for its reconstruction: Anatomical feasibility study

IntroductionRadial nerve palsy after humeral shaft fractures is often associated with formation of a neuroma in continuity. The current standard of treatment is neuroma resection and nerve grafting with contentious results. Anterior transposition of the radial nerve may reduce the length of its path, allowing reconstruction by primary suture. The aim of this study was to determine the maximum length of radial nerve defect that can be treated by the anterior transposition to allow primary suture to be performed. MethodsWe use 10 arms from five fresh cadavers. The radial nerve was dissected in the lateral inter-muscular septum and along the anterior aspect of the forearm. The radial nerve was transected at the level of the spiral groove and both stumps were than transposed anterior to the medial inter-muscular septum. The length of tension-free overlap that could be achieved was measured. ResultsThe average length of the overlap at zero degrees of elbow flexion was 10.00 ± 1.84 mm. Theoretically, this will allow a defect of 20 ± 3.69 mm SD to be treated by primary suture. ConclusionOur results suggest that anterior transposition can be used for radial nerve defects up to 2 cm; however, dissection of both stumps proved to be challenging.

Lateral Subvastus Lateralis versus Medial Parapatellar Approach for Total Knee Arthroplasty: Patient Outcomes and Kinematics Analysis.

The conventional approach for total knee arthroplasty (TKA) is a medial parapatellar approach (MPA). We aimed to study patient outcomes and kinematics with a quadriceps sparing lateral subvastus lateralis approach (SLA). Patients with neutral/varus alignment undergoing primary TKA were consented to undergo the SLA. At 1-year postoperative, patients underwent radiostereometric analysis. Patients were administered the Short Form 12 (SF-12), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Knee Society Score (KSS). Kinematics and outcome data were compared to a group undergoing TKA via conventional MPA. Fourteen patients underwent TKA via SLA with a mean age 71.5 ± 8.0 and mean body mass index (BMI) 31.0 ± 4.5. The MPA group had 13 patients with mean age 63.4 ± 5.5 (p = 0.006) and mean BMI 31.2 ± 4.6 (p = 0.95). The SLA resulted in a significantly more posterior medial contact point at 0 (p = 0.011), 20 (p = 0.020), and 40 (p = 0.039) degrees of flexion. There was no significant difference in medial contact point from 60 to 120 degrees, lateral contact point at any degree of flexion, or axial rotation. There was no difference in improvement in postoperative WOMAC, SF-12, KSS function, and total KSS knee scores between groups. The MPA group had a significantly greater improvement in KSS knee scores at 3 months (p < 0.001), 1 year (p = 0.003), and 2 years (p = 0.017). The SLA resulted in increased medial femoral rollback early in flexion. Although both approaches resulted in improved postoperative outcomes, the MPA group showed significantly greater improvements in KSS knee scores at 3 months, 1 year, and 2 years. Further studies are required to identify any benefits that the SLA may offer. LEVEL OF EVIDENCE: Therapeutic Level II.

Finite element analysis comparing a PEEK posterior fixation device versus pedicle screws for lumbar fusion

BackgroundPedicle screw loosening and breakage are common causes of revision surgery after lumbar fusion. Thus, there remains a continued need for supplemental fixation options that offer immediate stability without the associated failure modes. This finite element analysis compared the biomechanical properties of a novel cortico-pedicular posterior fixation (CPPF) device with those of a conventional pedicle screw system (PSS).MethodsThe CPPF device is a polyetheretherketone strap providing circumferential cortical fixation for lumbar fusion procedures via an arcuate tunnel. Using a validated finite element model, we compared the stability and load transfer characteristics of CPPF to intact conditions under a 415 N follower load and PSS conditions under a 222 N preload. Depending on the instrumented levels, two different interbody devices were used: a lateral lumbar interbody device at L4–5 or an anterior lumbar interbody device at L5-S1. Primary outcomes included range of motion of the functional spinal units and anterior load transfer, defined as the total load through the disk and interbody device after functional motion and follower load application.ResultsAcross all combinations of interbody devices and lumbar levels evaluated, CPPF consistently demonstrated significant reductions in flexion (ranging from 90 to 98%), extension (ranging from 88 to 94%), lateral bending (ranging from 75 to 80%), and torsion (ranging from 77 to 86%) compared to the intact spine. Stability provided by the CPPF device was comparable to PSS in all simulations (range of motion within 0.5 degrees for flexion–extension, 0.6 degrees for lateral bending, and 0.5 degrees for torsion). The total anterior load transfer was higher with CPPF versus PSS, with differences across all tested conditions ranging from 128 to 258 N during flexion, 89–323 N during extension, 135–377 N during lateral bending, 95–258 N during torsion, and 82–250 N during standing.ConclusionUnder the modeled conditions, cortico-pedicular fixation for supplementing anterior or lateral interbody devices between L4 and S1 resulted in comparable stability based on range of motion measures and less anterior column stress shielding based on total anterior load transfer measures compared to PSS. Clinical studies are needed to confirm these finite element analysis findings.

Reverse shoulder arthroplasty in obstetric brachial plexus injury: our experience with shoulder motion analysis

BackgroundObstetric brachial plexus injury (OBPI) is a weakening or paralysis of the upper arm caused by brachial plexus injury followed by a muscle paralysis with severe repercussions on the movement of the shoulder joint following a progressive glenohumeral joint deformity.This case series analyzes the clinical and radiological outcomes of reverse total shoulder arthroplasty (RSA) in OBPI patients with a follow-up of 2 years.Materials and methodsOBPI patients with secondary end-stage glenohumeral arthritis were enrolled in the study and they were treated with RSA. Patient demographics and clinical outcomes [Range of Motion (ROM), Visual Analog Scale (VAS), Oxford Shoulder Score (OSS)] were evaluated. A novel Shoulder motion analysis was carried out to investigate specific movement patterns of scapulothoracic movements in these patients. This study is a prospective cohort study.ResultsFour Patients (M: F = 1:3) were enrolled in the study, the mean age was 49.3 years (+ 2.75), the mean OSS (Oxford Shoulder Score) decreased from 48.8 (± 2.5) preoperatively to 18.30 (± 2.78), the mean VAS (Visual Analog Scale) decreased from 7.25 (± 0.5) to 1.7 (± 0.3) in the follow up (∆% relative pain reduction:− 76.5%), Shoulder ROM obtained an improvement (p < 0.05) except for abduction and external rotation. The average follow-up time was 26.3 months (+− 4.5). Shoulder motion analysis showed a complete loss of the scapular tilting above 90 degrees of flexion compared to the typical one of standard RSA with a pattern shifted towards scapular retraction (engaging trapezius and rhomboid muscles) to compensate the loss of the posterior tilting.ConclusionsRSA in OBPI patients demonstrated a significant improvement of pain symptoms and a moderate improvement in daily activities, anyway with a more appreciable quality of life over time even if the marked hypotrophy especially of the posterior shoulder muscles showed some limits in maintaining suspension of the upper limb and a minor external rotation, with an internal rotation attitude during the movements.Level of evidence: Level IV, Case series.

DETERMINING THE SAFETY AND ACCESSIBILITY OF DIRECT POSTERIOR PORTALS INTO THE KNEE WITH RESPECT TO THE NEUROVASCULAR STRUCTURES: A CADAVERIC STUDY

The posterior compartments of the knee are currently accessed arthroscopically through anterior, posteromedial or posterolateral portals. A direct posterior portal to access the posterior compartments has been overlooked due to a perceived high-risk of injury to the popliteal neurovascular structures. Therefore, this study aimed to investigate the safety and accessibility of a direct posterior portal into the knee.This cross-sectional study comprised a sample of 95 formalin-embalmed cadaveric knees and 9 fresh-frozen knees. Cannulas were inserted into the knees, 16mm from the vertical plane between the medial epicondyle of the femur and medial condyle of the tibia and 8 and 14mm (females and males respectively) from the vertical plane connecting the lateral femoral epicondyle and lateral tibial condyle. Landmarks were identified in full extension and cannula insertion was completed with the formalin-embalmed knees in full extension and the fresh-frozen in 90-degree flexion. Posterior aspects of the knees were dissected from superficial to deep, to assess potential damage caused by cannula insertion. Incidence of neurovascular damage was 9.6% (n=10); 0.96% medial cannula and 8.7% lateral cannula. The medial cannula damaged one small saphenous vein (SSV) in a male specimen. The lateral cannula damaged one SSV, 7 common fibular nerves (CFN) and both CFN and lateral cutaneous sural nerve in one specimen. All incidences of damage occurred in formalin-embalmed knees. The posterior horns of the menisci were accessible in all specimens.A medial-lying direct posterior portal into the knee is safe in 99% of occurrences. The lateral-lying direct posterior portal is of high risk to the CFN.