Proximal Aspect Research Articles

Acute and stress fractures of the metatarsals in athletes

Metatarsal fractures sustained in sport can either be acute, or stress fractures. The aim of treatment of any fracture of the metatarsals in an athlete should be to achieve bony union, allow return to play quickly and at the same level as prior to the injury with few complications. In addition, further injuries should be prevented. Up to 9% of metatarsal fractures occur in sport. The majority of these involve the fifth metatarsal, particularly the proximal aspect of it. This location has a problematic blood supply and has a high rate of non-union. There is a wealth of information published about proximal fifth metatarsal fractures in the sporting population, with a consensus that surgical management provides the best outcomes. The second to fourth metatarsals are most likely to sustain stress fractures. These are likely to heal with non-operative treatment with good outcomes. Stress fractures of the fifth metatarsal are at high risk for fracture propagation, displacement and non-union so are best managed surgically. These injuries can be effectively prevented by improving bone health and biomechanics.

Rib fracture as a cause of hindlimb lameness in a horse

SummaryA 2‐year‐old racing Thoroughbred gelding in training was presented with moderate (6/10) right hindlimb lameness unresponsive to regional anaesthesia of the right hindlimb. Gamma scintigraphic examination revealed severe, focal, increased radio‐pharmaceutical uptake over the dorsal aspect of the right 18th rib, which had an abnormal contour. Ultrasonographic examination of this area confirmed the presence of a complete, displaced fracture of the proximal aspect of the right 18th rib. Local infiltration with anaesthetic solution around the right 18th right rib (10 mL cranial and 10 mL caudal to the fracture site) abolished the right hindlimb lameness. A diagnosis of rib fracture causing moderate ipsilateral hindlimb lameness was made. The horse returned to walking exercise after 12 weeks of rest and was reported to be sound on the same limb 12 months after presentation. Caudal rib fractures should be considered as a possible cause of hindlimb lameness. Local diagnostic anaesthesia around the fracture site can aid localisation of the origin of lameness.

A Novel Patellar Tendon Reconstruction Technique Using Semitendinosus Allograft

A Novel Patellar Tendon Reconstruction Technique Using Semitendinosus Allograft

Modified abaxial sesamoid nerve block provides enhanced proximal diffusion compared to basisesamoid block and lower proximal diffusion than traditional low plantar nerve block in equine hind limbs: ex vivo and in vivo study.

To determine the proximal diffusion distance of radiopaque contrast medium and mepivacaine/methylene blue solution and incidence of inadvertent intrasynovial and intravascular injections of modified sesamoid nerve block (MASB) when compared with traditional plantar nerve analgesia techniques of the equine distal hind limb. Ex vivo model: 18 hind limbs; and in vivo model: 5 horses in a crossover study. In the ex vivo model, a mepivacaine/methylene blue solution was used to compare the diffusion distance between MASB, basisesamoid block (BSB), and traditional low plantar block (TLPB). Ten minutes after injection, skin was dissected and proximal diffusion distance of the dye patch was measured. In the in vivo model, both hind limbs were injected with radiopaque contrast medium with either MASB or TLPB. Ten minutes after injection, a radiograph was acquired and the proximal diffusion of the contrast medium patch was measured. In the ex vivo model, solution proximal diffusion distance for MASB was significantly longer than BSB (P < .050) and significantly shorter than TLPB (P < .050). Both techniques reached the proximal aspect of DFTS similarly (P = .289), and no difference in the incidence of intrasynovial or intravascular injections was observed (P = .292). In the in vivo model, contrast medium proximal diffusion of MASB was significantly shorter than TLPB (P < .050). The proportion of injections that diffused subcutaneously to the proximal aspect of the proximal pouch of the DFTS was not significantly different between techniques (P = .136). No difference in the incidence of DFTS intrasynovial or intravascular injections was observed (P = .305). MASB presented significantly more proximal diffusion than BSB and less proximal diffusion than TLPB, consistently reached the proximal aspect of DFTS, and presented a very low risk of intrasynovial and intravascular injections.

Shear wave elastography demonstrates different material properties between the medial collateral ligament and anterolateral ligament

BackgroundAnterolateral ligament and medial collateral ligament injuries could happen concomitantly with anterior cruciate ligament ruptures. The anterolateral ligament is injured more often than the medial collateral ligament during concomitant anterior cruciate ligament ruptures although it offers less restraint to knee movement. Comparing the material properties of the medial collateral ligament and anterolateral ligament helps improve our understanding of their structure-function relationship and injury risk before the onset of injury. MethodsEight cadaveric lower extremity specimens were prepared and mechanically tested to failure in a laboratory setting using a hydraulic platform. Measurements of surface strains of superficial surface of each medial collateral ligament and anterolateral ligament specimen were found using three-dimensional digital image correlation. Ligament stiffness was found using ultrasound shear-wave elastography. t-tests were used to assess for significant differences in strain, stress, Young's modulus, and stiffness in the two ligaments. FindingsThe medial collateral ligament exhibited greater ultimate failure strain along its longitudinal axis (p = 0.03) and Young's modulus (p < 0.0018) than the anterolateral ligament. Conversely, the anterolateral ligament exhibited greater ultimate failure stress than the medial collateral ligament (p < 0.0001). Medial collateral ligament failure occurred mostly in the proximal aspect of the ligament, while most anterolateral ligament failure occurred in the distal or midsubstance aspect (P = 0.04). InterpretationDespite both being ligamentous structures, the medial collateral ligament and anterolateral ligament exhibited separate material properties during ultimate failure testing. The weaker material properties of the anterolateral ligament likely contribute to higher rates of concomitant injury with anterior cruciate ligament ruptures.

Machine learning as a feedback tool for the gestalt principle of proximity

When teaching students about the underlying structure of images, the Gestalt Principles are frequently used. Students and teachers may not always agree on the Gestalt Principles that an image contains, making assessment activities focusing on this topic very subjective. When working with large class sizes or when using multiple markers, this subjectivity becomes more problematic. A DBSCAN-based feature generation process and a multi-layer perceptron-based model are suggested in this study for categorising images as exhibiting the principle of proximity. When classifying images as containing aspects of proximity, the model displays a high level of accuracy. The model was integrated as a component of a larger process that alters the original input images to highlight areas that demonstrate proximity. The use of these annotated images can aid in giving students feedback. However, as the model was trained on a synthetic data set, its accuracy on real-world student submissions is yet to be tested.

Aortic Arch Debranching and Thoracic Endovascular Aortic Repair (TEVAR) for Type B Aortic Dissection

Since its introduction, thoracic endovascular aortic repair (TEVAR) has revolutionized the treatment of type B aortic dissections (TBADs). However, the proximal aspect of the aortic pathology treated may infringe on the origin of the left subclavian artery or even more proximally. Hence, to ensure durable outcomes, the origin of these vessels needs to be covered, but an extra-anatomical bypass is required to perfuse vital branches, known as aortic arch debranching. This series aims to describe and delineate the disparities of aortic arch debranching during TEVAR for TBAD. A retrospective review and analysis of a multicenter international database was conducted to identify patients with TBAD treated with TEVAR between 2005 and 2021. Data analyzed included patient demographics, disease characteristics, operative characteristics, and postoperative outcomes with follow-up on mortality and reintervention. All statistical analyses were carried out using IBM SPSS 26. Patient survival was calculated using a Kaplan-Meier survival analysis, and a P value of less than 0.05 was considered statistically significant. A total of 58 patients were included in the analysis, of which 27 (46.6%) presented with complicated disease and 31 were uncomplicated, of which 10 (17.2%) were classed as high risk and 21 (36.2%) low risk. Zone 2 was the most common proximal landing zone for the stent graft. Left subclavian artery bypass was performed selectively (26%), with 1 stroke occurring, likely due to embolic reasons. A further 6 underwent more proximal aortic debranching before TEVAR (10%) and was a significant risk factor for mortality and the number of stents deployed. The overall rates of reintervention and mortality were 17.2% (n=10) and 29.3% (n=17). Aortic arch debranching and TEVAR for TBAD is associated with significant mortality. Future developments to treat aortic arch pathology could incorporate branched graft devices, eliminating the need for debranching, improving stroke rates, and reducing future reinterventions.

Effects of high-profile crossover feet on gait biomechanics in 2 individuals with Syme amputation.

Prosthetic treatment options for people with ankle disarticulation (i.e., Syme amputation) are limited. Prosthetic feet designed for people with Syme amputation are often low profile to accommodate build-height restrictions, resulting in decreased energy return during gait. High-profile crossover feet that attach to the posterior proximal aspect of the prosthetic socket can bypass these restrictions and may promote a more physiologic gait pattern. To compare level-ground gait biomechanics and patient-reported outcomes between crossover and traditional energy-storing feet in people with Syme amputation. Within-participant pilot study. Both participants were fit with energy-storing and crossover feet and were randomized to the order they used the feet. Participants used each foot for 2 weeks before assessment. Step length symmetry, prosthetic ankle range of motion, prosthetic-side energy return, and peak sound-side loading were determined from motion capture data obtained in a laboratory. Mobility and balance confidence were measured using standardized patient-reported outcome measures. Foot preference was assessed with an ad hoc survey. Two participants with Syme amputations completed the study. Prosthetic ankle peak dorsiflexion and push-off power increased with the crossover foot compared with the energy-storing foot for both participants. Both participants reported an overall preference of the crossover foot. Changes in patient-reported outcomes did not exceed published minimum detectable change values. Crossover feet increased prosthetic ankle range of motion and energy return compared with traditional energy-storing feet in this pilot investigation of 2 participants. Crossover feet seem to promote physiologic gait and may be a promising alternative to traditional low-profile feet for people with Syme amputation.

Avoiding the posterior interosseous nerve during 2-incision distal biceps tendon repair: an anatomic study.

The posterior interosseous nerve (PIN) is the most commonly injured motor nerve during distal biceps tendon repair resulting in severe functional deficits. Anatomic studies of distal biceps tendon repairs have evaluated the proximity of the PIN to the anterior radial shaft in supination, but limited studies have evaluated the location of the PIN in relation to the radial tuberosity (RT), and none have examined its relation to the subcutaneous border of the ulna (SBU) with varying forearm rotation. This study evaluates the location of the PIN in relation to the RT and SBU to help guide surgeons in safe placement of the dorsal incision and the safest zones of dissection. The PIN was dissected from arcade of Frohse to 2 cm distal to the RT in 18 cadaver specimens. Four lines were drawn perpendicular to the radial shaft at the proximal, middle, and distal aspect of and 1 cm distal to the RT in the lateral view. Measurements were recorded with a digital caliper along these lines to quantify the distance between the SBU and RT to the PIN with the forearm in neutral, supination, and pronation with the elbow at 90° flexion. Measurements were also made along the length of the radius at the volar, middle, and dorsal surfaces at the distal aspect of the RT to assess its proximity to the PIN. Mean distances to the PIN were greater in pronation than supination and neutral. The PIN crossed the volar surface of the distal aspect of the RT -6.9±4.3 mm (-13, -3.0) in supination, -0.4±5.8 mm (-9.9, 2.5) in neutral, and 8.5±9.9 mm (-2.7, 13) in pronation. One centimeter distal to the RT, mean distance to the PIN was 0.54±4.3 mm (-4.5, 8.8) in supination, 8.5±3.1 mm (3.2, 14) in neutral, and 10±2.7 mm (4.9, 16) in pronation. In pronation, mean distances from the SBU to the PIN at points A, B, C, and D were 41.3±4.2, 38.1±4.4, 34.9±4.2, and 30.8±3.9 mm, respectively. PIN location is quite variable, and to avoid iatrogenic injury during 2-incision distal biceps tendon repair, we recommend placement of the dorsal incision no more than 25 mm anterior to the SBU and carrying out deep dissection proximally first to identify the RT before continuing the dissection distally to expose the tendon footprint. The PIN was at risk of injury along the volar surface at the distal aspect of the RT in 50% with neutral rotation and 17% with full pronation.

Heat Generation and Risk of Thermal Necrosis during Minimally Invasive Hallux Valgus Correction Utilizing a Shannon Burr: A Cadaveric Study

Category: Midfoot/Forefoot; Other Introduction/Purpose: Minimally invasive (MIS) bunion correction is growing in popularity as a treatment option of hallux valgus deformities. This technique has been shown to help with post-operative pain and improve functional outcomes. Despite these benefits there are concerns that the Shannon burr may lead to excess heat generation, thermal necrosis of bone and potentially increase the risk of nonunion. The purpose of our study was to assess the heat generation while using a Shannon burr during MIS first metatarsal osteotomies. Methods: Four below knee cadavers were utilized and osteotomies of the distal and proximal aspects of each of the first metatarsal were performed utilizing a 2mm x 20mm Shannon burr under fluoroscopic guidance. 3 K-type thermocouples were placed in each metatarsal, one distal, one in between and one proximal to the osteotomy sites. Temperatures were evaluated during the entire burring process and after to assess heat dissipation and total heat generated. Three different techniques of burring were utilized, 1. Continuous without irrigation, 2. Continuous with irrigation and 3. Pulse burring technique with irrigation (20 seconds on, 10 seconds off). Results: The pulse burring technique with irrigation showed the overall lowest max temperature and change in temperature compared to the other techniques. Average burr time, maximum heat generation and overall change in heat was 86.2 seconds, 102.4 °F and 78.9 °F for all trials. Conclusion: The pulse burr technique with irrigation generated less heat than both continuous burring with and without irrigation. There was an overall trend toward higher heat generation with longer burr times regardless of irrigation and burring technique. Utilizing a Shannon burr with pulse burring and irrigation can minimize heat generation and potentially decrease the risk of thermal necrosis of bone.

Comparison of the Passivity between CAD/CAM Implant Frameworks and Three Different Conventional Techniques Before and After Applying Veneering Porcelain

Background: The passivity of the fit may be at risk during the casting as well as the firing of the veneering ceramic. In this study, the comparison of the passivity between computer-aided design/computer-assisted manufacturing (CAD/CAM) implant frameworks and three different conventional techniques before and after applying veneering porcelain was investigated. Methods: In this laboratory cross-sectional study, four groups (n=6) of 3-unit screw-retained implant-supported denture prostheses (ISDPs) were fabricated on a master model with 2 implants. The study groups were as follows: conventional casting with Ni-Cr alloy (group 1), casting with Ni-Cr alloy followed by sectioning and soldering the samples (group 2), double casting with Ni-Cr framework (group 3), and using CAD/CAM-fabricated framework (group 4). All frameworks received porcelain veneer. The one-screw test was performed before and after veneering to measure the vertical misfit at the abutment-framework interface using a stereomicroscope. The mean vertical misfit values were determined at the buccal, lingual, and proximal aspects. The data were analyzed using the Kruskal-Wallis and post hoc tests (α=0.05). Results: The accuracy of the fit varied significantly before and after veneering among the study groups (P&lt;0.001). Frameworks prepared with CAD/CAM showed lower mean marginal misfit values compared to the other fabrication methods (P&lt;0.001). Conclusions: Firing the veneering porcelain attached to a screw-retained ISDP may have an adverse effect on the accuracy of the fit. Soft non-pre-sintered CAD/CAM frameworks had better passivity compared to other three conventional methods applied.

Fracture Resistance of Laboratory Composite Versus All-Ceramic Restorations in Class II Inlay Cavity Preparations: An In Vitro Study.

A posterior tooth's occlusal surfaces and the proximal surface can be restored by using an inlay, which is an intra-crown cast reconstruction without affecting the cusps of the tooth. When an inlay is prepared using an indirect approach, issues with traditional filling approaches, including poor morphology of the occlusal aspect or proximal aspect, inadequate resistance to wear, or subpar mechanical qualities of the directly inserted filler substance, are overcome. The current study was conducted in order to compare and assess the resistance to fracture of dental materials used in the preparation of inlay restorations indirectly, like composite restorations prepared by laboratories indirectly, inlays formed indirectly of monolithic translucent ceramic derived from zirconia, and inlays formed indirectly of traditional monolithic ceramic derived from zirconia. For the investigation, 100 human premolars of the maxilla that were extracted recently were chosen. A self-polymerizing acrylic resin was used to incorporate the tooth roots in a band made up of polyvinyl chloride up to 2 mm below the cement-enamel junction. The dimension of the band was 1.3 cm by 1.9 cm. Five categories of 20 specimens of such teeth were formed. Category one, featuring teeth in good condition, acted as the positive control category. The remaining four categories of teeth received inlay tooth preparation. The research samples underwent thermocycling after having been preserved for a full week following the cementation of inlay replacements. Then, in a universal testing apparatus, every sample endured axial compressive force with a metal globe delivered vertically at a crosshead rate of 1 mm/minute. The amount of force necessary to cause a fracture was measured in Newtons (N). The mean values of resistance against fracture in specimens in categories 1-5 were 1208.87 N, 614.89 N, 733.05 N, 1179.14 N, and 1148.49 N, respectively. The values of fracture resistance in specimens where an inlay cavity preparation was done but not filled were lower than those in traditional monolithic ceramic derived from zirconia and tooth specimens with inlays formed of monolithic translucent ceramic derived from zirconia, and the difference was significant statistically (p=0.001). The values of fracture resistance in composite inlay restorations prepared by laboratories were indirectly lower than those of monolithic ceramic derived from zirconia and tooth specimens with inlays formed of monolithic translucent ceramic derived from zirconia, and the difference was significant statistically (p=0.004). Within the constraints of the current investigation, we can state that indirect zirconia-based ceramic products offer adequate fracture resistance, but additional research is needed to determine how well these materials hold up under different types of pressures before employing them in clinical tooth restoration.

75 Intraoperative Use of Infrared Thermal Imaging Camera – a Clinical Aid for Pedicled Flaps in Hand Reconstruction

Abstract Introduction Venous insufficiency remains one of the commonest causes for flap failure. Forward-looking infrared (FLIR) thermography measures infrared emissions from dissipated heat and converts temperature values into an image. This has various advantages to the current use of indocyanine green (ICG) angiography to assess flap perfusion. Case A man in his mid-30s was involved in a road traffic accident and sustained extensive injuries to his right hand. These included multiple metacarpal fractures, degloving of the proximal aspect of the entire thumb and significant skin loss on the volar distal forearm. After several washouts and tissue debridement, a pedicled chest wall flap was performed. Five weeks later the chest wall flap was divided using an infrared thermal imaging camera (FLIR E5) intraoperatively as a clinical aid to assess perfusion. This detected a small area of venous congestion which was not detectable by clinical assessment. Discussion There are drawbacks to the current intraoperative use of ICG angiography to assess flap perfusion. These include hot flushes and skin rashes, and the technique requires an intraoperative injection, extensive equipment involving a screen and a specialised camera. In comparison FLIR cameras are handheld, easy to use and involves a one-off cost of purchasing the camera that is relatively inexpensive compared to ICG angiography. Conclusions Thermal imaging techniques such as FLIR provides an alternative intraoperative option for patients who are unable to have ICG, for centres that do not have access to ICG and for surgeons looking for more convenient alternatives.

Correlation between hand grip endurance and scapular muscle endurance in asymptomatic individuals

INTRODUCTION: Gripping activity is an essential daily activity at home and at the workplace, where lifting and holding loads with a relatively static grip using isometric contraction is often required. Muscle strength and endurance in the proximal aspect of the upper extremities influence hand function, and individuals with reduced strength and endurance are more prone to developing work-related musculoskeletal disorders. Good grip endurance might be influenced by the stabilization provided by shoulder muscles. This study aims to determine the correlation between hand grip endurance and scapula muscle endurance among young asymptomatic individuals. METHOD:The sample size for this study is n = 62, based on previous studies. Healthy individuals of both genders, aged between 18 and 25 years, were included. An objective assessment of grip endurance was performed using a hydraulic hand dynamometer, while scapular endurance was evaluated using the scapular muscle test. RESULTS: Data analysis was performed using SPSS version 20. There were significant positive correlations between scapular endurance measures and the hand grip endurance on both sides (Pearson correlation test, r = 0.612 (p &lt; 0.001) and r = 0.524 (p &lt; 0.001), respectively, for non-dominant and dominant hand grip endurance). FINAL CONSIDERATIONS: The preliminary findings of this study support the notion that scapular muscle endurance is related to hand grip endurance, suggesting that scapular endurance training may be an effective adjunct in the rehabilitation process for upper extremity functions.

A Weighting Method Based on the Improved Hesitation of Pythagorean Fuzzy Sets

The existing expert weight determination method for multi-attribute decision making based on the Pythagorean fuzzy number approach does not make sufficient use of the hesitation involved with the decision information, which may cause biased weight assignment. Therefore, to address the issue of unknown expert weights and attribute evaluation based on Pythagorean fuzzy numbers in multi-attribute group decision-making problems, a weight determination method is proposed that improves the treatment of hesitation in Pythagorean fuzzy sets. Firstly, the proximity of experts and similarity of the modified ones are determined according to the evaluation matrix. Then, the expert weights are integrated from the aspects of proximity and corrected similarity to obtain an assembled comprehensive evaluation matrix. Finally, the alternatives are ranked using the PF-TOPSIS method. The results of expert weight analysis and data verification demonstrate that the proposed method fully utilizes expert decision-making information, leading to a significant improvement in the rationality and accuracy of multi-attribute group decision-making problems.

Characteristics of CBCT versus panoramic signs of the surrounding bone of molar root protrusions into the maxillary sinus.

The study aimed to (a) investigate the amount and characteristics of the surrounding bone of protruded molar roots into the maxillary sinus using cone-beam computed tomography (CBCT) and (b) assess the correlation between the amount of bone with panoramic high-risk signs. Radiographs of 408 roots protruding beyond the sinus floor were evaluated. Axial CBCT images were used to investigate then classify eight characteristics of surrounding bone: no bone; bone < half the root girth in the proximal or buccal-palatal aspect; bone covering half the root girth in the proximal or buccal-palatal aspect; bone > half the root girth in the proximal or buccal-palatal aspect; and, complete bone. These were then grouped into four degrees of bone support: no bone; bone ≤ half the root girth; bone > half the root girth; and, complete bone. Panoramic signs were subclassified as: projection of root; interruption of the sinus floor; darkening of the root; upward curving of the sinus floor; absence of periodontal ligament space; and, absence of the lamina dura. Correlation between the degree of bone and the panoramic signs was evaluated using the Chi-square or Fisher's exact tests. Positive and negative predictive values, sensitivity, specificity, accuracy, and receiver operating characteristic analysis were calculated. Complete bone support was the most common. 'Projection of root' had a high negative predictive value and sensitivity. 'Absence of the periodontal ligament space and lamina dura' had a high positive predictive value, specificity, accuracy, and area under the curve. These two signs were significantly correlated with the degree of bone support.

Poster 190: Utilization of Distal Clavicle Bone Grafting in the Treatment of a Mobile Mesoacromion: Rationale and Technique

Objectives: The treatment of symptomatic unstable os acromiale can be fraught with challenges. It is estimated that between 3-5% of the population has an unfused mesoacromion, but only a small fraction of those shoulders develop a painful, mobile mesoacromion that requires treatment. The variety of concomitant shoulder pathology and overlapping symptoms can make diagnosis and treatment difficult. Furthermore, there remains no consensus for the optimal surgical treatment when conservative methods fail. Surgical options include fragment excision, acromioplasty, and open reduction internal fixation (ORIF) with or without bone grafting. A variety of arthroscopic and open techniques have been described with a large amount of heterogeneity in the literature making comparison of these techniques difficult. Biomechanical forces through the clavicle and acromioclavicular (AC) joint throughout shoulder range of motion have been described in the literature. These forces have theoretical implications on the relationship between the distal clavicle and mesoacromion. Shear, rotational, translational and compression forces imparted against the acromion, by the clavicle and the acromioclavicular ligaments, impart those same forces on the mesoacromial defect via the linkage of the AC joint. There are currently no studies describing the utility in using the distal clavicle as a bone graft source during ORIF of symptomatic mesoacromion. The cross sectional shape and surface area of the distal clavicle is remarkably similar to that of the acromial process. We describe a surgical technique utilizing the distal clavicle as a bone grafting source and present a case series of 8 patients with 100% union rate. Methods: A retrospective analysis was done on 8 patients from 2001-2016 who underwent open reduction internal fixation (ORIF) with distal clavicle bone grafting of a symptomatic, mobile mesoacromion by a single surgeon. The technique utilizes a saber type incision for exposure of the acromion, AC joint, and distal clavicle. Small splits in the anterior and posterior deltoid are utilized to palpate the anterior and posterior aspect of the acromion. Two parallel Kirschner wires (K wires) are placed from anterior to posterior through the acromion crossing the mesoacromion site. The proximal and distal aspects of the site are prepared and rasped. The distal clavicle is skeletonized and 9mm of distal clavicle is removed using a micro saw. The distal clavicle is sliced to 2-3 mm thickness creating a "wafer" of local bone graft. Two narrow slots are placed into the wafer using a small rongeur. These slots are spaced at the exact distance of the parallel K wires. The wafer of bone graft is then placed into the prepared mesoacromion defect and allowed to straddle the K wires via the slots. The acromion is then clamped from front to back using a bone clamp and cannulated screws are placed over the K-wires. Supplemental tension band fixation was used for the earlier portion of the senior author’s practice. Over the course of the technique, with the development of modern screws, the supplemental tension band was felt to be unnecessary. Soft tissues were closed in a standard fashion. Results: The median patient age was 52.5 (range, 41-59) with 75% male and 87.5% Caucasian. The median body mass index (BMI) was 29.4 (range, 23.9-39.2), 62.5% were non-smokers, 25% were type 2 diabetics, 37.5% had hypertension and 25% had no comorbidities. The patients who underwent this procedure with a median follow-up of 6 years (range 2-18). All procedures were done utilizing the distal clavicle bone graft technique described above with fixation reinforced by tension band in 6 of the 8 patients. Seven of 8 patients had concomitant shoulder pathology which included either partial or full rotator cuff tears (n=6), AC arthritis (n=4), glenohumeral (GH) arthritis (n=2) and biceps injury (n=2). Six of 8 patients underwent additional procedures during the index mesoacromion ORIF including rotator cuff repair (n=3), biceps tenodesis (n=4), and AC or GH debridement (n=5). One patient had an acute superficial postoperative infection successfully treated with irrigation and debridement. Otherwise, there were no complications related to the index procedure. Postoperatively all patients had symptomatic relief and went on to radiographic union of the mesoacromion. Conclusions: There remains a paucity of literature to help guide surgical treatment of symptomatic mesoacromion. Studies are largely limited to retrospective reviews and case series with various surgical techniques utilized. Therefore, the importance of relying on surgical experience and expert opinion cannot be overemphasized. This is the first study describing the use of the distal clavicle as bone graft for ORIF of the mesoacromion. Use of a distal clavicle bone graft obviates the need for a separate bone graft harvest site. Furthermore, it reduces abutment, translational and rotational forces on the mobile mesoacromion, maintains acromion length, and increases surface area for bony union. This evolved technique resulted in 100% union rate in our series of 8 patients with a median 6 year follow-up.

Proximal tibial aspect ratio and matching of tibial component in total knee arthroplasty: a narrative review

Proximal tibial aspect ratio (PTAR) is closely related to age, disease status and cutting parameters with considerable inter-individual variation independent of gender and race, nevertheless the aspect ratio of tibial components from different manufacturers remains relatively constant from smallest to largest size. As a result, component mismatching is an unavoidable dilemma during tibia preparation in total knee arthroplasty (TKA). Various prosthesis systems all can achieve more than 80% coverage on proximal tibia, whereas their optimal fit rates are generally not more than 50%. It is difficult for symmetrical components to avoid anteroposterior mismatch, internal malrotation tends to occur when maximum coverage is pursued on the resected surface with a medial dominant plateau or lower PTAR. Although it is easier to achieve a balance of rotation and coverage with anatomical components, significant anteromedial overhang tends to appear on the resected surface with a symmetrical or lateral dominant plateau. Further researches should focus on the law of inter-individual variability of proximal tibial morphology, the quantitative definition of "ideal matching" safety zone of key morphological parameters on different areas of proximal tibia and the methodology of realizing"ideal matching"in the majority patients with the least amount of component sizes. In addition, with the rapid development of additive manufacturing and digital orthopedic technology, individual customized implant is expected to become a breakthrough point in the field of TKA component fitting.

A Randomized Double-Blind Clinical Trial Evaluates the Efficacy of Alternative Herbal Mouthwashes.

The removal of dental plaque is the primary step in achieving good oral hygiene. Mechanical plaque removal measures have questionable efficacy in inaccessible areas and proximal aspects of the oral cavity. Out of the several types of mouthwash available, chlorhexidine (CHX) is regarded as the gold standard, but considering its adverse effects, herbal alternatives are being sought after. So, the aim of the study was to evaluate the efficacy of alternative herbal mouthwashes. In this randomized, double-blind study, 125 selected patients were divided into five groups. Group 1: negative control - distilled water (DW); group 2: positive control - hexidine mouthwash (ICPA, Gujarat, India); group 3: FeelFresh Herbal Mouthcare Gargle (Able Exports, Gujarat, India); group 4: HiOra mouthwash (Himalaya Wellness Company, Bengaluru, India); group 5: Colgate MaxFresh Fresh Tea mouthwash (Colgate-Palmolive, India). Plaque index (PI), gingival index (GI), and microbial count (CFU) were evaluated before and after the intervention. The difference among the three types of herbal mouthwash was statistically non-significant. The lowest PI, GI, and CFU values were obtained in the subjects of group 4. Herbal mouthwashes are a promising alternative and are effective in maintaining oral hygiene.

Proximal radiolucent lines around fully hydroxyapatite-coated tapered femoral stems: should we be concerned?

Radiolucent lines occasionally develop around the proximal aspect of fully hydroxyapatite (HA)-coated tapered femoral stems after total hip arthroplasty (THA). It was hypothesised that distal wedging of stems may predispose to proximal radiolucent line formation, which may negatively impact clinical outcome. All primary THA performed with a collarless fully HA-coated stem that had a minimum of 1 year of radiographic follow-up were identified in a surgical database (n = 244). Radiographic measures of proximal femoral morphology and femoral canal fill at the middle and distal thirds of the stem were analysed for association with the presence of proximal radiolucent lines. Linear regression was used to explore any association between radiolucent lines and patient reported outcome measures (PROMs), available in 61% of patients. Proximal radiolucent lines developed in 31 cases (12.7%) at final follow-up. Dorr A femoral morphology and increased canal-fill at the distal ⅓ of the stem correlated with the development of radiolucent lines (p < 0.001). No correlation was observed between pain or PROMs and the presence of proximal radiolucent lines. We observed an unexpectedly high incidence of proximal femoral radiolucent lines about collarless fully HA coated stems. Distal-only implant wedging in Dorr A bone may compromise proximal fixation. Although this finding did not correlate with short-term outcomes, the long-term clinical impact requires further study.