Mean Anterior Elevation Research Articles

Short-term clinical and radiographic outcomes with modular long stem for revision reverse total shoulder arthroplasty

BackgroundWhen performing reverse total shoulder arthroplasty with compromised proximal bone fixation, surgeons must consider using specialized stems with a distal press-fit design. In this study, the authors report on the clinical and radiographic outcomes of patients who underwent surgical management with modular diaphyseal press-fit stems. MethodsIn 2017-2021, patients who underwent revision reverse total shoulder arthroplasty reconstruction with diaphyseal press-fit stems (Aequalis Adjustable Stem [AS] or Aequalis Flex Revive Stem [RS]; Stryker, Kalamazoo, MI, USA) with minimum 1-year follow-up were identified. Patients with complex proximal humerus and scapula fractures, neurological injuries, and custom humeral replacements were excluded. Demographics and clinical follow-up data including range of motion, Visual Analog Scale (VAS), Simple Shoulder Test (SST), American Shoulder Elbow Surgeons (ASES) Score, and Single Assessment Numeric Evaluation were retrospectively reviewed. Postoperative radiographs were reviewed for aseptic humeral loosening, periprosthetic instability, stress shielding, periprosthetic fractures, and humeral stem failure. ResultsSixty-five patients (29 AS and 36 RS) had mean follow-up of 25 months (standard deviation ± 16). Mean anterior elevation improved from 57° ± 39 preoperative to 121° ± 31 postoperatively. Mean external rotation improved from 3° ± 17 to 34° ± 16. Mean internal rotation improved from 4° ± 13 to 35° ± 26. Mean VAS improved from 6.7 ± 2.2 to 2.9 ± 1.5. Mean SST improved from 13% ± 13% to 65% ± 22%. Mean ASES score improved from 19 ± 13 to 60 ± 18. Mean Single Assessment Numeric Evaluation improved from 25% ± 18% to 71% ± 17%. There were statistically significant differences in mean postoperative VAS (P = .0017), SST (P = .025), and ASES score (P = .0228) in favor of the RS group. There were no other notable differences between groups. The most common complications were aseptic humeral stem loosening (24% vs. 3%, P = .018) and periprosthetic instability (10% vs. 6%, P = .649) for the AS and RS cohorts, respectively. There was no statistically significant difference between surgical revision rates between the AS and RS cohorts (24% vs. 8%, respectively. P = .096). DiscussionDiaphyseal press-fit modular humeral stem can provide a viable surgical alternative in compromised proximal humeral bone. At short-term follow-up, the clinical and radiographic outcomes are comparable to other stem designs. Further studies are necessary to identify risks and causes of failure associated with modular diaphyseal press-fit stems.

Accelerated corneal collagen cross-linking in progressive keratoconus: Five-year results and predictors of visual and topographic outcomes.

To analyze the 5-year results of accelerated corneal collagen crosslinking (CXL) for progressive keratoconus and identify preoperative characteristics predictive of visual and topographic outcomes. A prospective interventional case series. Nineteen eyes of 19 patients receiving accelerated CXL with settings of 18 mW/cm2 for 5 min were included. Clinical and topographic parameters were assessed. Linear regression and logistic regression were used to compare the R2 and odds ratio (OR), respectively, between baseline characteristics and postoperative outcomes. Corrected distance visual acuity (CDVA) remained stable from 0.28 ± 0.21 to 0.25 ± 0.18 logMAR (P = 0.486). The mean cylindrical refraction was stable (P = 0.119). The maximal keratometry (Kmax) decreased from 61.99 ± 10.37 to 59.25 ± 7.75 D (P < 0.001), flattening in the flattest and steepest meridians and mean keratometry were also observed (P ≤ 0.040). The mean anterior elevation at the apex reduced from 21.42 ± 16.69 to 18.53 ± 12.74 μm (P = 0.013) and changes in posterior elevation were non-significant (P = 0.629). Preoperative Kmax best predicted the postoperative change in Kmax (R2 = 0.55, P < 0.001) compared to the other baseline characteristics (P ≤ 0.028), whereas preoperative CDVA was the only significant predictor of postoperative change in CDVA (R2 = 0.41, P = 0.003). Accelerated CXL is less likely to fail in eyes with a steeper preoperative Kmax (OR = 0.74, P = 0.040) or greater posterior elevation at the apex (OR = 0.91, P = 0.042). Kmax significantly decreased following accelerated CXL. Eyes with worse preoperative CDVA and higher Kmax were more likely to have an improvement in visual acuity and corneal flattening.

Epithelium-off corneal cross-linking in progressive keratoconus: 6- year outcomes

To evaluate the long-term results of corneal collagen cross-linking (CXL) with epithelium removal in patients with progressive keratoconus. This retrospective study included 27 eyes of 18 patients who underwent CXL surgery for progressive keratoconus between April 2009 and March 2012. Best-corrected visual acuity (BCVA), manifest refraction spherical equivalent (SE), maximum keratometry reading (K max), mean of the minimum and maximum keratometry readings (mean-K), central corneal thickness (CCT), and anterior and posterior elevation at the apex preoperatively and year 1, 3 and 6 were evaluated and compared. P values<0.05 were considered to be statistically significant. Mean BCVA was 0.35±0.28 logMAR preoperatively and 0.23±0.20 logMAR 6 years after the procedure (P=0.01). Mean SE decreased from -4.3±2.45 diopters (D) to -3.91±2.12 D (P=0.03). Mean K max decreased from 49.6±3.2 D to 48.6±2.8 D (P=0.04), and mean-K decreased from 47.6±2.5D to 46.9±2.6 D (P=0.04). CCT decreased insignificantly from 466.5±32.1μm to 465.4±26.6μm (P=0.65). Mean anterior elevation at the apex decreased from 12.8±7.9 to 12±8.3μm (P=0.04), and posterior elevation decreased from 27.1±17.4μm to 26.8±18.5μm (P=0.27). Mean-K, max-K, BCVA and CCT showed no change over the last 5 years. After the first year, no significant change was observed in BCVA, SE, max-K, mean-K and CCT, which were therefore considered stable. On the other hand, anterior and posterior elevation readings continued to decrease up to 6 years after CXL. Based on our 6-year results, CXL can halt progression of keratoconus and reduce the need for keratoplasty.

Comparison of Reverse Shoulder Arthroplasty and Hemiarthroplasty for Proximal Humeral Fractures: What about Functional Outcome? Reverse versus Hemiarthroplasty in Shoulder Fractures

Purpose: Shoulder replacement becomes more indicated in complex fractures of the humeral head. Indications depend on some factors especially age and fracture’s pattern. The aim of our study is to compare the functional results of both reverse shoulder arthroplasty (RSA) and hemi-arthroplasty (HA) in complex proximal humerus fractures. Materials and Methods: Fifty-two shoulder arthroplasties (20 reverse shoulder arthroplasties, 38 hemiarthroplasties), were reviewed retrospectively, between January 2010, and December, 2015. Preoperative, operative, and postoperative evaluations were achieved based on medical observations. At last follow-up, functional outcomes were established according Constant-Murley Score and American Shoulder and Elbow Surgeons (ASES) score. Complications rates were well-defined and compared between the study groups. Results: The mean of follow-up was 41.5 months. Comparing the study groups, reverse shoulder arthrosplasties were significantly older (mean age: 76.3 versus 66). These fractures occur more in women (70% versus 57%). At last follow-up, functional outcomes were better in reverse shoulder arthroplasty group (Constant-Murley Score 76 versus 59; ASES score 56 versus 41). The mean anterior elevation and external rotation were better in reverse shoulder arthroplasty respectively (110°versus 88°; 28° versus 19°). Revision was more required in hemiarthroplasty group than reverse shoulder arthroplasty group. Conclusion: Reverse shoulder arthroplasty seems to improve functional outcome at intermediate and long-term of follow-up of proximal complex humeral fractures on comparison to hemiarthroplasty.

Visual and Refractive Outcomes and Tomographic Changes after Femtosecond Laser-assisted Intrastromal Corneal Ring Segment Implantation in Patients with Keratoconus.

Purpose:To evaluate the visual, refractive, and tomography changes after femtosecond laser-assisted intrastromal corneal ring segment (ICRS; Intacs® SK) implantation in patients with keratoconus.Methods:In this prospective interventional case series, Intacs SK ICRSs were inserted using a femtosecond laser into eyes with stage I–IV keratoconus. Visual, refractive, and corneal tomography changes, along with surgical complications, were analyzed 1 week, 2 months, and 6 months postoperatively.Results:The study evaluated 71 eyes of 52 patients (mean age: 27.5 years). Six months postoperatively, the spherical equivalent, mean sphere, and mean cylinder were decreased by 2.07, 1.47, and 1.13 diopters (D), respectively. The mean preoperative uncorrected distance visual acuity (UDVA) increased from 0.87 ± 0.26 to 0.46 ± 0.19 LogMAR and the mean preoperative corrected distance visual acuity (CDVA) increased from 0.55 ± 0.21 to 0.28 ± 0.17 LogMAR (P < 0.001). Flat and steep keratometry decreased by a mean corneal power in the 3-mm zone, and mean anterior elevation decreased by 0.91 D, 2.52 D, and 1.03 microns (P < 0.001), respectively. Among all eyes, 93.0% gained one or more lines of CDVA. Mean internal anterior chamber depth decreased from 3.25 ± 0.33 to 3.14 ± 0.45 mm (P = 0.001), and mean irregularity in the 3-mm zone decreased from 5.63 ± 1.71 to 5.24 ± 1.82 (P = 0.006). However, mean posterior elevation and irregularity in the 5-mm zone did not change significantly.Conclusion:Implantation of one or two Intacs SK segments is safe and effective to treat keratoconus, leading to significant improvement in UDVA, CDVA, and refractive error.

Effect of dry eye on Scheimpflug imaging of the cornea and elevation data

ObjectiveTo evaluate the effect of dry eye on Scheimpflug imaging of the cornea and elevation data. DesignProspective observational study. ParticipantsScheimpflug images of 50 patients with dry eye who were being tested for eligibility for corneal refractive surgery were screened. Twelve eyes of 12 patients with abnormal Belin/Ambrosio enhanced ectasia display (BAD) anterior elevation difference were included in the study. The patients had no history of contact lens wear or any other sign of ectasia. MethodsPeak central corneal densitometry value, corneal volume, pachymetry at the thinnest point, and BAD anterior elevation difference value at the centre of the 9 mm zone were recorded before and after 4 weeks of dry eye treatment. Measurements were compared with the Wilcoxon signed rank test. ResultsThe mean corneal peak densitometry and volume were similar before and after therapy (p = 0.465 and p = 0.441, respectively). The mean anterior elevation difference value at the centre of the 9 mm zone before treatment (6.67 ± 1.72 µm) was significantly higher than the mean post-treatment value (4.00 ± 1.48 µm) (p = 0.002). The mean pachymetry at the thinnest location after treatment (548 ± 11.0) was significantly higher than the pretreatment value (538 ± 8.5) (p = 0.027). ConclusionsBAD anterior elevation differences and pachymetric measurements may be affected by ocular surface or tear film abnormalities associated with dry eye disease. Repeated evaluations after treatment may reveal normal results.

Reverse Shoulder Arthroplasty with a New Convertible Short Stem: Preliminary 2- to 4-year Follow-up Results

Background The Grammont-style reverse shoulder arthroplasty (RSA) has demonstrated complications intrinsic to its design such as tuberosity fracture and scapular notching. A new short-stem press-fit humeral component with an onlay tray has been devised to avert these issues. We hypothesize that the clinical outcomes and rates of humeral complications of this new stem will be comparable to those of the traditional Grammont design and the lateralization obtained from the stem’s lower neck-shaft angle will decrease the rate of notching without creating instability. Methods We retrospectively evaluated 100 patients who underwent RSA with an onlay short-stem humeral component with a minimum follow-up of 2 years. Clinical outcomes as well as standard radiological examinations were documented pre- and postoperatively. Several correlations were analyzed. Results At mean 32.6-month follow-up, the cohort demonstrated a significant improvement in several outcomes: Constant score increased from 25.5 to 69.7 points, mean anterior elevation increased from 82.1° to 141.9°, external rotation from 5.6° to 25.1°, and internal rotation from sacrum to the L3 vertebral level. There was a 30% rate of stem malalignment and 37% rate of scapular notching, not associated with any adverse clinical outcomes. The overall rate of complications was 15%, of which scapular fractures were most common (5%). Conclusion Our short-term results suggest that the clinical outcomes and rates of humeral complications are similar to those reported for the Grammont RSA, demonstrating less scapular notching, but increased scapular stress fractures and potential subsidence of the prosthesis due to the metaphyseal press-fit require further investigations.

Functional outcome after primary hemiarthroplasty in three or four part proximal humerus fracture: A short term followup.

Background:Several modalities of treatment are being used for the management of proximal humerus fractures. Primary hemiarthroplasty in proximal humerus fracture is indicated in three or four part fracture or fracture dislocations. It is also indicated if fracture involves a large area of articular cartilage loss and viability of head is doubtful. We studied the functional outcome of hemiarthroplasty in comminuted proximal humerus fracture.Materials and Methods:29 patients of three or four part proximal humerus fractures, (according to Neer's classification) who underwent primary shoulder hemiarthroplasty were included in this retrospective study. 20 patients were of more than 55 years of age. Functional evaluation based on Constant score and radiological assessment by periodic X-rays were done. All patients were operated in a ‘beach chair position’. The lesser and greater tuberosities were dissected with their tendinous attachments and were later reattached to the proximal humerus for stability of the prosthesis. Cemented prosthesis was used in all cases.Results:Three patients died and two patients were lost to followup during the course of the study, so 24 patients were finally included in the study. Mean Constant score was 56.62 (range 42.5-65.5) after mean followup of 18.28 months (range 12-24 months). Mean anterior elevation was 118.2° (range 75°-150°) and mean active abduction was 102°(range 50°-135°). Nineteen patients (79.16%) were satisfied about their functional outcome. Proximal migration of tuberosity was present in four patients. These patients had decreased abduction with impingement. One patient had higher placement of prosthesis and one patient had radiolucency at bone cement interface. There were no heterotopic ossification, dislocation, superficial, or deep infection.Conclusion:This study showed that hemiarthroplasty in a grossly comminuted proximal humerus fracture is a viable alternative to osteosynthesis. Tuberosity healing plays a main role in good range of motion and better functional outcome after shoulder hemiarthroplasty.

Corneal Changes in Childhood Glaucoma

To study the clinical features and topography of the cornea in eyes with childhood glaucoma. Cross-sectional, observational study. Fifty-eight eyes with childhood glaucoma and 28 eyes of age-matched controls. Clinical and topographic corneal changes were evaluated. Corneal topographic changes were evaluated on Orbscan (Orbscan Topography System II; Bausch & Lomb, Salt Lake City, UT) in eyes with childhood glaucoma and those changes were compared with the control eyes. Fifty-eight eyes with childhood glaucoma and 28 eyes of age-matched controls were evaluated. Thirty-six eyes (62.1%) were classified as having primary childhood glaucoma and 22 eyes (37.94%) as having childhood glaucoma with associated ocular anomalies. The corneas in 18 of 58 eyes (31.0%) with childhood glaucoma were clear, whereas 24.1% of eyes (14/58 eyes) had some corneal opacification. Haab's striae were noted in 44.8% of eyes (26/58 eyes) and were most frequently present between 3 and 5 mm from the optical axis. The mean posterior elevation recorded in eyes with childhood glaucoma controlled with medication or surgery was significantly higher than that in control eyes: 0.043 ± 0.027, 0.042 ± 0.017, and 0.018 ± 0.058 μm, respectively (P < 0.0001). The presence of Haab's striae was correlated significantly with a higher posterior elevation (P = 0.0396) and poor vision. The mean anterior elevation in eyes with childhood glaucoma (0.022 ± 0.015 μm) and in control eyes (0.015 ± 0.078 μm) was comparable (P = 0.08). Corneal astigmatism in eyes with childhood glaucoma was significantly higher and irregular compared with that in control eyes: 2.09 ± 1.40 versus 0.93 ± 0.60 diopter cylinder (P = 0.0001); the irregularity index was 2.8 (range, 1-18.1) and 2.3 (range, 0.6-2.3) at 3 mm (P = 0.0005) and 3.2 (range, 1.4-21.3) and 1.8 (range, 0.5-2.9) at 5 mm, respectively (P = 0.0003). Best-corrected visual acuity correlated significantly with cup-to-disc ratio, axial length, refractive error, astigmatism, and posterior corneal elevation. Multivariate analysis showed a significant correlation only with cup-to-disc ratio and axial length. Childhood glaucoma causes a significant increase in posterior corneal elevation and irregular astigmatism, which contribute to visual disability in such eyes.

Large metaphyseal volume hemiprostheses for complex fractures of the proximal humerus

Results of hemiarthroplasty after acute complex proximal humerus fractures are controversial. The main problem is the fixation and healing of the greater tuberosity (GT). To address this problem a hemiarthroplasty with a large metaphyseal volume was designed and introduced. Thirty hemiarthroplasties were implanted for acute, complex, proximal humeral fractures in30 consecutive patients (average age: 63.3years; range, 41-78). One patient was lost; 2 patients could only be interviewed telefonically. Two patients had to be revised because of secondary displacement of the GT within the first 2 postoperative years. The remaining 25 patients were assessed clinically, radiographically, and with computer tomography (CT) imaging after a mean of 25months (range, 24-29). Greater tuberosity healed in situ in 23 patients. In 12 cases, CT documented severe resorption of GT without displacement of a measurable bone fragment and an intact clinical cuff function with a radiographically preserved acromio-humeral distance. The mean Constant score was 59 points (range, 26-81), the mean relative Constant score 75% (range, 31-100). The mean anterior elevation was 117° (range, 45-160). The mean subjective shoulder value was 70% (range, 25-98). In 4 cases (14%), tuberosity dislocation occurred which was associated with an increase of fatty infiltration and poor result. The 2-year results with a large metaphyseal volume fracture-prosthesis showed good to excellent results, with a failure rate of 14%. Substantial resorption of the greater tuberosity was frequent, but was not associated with functional incompetence of the rotator cuff. The overall results obtained justify its continued use.

Corneal Collagen Cross-linking with Riboflavin and Ultraviolet A Irradiation for Keratoconus: Long-term Results

To evaluate the long-term results of corneal collagen cross-linking (CXL) in patients with progressive keratoconus. Prospective case series. This study was conducted on 40 eyes of 32 patients with progressive keratoconus between 2006 and 2012. Patients underwent CXL no later than 1 month after baseline examinations. For CXL, ultraviolet irradiation was applied for 30 minutes, during which riboflavin instillation was repeated every 3 minutes. Patients were tested for best-corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), manifest refraction spherical equivalent (MRSE), and Scheimpflug imaging from which we extracted maximum keratometry reading (max-K), average of minimum and maximum keratometry readings (mean-K), central corneal thickness (CCT), and anterior and posterior elevation at the apex at baseline, at 1, 3, 6 months after CXL, and 1, 2, 4, and 5 years later. We studied results at 5 years after CXL as well as the trend of changes over the 5-year period. Mean UCVA was 0.67 ± 0.52 logarithm of the minimum angle of resolution (logMAR) at baseline and 0.65 ± 0.51 logMAR at 5 years after the procedure. For mean BCVA, these values were 0.31 ± 0.28 and 0.19 ± 0.20 logMAR, respectively (P = 0.016). The mean MRSE changed from -3.18±2.23 diopters (D) to -2.77 ± 2.18 D, and mean refractive cylinder error changed from -3.14 ± 2.22 to -2.49 ± 1.71 D (P = 0.089). Mean max-K and mean-K decreased by 0.16 ± 2.20 and 0.10 ± 1.69 D, respectively. The CCT increased from 483.87 ± 29.07 to 485.95 ± 28.43 μm. Mean anterior elevation at the apex changed from 13.9 2 ± 8.28 to 11.45 ± 8.18 μm (P = 0.030) and posterior elevation at this point changed from 29.54 ± 18.39 to 26.34 ± 19.59 μm. The mean-K, max-K, UCVA, and astigmatism showed no change over time during these 5 years. After the first year, BCVA, MRSE, and CCT showed no change and stabilized, whereas elevation readings continued to decrease up to 5 years after CXL. Based on our 5-year results, treatment of progressive keratoconus with CXL can stop disease progression, without raising any concern for safety, and can eliminate the need for keratoplasty. The authors have no proprietary or commercial interest in any of the materials discussed in this article.

3-D Characterization of the Corneal Shape in Fuchs Dystrophy and Pseudophakic Keratopathy

To characterize the 3-D corneal shape deformation incurred by Fuchs corneal dystrophy and pseudophakic bullous keratopathy by using the integrated analysis of Orbscan (Bausch & Lomb Surgical, Rochester, NY) topographic maps of affected and normal corneas. One hundred thirty-seven patients with Fuchs dystrophy or pseudophakic keratopathy were divided into three groups according to the severity of the disease: mild (central corneal thickness [CCT], 500-710 μm; n = 46); moderate (710-775 μm; n = 45), and severe (775-1100 μm; n = 46). A control group included 411 normal subjects matched for age and refractive spherical equivalent (three control subjects for each subject with Fuchs or pseudophakic keratopathy). The four groups were compared by using 3-D corneal shape atlases illustrating mean anterior elevation, posterior elevation, and pachymetry. Whereas the atlases showed little anterior surface deformation, the posterior surface presented a significant central bulging toward the anterior chamber. The thinnest point was displaced away from the center, toward the superior nasal midperiphery. The corneal periphery remained relatively unaffected by the disease, except in the final stage. 3-D atlases provided detailed new information on the 3-D corneal shape deformation incurred by Fuchs corneal dystrophy throughout disease progression.

Tomographic Normal Values for Corneal Elevation and Pachymetry in a Hyperopic Population

Purpose: To establish a normative data base with respect to corneal pachymetry and elevation tomography appropriate for refractive surgery screening of hyperopic individuals. Methods: 100 eyes of 51 consecutive hyperopic patients were examined with the Oculus Pentacam HR to determine corneal pachymetry and anterior and posterior elevation values at the apex and thinnest point. All patients were otherwise screened as normal and all principal meridians were hyperopic. Results were compared to a previously studied data base of myopic individuals from the same practice. Results: The average corneal thickness at the apex and thinnest point was not significantly different between the hyperopic and myopic groups (P>0.05 at both locations). The mean anterior elevation at the apex was0.4 ± 1.9 µm in the hyperopic group vs. 1.6 ± 1.3 µm in the myopic group (P<0.001). The mean anterior elevation at the thinnest point was-0.1 ± 2.2 µm in the hyperopic group vs. 1.7 ± 2.0 µm in the myopic group (P<0.001). The mean posterior elevation at the apex was5.7 ± 3.6 µm in the hyperopic group vs. 0.8 ± 3.0 µm in the myopic group (P<0.001). The mean posterior elevation at the thinnest point was10.6 ± 5.7 µm for the hyperopic group vs. 3.6 ± 4.1 µm for the myopic group (P<0.001). When adjusted for age, the posterior elevation changes remained statistically significant. Conclusions: Hyperopic individuals exhibited greater variation in posterior tomographic elevation values than a comparable myopic group. Currently used data bases need to be adjusted for screening hyperopic individuals to reduce the number of false positives associated with using a myopic biased data set.

Effect of posterior offset humeral components on range of motion in reverse shoulder arthroplasty

The purpose of this study was to evaluate the effect of eccentric humeral components with different degrees of posterior offset on range of glenohumeral motion in reverse shoulder arthroplasty. Uncemented PROMOS® reverse shoulder prostheses were implanted in eight human cadaveric shoulder specimens. Passive range of motion was evaluated with a robot-assisted shoulder simulator. Three movements were tested: abduction, anterior elevation and external rotation. Each specimen was tested with a customary reverse humeral component and two eccentric components with 3 and 6 mm of posterior offset respectively. Mean abduction was 81° (standard deviation [SD] 12) for the customary reverse components, 81° (SD 13) for the 3 mm eccentric and 82° (SD 15) for 6-mm eccentric implants. Mean anterior elevation was 68° (SD 13) in the regular group and 66° (SD 14) and 63° (SD 14) for 3- and 6-mm eccentric groups. With all configurations, 90° of external rotation were achieved without requiring more than 2 N·m of applied rotational moment. Although there was no statistically significant difference between the conventional and the eccentric implants, anterior elevation was decreased by almost 20° in three of eight shoulders with the posterior offset configurations. This was due to a conflict between the proximal humerus and the anterior aspect of the acromion or the coracoid. Although eccentric humeral components can be useful in reverse shoulder arthroplasty to avoid anterior cortical defects in individuals with pronounced humeral head posterior offset, a potential conflict between proximal humerus and scapula may have an unfavourable effect on range of anterior elevation. However, this observation is only true for the uncemented PROMOS® reverse prosthesis. Other reverse shoulder designs with posterior offset components are yet to be tested.

Anterior Segment Measurements Using Pentacam and Orbscan II 1 to 5 Years After Refractive Surgery

To compare anterior segment measurements between Pentacam and Orbscan II after laser surface ablation. Corneal thickness, anterior elevation, posterior elevation, and anterior chamber depth more than 1 year after laser refractive surgery were measured using Pentacam and Orbscan II in 51 eyes that underwent laser epithelial keratomileusis (LASEK) and 21 eyes that underwent photorefractive keratectomy (PRK). As controls, the same comparisons were made in 52 unoperated eyes. Mean follow-up was 28.2 months in the LASEK group and 49.9 months in the PRK group. Mean corneal thickness using Pentacam was thicker than that using Orbscan by 10.4 microm in unoperated eyes, 22.6 microm in LASEK eyes, and 11.0 microm in PRK eyes, but the two devices showed good correlation in all groups. Mean anterior elevation was highly correlated between the two devices with 2.1-microm differences in LASEK eyes, but posterior elevation showed no correlation with significant discrepancies. Mean anterior chamber depth was 0.12-to 0.14-microm thicker with Pentacam than with Orbscan, and highly correlated in all groups. Pentacam and Orbscan showed good correlations in corneal thickness, anterior elevation, and anterior chamber depth despite some differences in mean values. The two devices, however, showed no correlation in posterior elevation measurements, a difference that was greater in the postoperative groups.

Fraturas em duas e três partes do úmero proximal tratadas com sutura não absorvível

OBJETIVO: Avaliar os resultados clínicos e radiográficos dos pacientes com fraturas em duas e três partes da extremidade proximal do úmero tratados por sutura não absorvível, com incorporação do manguito rotador, o que permite aumentar a estabilidade da fixação, principalmente em pacientes com pobre qualidade óssea. MÉTODOS: Dezenove pacientes foram operados, sendo 15 do sexo feminino e quatro do masculino, com média de idade de 57,4 anos (23-79 anos) e seguimento médio de 53,4 meses (sete a 144 meses). De acordo com a classificação de Neer, havia 10 fraturas em três partes (colo cirúrgico e tubérculo maior) e nove fraturas em duas partes (duas do tubérculo maior e sete do colo cirúrgico). Todos foram operados na posição " cadeira de praia" , com anestesia endotraqueal e bloqueio do plexo braquial. O acesso deltopeitoral foi utilizado para fraturas em duas partes do colo cirúrgico e fraturas em três partes. Para fraturas em duas partes do tubérculo maior, foi utilizado acesso transacromial. As fraturas foram reduzidas e fixadas com sutura não absorvível nº 5. O ângulo cervicodiafisário foi medido para avaliação da consolidação viciosa. RESULTADOS: Verificou-se consolidação óssea em 95% dos pacientes. A média da elevação anterior nos pacientes com fratura em duas partes foi de 163,3° (90°-180°); a rotação externa média, de 56° (30° a 90°); e a rotação interna média, de T10 (S1-T5). Nos pacientes com fratura em três partes, a média de elevação anterior foi de 163° (100°-180°); a rotação externa média, de 52,5° (5°-70°) e a rotação interna média, de T10 (L4-T7). A força de abdução foi igual à do lado contralateral em 12 pacientes e menor em sete. O tempo necessário para o paciente retornar às atividades anteriores foi, em média, de 5,19 meses (dois a 12 meses). Na avaliação radiológica, o ângulo cervicodiafisário médio foi de 141° (110°-170°) nas fraturas em duas partes e de 150° (106°-210°) nas fraturas em três partes, sendo verificada consolidação em valgo em nove pacientes (59%) e, em varo, em dois pacientes. De acordo com o escore da UCLA, verificaram-se 88,8% de bons e excelentes resultados e 11,2% de maus resultados, para ambos os tipos de fratura. Os últimos, representados por um caso de pseudartrose e outro, por uma capsulite adesiva no pós-operatório. CONCLUSÃO: As fraturas em duas e três partes do úmero proximal podem ser satisfatoriamente tratadas com sutura não absorvível com incorporação do manguito rotador, particularmente nos idosos. Complicações relacionadas aos metais estão afastadas. Pacientes com fraturas do tubérculo maior tratados com suturas podem ter resultados similares aos daqueles com fraturas do colo cirúrgico. Embora o objetivo da cirurgia seja a reconstrução anatômica, alguma deformidade residual não impede resultado satisfatório. O método é pouco invasivo, permite estabilidade razoável dos fragmentos, com altos índices de consolidação óssea e satisfação do paciente. A cooperação do paciente é crucial para o sucesso terapêutico.

Role of Orbscan II in screening keratoconus suspects before refractive corneal surgery

Objective To evaluate the relationship between videokeratographic keratoconus screening programs and Orbscan II topography. Design Prospective, observational case series and instrument validation study. Participants Sixty consecutive eyes with suspicious videokeratography (TMS-1, Tomey Technology, Waltham, MA) were evaluated before undergoing laser in situ keratomileusis (LASIK) surgery. A control group of 50 consecutive eyes without suspicious features by videokeratography was also evaluated. Methods Keratoconus screening programs, using the Rabinowitz and Klyce/Maeda methods and Orbscan II (Bausch & Lomb, Claremont, CA) topographies were performed on these patients. Main outcome measures Specific parameters evaluated on the Orbscan II topographies were anterior elevation, posterior elevation, and thinnest pachymetry. Results Compared with a control group of patients without suspicious videokeratography, there was a statistically significant difference in the mean posterior elevation and mean anterior elevation in the groups with positive keratoconus testing with the Rabinowitz or Klyce/Maeda methods. For patients who met both the Rabinowitz and Klyce/Maeda criteria for keratoconus, the mean posterior elevation was 44 ± 2.5 μm compared with a posterior elevation of 21 ± 0.6 μm for the control group. There was no statistically significant difference in the mean thinnest pachymetry between the control group and all keratoconus suspect groups. Conclusions Patients with positive keratoconus screening tests have higher anterior and posterior elevation on Orbscan II topography. When used in combination with videokeratography, the Orbscan II topography system may be helpful in identifying patients who are potentially at high risk for developing ectasia after LASIK.