Unstable Joint Research Articles

Vascularized Bone Flaps for Salvage Ankle Fusion

Objective: The ankle is a critical load-bearing joint for the lower extremity that is prone to damage from a variety of causes. Achieving stable bony fixation is paramount to restoring function after ankle injury. Initial attempts at fixation with hardware may fail, or large bone deficits may make primary fixation impossible. Vascularized bone grafts can be used to create stable and functional reconstruction of the ankle. Methods: We reviewed our experience using vascularized bone flaps to achieve bony ankle fusion in patients with unstable ankle joints. We then developed indications for whether the use of pedicled flaps versus free tissue transfer will best accomplish successful fusion. Results: At our institution, a single surgeon has performed 6 cases of vascularized bone grafts for ankle fusion. Three of these were pedicled fibula flaps and three were free fibula flaps. One of the free fibula flaps had persistent non-union and was salvaged with a medial femoral condyle free flap to achieve bony fusion. All patients had improved pain and were able to bear weight on the ankle joint post-operatively. Pedicled fibula flaps can be used when there is avascular necrosis of the talus or distal tibia, non-union after ankle fusion, failed total ankle replacement, or for large bony defects. Free fibula flaps are required when there is non-union of the distal fibula, if there is need for tibiotalocalcaneal fusion, and therefore need to extend the fibula to the calcaneus, or if the lateral malleolus has been already taken down during prior ankle fusion. Conclusion: Ankle reconstruction presents a challenging problem, but vascularized bone grafts can provide stable and functional results for patients. Using the indications we have developed for the use of pedicled flaps versus free tissue transfers can help other surgeons tackle these difficult cases. Corresponding Author: Gretchen Stieg MD, Department of Plastic & Reconstructive Surgery Detroit Medical Center/Wayne State University, 4160 John R, Suite 400, Detroit, MI 48201, Email: [email protected], Phone: (407) 252-0909

Radiofrequency Ablation for the Management of Pain of Spinal Origin in Orthopedics.

Radiofrequency (RF) is a minimally invasive procedure for interrupting or modifying nociceptive pathways to manage musculoskeletal neuropathic and nociplastic pain. RF has been used to manage cervical and lumbar facet joint syndromes. The benefits of RF are the following: it is safer than surgery; it doesn´t need general anesthesia, by that means diminishing the complications; it causes pain alleviation for a minimum of 3-4 months; it can be repeated if needed; it improves joint function; and it minimizes the necessity for oral pain treatment. RF must not be used in pregnant women; unstable joints, uncontrolled diabetes mellitus; and presence of an implanted defibrillator. Even though complications from RF are rare, possible adverse events are infection, hemorrhage, numbness or dysesthesia, greater pain in the procedure area, and differentiation impact. Even though there is a peril of injuring non-targeted neural tissue and other tissues, this can be lessened by carrying out the procedure with the help of fluoroscopy, ultrasonography or computed tomography. RF seems to be a helpful procedure for relieving chronic pain syndromes; despite this, definite proof of the procedure's effectiveness is still needed. RF is an encouraging procedure for treating chronic spinal pain, especially when other procedures are pointless or not feasible.

SURGICAL TREATMENT OF ACROMIOCLAVICULAR DISLOCATION: HOOK PLATE VERSUS SUTURE BUTTON.

We aimed to compare the functional and radiographical outcomes of reconstruction of acute unstable acromioclavicular joint (ACJ) dislocation using Hook Plate (HP) versus Suture Endobutton (SE) fixation techniques. Forty-six consecutive patients with grade III to V ACJ dislocation according to Rockwood classification who underwent either HP or SE fixation in the period between January 2017 and June 2020 were evaluated. The treatment modalities were divided into either HP or SE fixation. The radiological assessment included standard anterior-posterior (AP) views to evaluate coracoclavicular (CC) distances for vertical reduction. CC distances were grouped as preoperative (CC1), early postoperative (CC2), and late postoperative (CC3). The distance variance between CC2 and CC3 was referred as ΔCC (CC3 - CC2). A statistically significant difference was found in ΔCC between the two groups (p=0.008). ΔCC was significantly higher in the SE group compared to the HP group (p<0.05). The Constant and UCLA Scores of patients in the SE group were found to be significantly higher than in the HP group patients. Clinical outcomes were more satisfactory in patients with acute unstable ACJ dislocation who underwent SE compared to HP procedures, at the end of the first year. Evidence Level IV; Case Series.

Distal Radioulnar Joint: Normal Anatomy, Imaging of Common Disorders, and Injury Classification.

The distal radioulnar joint (DRUJ) is the distal articulation between the radius and ulna, acting as a major weight-bearing joint at the wrist and distributing forces across the forearm bones. The articulating surfaces are the radial sigmoid notch and ulnar head, while the ulnar fovea serves as a critical attachment site for multiple capsuloligamentous structures. The DRUJ is an inherently unstable joint, relying heavily on intrinsic and extrinsic soft-tissue stabilizers. The triangular fibrocartilage complex (TFCC) is the chief stabilizer, composed of the central disk, distal radioulnar ligaments, ulnocarpal ligaments, extensor carpi ulnaris tendon subsheath, and ulnomeniscal homologue. TFCC lesions are traditionally classified into traumatic or degenerative on the basis of the Palmer classification. The novel Atzei classification is promising, correlating clinical, radiologic, and arthroscopic findings while providing a therapeutic algorithm. The interosseous membrane and pronator quadratus are extrinsic stabilizers that offer a minor contribution to the joint's stability in conjunction with the joints of the wrist and elbow. Traumatic and overuse or degenerative disorders are the most common causes of DRUJ dysfunction, although inflammatory and developmental abnormalities also occur. Radiography and CT are used to evaluate the integrity of the osseous constituents and joint alignment. US is a useful screening tool for synovitis in the setting of TFCC tears and offers dynamic capabilities for detecting tendon instability. MRI allows simultaneous osseous and soft-tissue evaluation and is not operator dependent. Arthrographic CT or MRI provides a more detailed assessment of the TFCC, which aids in treatment and surgical decision making. The authors review the pertinent anatomy and imaging considerations and illustrate common disorders affecting the DRUJ. Online supplemental material is available for this article. © RSNA, 2022.

Ausgesuchte Verletzungen bei Kindern und ­Adoleszenten: Klinische Aspekte und Therapieansätze für Sportärzte

Children and adolescents are in a complex biological balance where their bodies are constantly changing and exposed to various forces. Hormonal changes during growth, especially during puberty, influence the growth and development of bones and muscles. Increased joint laxity in children can lead to unstable joints more prone to injuries. Injuries in children and adolescents often involve growth plates, apophyses, ligaments, and the meniscus. Accurate diagnosis and appropriate treatment are crucial to avoid potential complications and ensure the long-term health of young patients.

Arthrozheal®, a Bioactive Fibrin Scaffold for Joint Cartilage, Tendon and Soft Tissue Lesions. Latest Results and Application Perspectives.

Treatment of articular cartilage, tendon and soft tissue damage remains a challenge for the practicing orthopaedic surgeon. Due to the multifactorial aetiology of these lesions, there is a narrow therapeutic window within which they can be treated successfully, thus preventing progression to other musculoskeletal tissues. Recently, a new material that combines platelet-rich fibrin with collagen and is applied as a gel scaffold (ArthroZheal®, Vivostat A/S, Allerød, Denmark) has been shown to provide unique results in these patients. We arthroscopically treated 210 patients (114 knees, 32 hips, 52 shoulders, 12 ankle joints) with ArthroZheal®. The basic idea was to adjust treatment to the individual patient and to repair related and/or contributing problems before or along with treatment of chondral/tendon/ligament injuries. Arthroscopy was our preferred surgical method; the goal was to restore and preserve function, alleviate pain and minimise progression to osteoarthritis. We excluded cases of inflammatory arthropathy, unstable or malaligned joint, "kissing lesions" (bipolar), infection, obesity, massive rotator cuff rupture and multiligament instability. Our results were more than promising. We observed improved mobility in 93%, reduced pain in 95% at 3 months and further improvement at 6 months, with near-normal ROM (97% ) and pain-free status (98%). The MRI at 12 months post application showed cartilage restoration/reformation in 94% of patients, improved cartilage quality (84% )-by 2nd-look arthroscopic confirmationand normal tendon or ligament reconstruction (without stitching of the affected area)(95%). We were concerned about bone marrow oedema and rehab compliance among elderly patients. For successful regeneration of tissue lesions and osteochondral defects, natural gel bioscaffolds, combined with platelet rich fibrin (PRF) with chondroinductive and osteoinductive growth factor stimulators (ArthroZheal®) are required. There is no "gold standard" in the treatment of cartilage defect/tissue lesions or preferred treatment option. Many algorithms are used, which mostly rely on the surface area of the defect/site of lesion and on surgeon experience. An important issue is that rehabilitation depends on the treatment mode used and on the defect/lesion characteristics (classification and qualification). While a return to functional work and sports is possible with all procedures, different lengths of time are needed.

Clinical and radiologic outcomes of the modified phemister procedure with coracoclavicular ligament augmentation using mersilene tape versus hook plate fixation for acute acromioclavicular joint dislocation

BackgroundThe clinical superiority of surgical treatment for acromioclavicular (AC) joint dislocation remains controversial. The aim of this study was to compare the clinical and radiological outcomes of the modified Phemister procedure with CC ligament augmentation using Mersilene tape to those of hook plate fixation for acute AC joint dislocation.MethodsIn this study, patients who received modified Phemister surgery with CC ligament augmentation using Mersilene tape (PM group) or hook plate fixation (HK group) for acute unstable AC joint dislocation with a minimum 5-year follow-up period were retrospectively reviewed. The clinical outcomes were evaluated according to blood loss during surgery, surgical duration, visual analogue scale (VAS), Constant-Murley score (CMS), University of California at Los Angeles (UCLA) shoulder rating scale, and the occurrence of complications. Radiological outcomes were assessed from radiographs according to multiple parameters, including CC distance maintenance, acromion osteolysis, and the presence of distal clavicle osteolysis.ResultsA total of 35 patients completed follow-up for more than 5 years and were analyzed in this study (mean = 74.08 months). There were 18 patients in the PM group and 17 in the HK group. The PM group exhibited similar improvement in functional outcome to the HK group. Regarding radiological outcomes, the HK group had a superior performance in terms of CC distance maintenance, of statistical significance (CCDR: 94.29 ± 7.01% versus 111.00 ± 7.69%, p < 0.001) after a one-year follow-up period. However, there were 4 cases of acromion osteolysis and 2 cases of distal clavicle osteolysis in the HK group.ConclusionHook plate fixation was found to be superior to the modified Phemister technique with CC ligament augmentation using Mersilene tape in terms of CC distance maintenance, but there was no significant difference in the functional outcome after 5 years of follow-up. Both surgical methods are reliable options for the treatment of acute AC joint dislocation. Modified Phemister surgery with CC ligament augmentation using Mersilene tape is a relatively lower-cost option for acute AC joint dislocation without the need of a second surgery for implant removal.

Acute Traumatic Isolated Subluxation of Trapeziometacarpal Joint: Case Report-Literature Review

Trapeziometacarpal joint (TMCJ) of the thumb is an unstable joint anatomically and depends on the integrity and normal functionality of the ligaments to prevent dislocation. Dislocation or subluxation of trapezio-metacarpal joint generally appears more often as injuries accompanied with intraarticular fracture of base of first metacarpal or trapezium. Isolated dorsolateral subluxation of trapeziometacarpal joint appears more often with osteoarthritis of the joint rather than as traumatic lesion and is an unstable injury because ligaments of the joint present some degree of impairment. Suspicions to diagnose the injury and precocious therapeutic management avoid complications which lead to impairment of hand function quality. Therapeutic procedures for TMCJ dislocation is controversial in literature. The aim of this study is to present a case of a 28 year-old man, who after a direct impact with a heavy object (hummer) over the base of the thumb, presented in the emergency department with an anterolateral subluxation of trapeziometacarpal joint and based on this case, to recall the modalities of the adequate treatment of the respective injury in literature.

Pedobarography — monitoring method of functional restoration of unstable ankle joint injuries

The pedobarography method makes it possible to objectify the dynamics of restoring the functional capacity of an injured limb. The value of the method is gaining popularity in determining the functional results of surgical treatment of the patients with ankle joint injuries. The details of pedobarographic monitoring during the treatment allow to obtain digital indices, which with careful statistical analysis can significantly improve not only the diagnostic process, but also control the process of functional recovery of the patients with injuries of the lower extremities. Changes in quantitative digital static and dynamic indices of pedobarography mean progress in the functional restoration of the injured limb or the need in the correction of the rehabilitation process. However, there is a problem in the interpretation and specification of the known indices and indices in accordance with the pathology. A review of the scientific publications based on the Scopus, Web of Science and The Cochrane Library databases is designed to analyze the possibilities of using the pedobarography method in the diagnosis of ankle joint injuries, tibial bone fractures, which in accordance with quantitative indices make 20-28 % of all fractures of human bones. The kinematic features of the human body in normal and pathological conditions should be carefully analyzed and practically used in the monitoring process of the recovery of walking during the rehabilitation period in the patients with ankle joint fractures and not only. Control and detection of the deviations of pedobarographic indices should be analyzed in details with the aim of early detection of an unresolved problem before the appearance of clinical signs of chronic instability. The literature search proves that the analysis of the entire range of static and dynamic indices of pedobarography of damaged and healthy limbs during the period of postoperative recovery of walking makes it possible to evaluate the effectiveness of rehabilitation measures aimed at functional restoration of unstable injuries of the ankle joint.

Open reduction and internal fixation of Ideberg type IA glenoid fractures: Tricks, pearls, and potential pitfalls based on a retrospective cohort of 33 patients focusing on the rehabilitation protocol.

The standard treatment of anterior glenaoid fractures carrying > 20% of the glenoid fossa is open reduction and internal fixation (ORIF). In the herein study, we report our outcomes in a retrospective cohort of anterior and anteroinferior glenoid rim fractures using an accelerated postoperative rehabilitation protocol. A secondary aim is to describe the surgical steps for ORIF of anterior and anteroinferior glenoid rim fractures using the anterior axillary approach, describing the tricks, pearls, and pitfalls of this surgical technique. A retrospective cohort of skeletally mature patients treated for an anterior glenoid rim fracture carrying > 20% of the glenoid fossa during a 10-year period were operated on using a vertical axillary incision, osteosynthesis with 2.0-mm cortical screws, and labral repair with small diameter metallic anchors and non-absorbable sutures. Rehabilitation began on the first postoperative day, including passive external rotation exercises and active-assisted flexion, adduction, and abduction exercises as tolerated. The exercises are performed with the patient sitting or lying down. Phase 1 is continued for 6-10weeks until the patient regains painless, normal, or near-normal ROM. Usually by 10weeks, the fracture and labrum are healed, so phase 2 rehabilitation begins with strengthening and ROM exercises. Radiologic and clinical outcomes, including active range of motion (ROM), glenohumeral stability, and visual analogue scale (VAS) were measured. About 33 patients (35 fractures) had complete medical records and pre- and post-operative imaging exams available for further analysis regarding the surgical protocol, with a mean of 4.8years. The mean DASH questionnaire was 3.75 ± 9.0 and the mean CM score was 62.5 ± 0.1. Active flexion and internal rotation were recovered in all patients, while external rotation presented an average loss of 8° (p = 0.12) and abduction of 5° (p = 0.33). The mean VAS was 1.1 ± 0.8. No patient reported major or disabling symptoms, or great difficulty or inability to perform daily or recreational activities. No patient presented residual instability of the glenohumeral joint. In this retrospective cohort, ORIF using a vertical axillary incision, osteosynthesis with 2.0-mm screws, and labral repair with small diameter metallic anchors and non-absorbable sutures was a safe approach, with a minimal risk of complications and residual instability. The accelerated postoperative rehabilitation protocol, allowing immediate passive external rotation of the operated shoulder, resulted in a non-significant loss of ROM compared to the contralateral side. Therefore, we recommend this management strategy for anterior glenoid rim fractures in patients with unstable shoulder joint after traumatic glenohumeral dislocation. Therapeutic Study (Surgical technique and Retrospective cohort).

Analysis of X-ray parameters of the acetabulum in patients with cerebral palsy

BACKGROUND: Among the orthopedic consequences of cerebral palsy, instability of the hip joints is one of the most common. Most children with cerebral palsy at birth have close to normal relationships in their hip joints that gradually deteriorates. Progressive instability of the hip joint leads to subluxation and then dislocation of the hip, to a decrease in the range of motion in the joints, to movement disorders and a defect in the ability to sit, as well as an impairment in hygienic care of the child.&#x0D; AIM: To analyze the X-ray anatomical structure of the acetabulum in unstable hip joint in children with cerebral palsy.&#x0D; MATERIALS AND METHODS: We examined 42 hip joints in 23 patients with cerebral palsy. Participants were divided into two groups. The main group included the results of the examination of unstable hip joints (31 studies), and the control group included the results of the examination of stable joints (11 studies).&#x0D; RESULTS: The average index of anteversion of the acetabulum in the main group with a functioning Y-shaped cartilage was 2.5 more than the average value of the norm (p = 0.029), with a nonfunctioning Y-shaped cartilage at 6 less than the normal value (p = 0.017). There was a positive moderate correlation between the anteversion of the acetabulum and the anterior margin angle (r = 0.424, p = 0.017), and a positive moderate correlation between the acetabular index and the anterior margin angle (r = 0.398, p = 0.027).&#x0D; CONCLUSIONS: The study showed that changes in the acetabulum in patients with pathological dislocation or subluxation of the hip against the background of spastic cerebral palsy were manifested by deformation in the horizontal plane due to retroversion of the acetabulum.

Mid-term to Long-term Follow-up Results of Reconstruction for Thumb Radial Polydactyly.

Preaxial or radial polydactyly is one of the most common hand congenital anomalies in newborns. Contemporary reconstruction methods include ligament reconstruction, excision of the polydactylous thumb, osteotomy, and other surgical techniques according to the type of polydactyly. The purpose of this study was to report mid-term to long-term reconstruction results for thumb (radial) polydactyly. We retrospectively reviewed the medical records of patients who underwent reconstruction surgery for preaxial polydactyly. Clinical outcomes, including the range of motion (ROM), pain, and complications, were evaluated. We assessed the final radiographs of the reconstructed thumb to identify the potential development of arthritis or other remaining deformities. After excluding cases without a simple radiograph and cases with a short follow-up period of fewer than 5 years, 26 thumbs were included. The surgical technique followed including excision of polydactylout thumb was tailored to the type of polydactyly. If the nail size of the thumbs was similar, the Bilhaut-Cloquet method was preferred. The mean age of the patients at the surgery and final follow-up was 14.9 months (range: 8 to 30mo) and 11.9 years (range: 5.8 to 19.3y), respectively. The mean follow-up was 128.8 months years (range: 60 to 219mo), and the mean ROM of the thumb was 32.7 and 57.5 degrees in the distal interphalangeal joint (DIP) and metacarpophalangeal (MP) joint, respectively. Ulnar or radial side instability was prominent in 7 patients in the involved joints (26.9%). One patient underwent interphalangeal (IP) fusion for extension lag with pain. The radiologic evaluation revealed that 2 patients developed radiographic evidence of IP joint arthritis (7.7%). Radial deviation of the MP or IP joint existed in 13 cases (range: 5 to 40 degrees) (50.0%), and ulnar deviation of the MP or IP joint existed in 2 cases (range: 19 to 20 degrees) (7.7%). In mid-term to long-term experience, sequelae such as joint instability, joint stiffness, and remaining deformity cannot be neglected. An unstable MP joint may result if the DIP joint remains stiff or has a lower ROM. Level IV-therapeutic studies.

Magnetic Resonance Imaging (MRI) Based Diagnosis of Anterior Cruciate Ligament (ACL) TEARS in Patients with Internal Derangements of Knee

Objective: To assess the role of magnetic resonance imaging (MRI) in diagnosing anterior cruciate ligament (ACL) tears in patients with knee internal derangements.&#x0D; Study Design: Prospective longitudinal study.&#x0D; Place and Duration of Study: Department of Radiology, Combined Military Hospital, Kharian Pakistan, from Sep 2019 Aug 2020.&#x0D; Methodology: 40 patients of any age and gender were part of the study with painful or unstable knee joints. A clinical examination was performed after recording demographic data. In addition, MRI was performed, and primary and secondary signs were noted for each case.&#x0D; Results: The range of patients was 15 to 63, with a mean age of 36.3 ± 12.62 years. Most of the patients were male (n=29; 72.5%), whereas only 11 (27.5%) were females. In total, 27 (67.5%) complete and 13 (32.5%) partial Anterior cruciate ligament (ACL) tears were present. Blumensaat’s angle&gt; 15 degree was present in 10 (37.03%) complete tear cases and 2 (15.38 %) partial tear cases. Anterior tibial displacement was evident in 4 (14.81%) complete tear cases and 3 (23.07 %) partial tear cases. Posterior cruciate line (PCL) angle was apparent in 21 (77.77%) complete tear cases and 12 (92.30 %) partial tear cases.&#x0D; Conclusion: The use of MRI is advocated for diagnosing Anterior cruciate ligament (ACL) tears in patients with knee internal derangements.

Prevalence and Risk Factors of Surgical Treatment for Klippel-Feil Syndrome.

BackgroundRecently, there have been some reports on surgical treatment for Klippel–Feil syndrome, but the prevalence and risk factors of surgery have not been well evaluated. This study sought to find the prevalence and potential risk factors of surgical treatment.MethodsA retrospective radiographic review of 718 Klippel–Feil syndrome patients seen at Peking University Third Hospital from January 2010 to October 2017 was performed. Parameters included age, gender, deformity, cervical instability, Samartzis classification, and surgical treatment. Based on the surgical treatment they received, patients were divided into a surgery group and a non-surgery group. Prevalence and possible risk factors of surgical treatment were assessed.ResultsA total of 718 Klippel–Feil syndrome patients, including 327 men and 391 women, with an average age of 46.8 years were enrolled. According to the Samartzis classification scheme, 621 cases (86.5%) were classified as type I, 48 cases (6.7%) were classified as type II, and 49 cases (6.8%) were classified as type III, respectively. The most commonly fused segments were C2–3 (54.9%) and C5–6 (9.3%). Of all 718 patients, 133 (18.5%) patients underwent surgical treatment, mainly via the posterior approach (69.9%). The clinical factors included age, gender, deformity, instability, and Samartzis classification. Men were more likely to require surgical treatment (p < 0.001). Patients with instability (p < 0.001) or patients with deformity (p = 0.004) were also more likely to undergo surgery. All three of these variables were included in the binary regression analysis. Finally, gender (p < 0.001) and unstable joints (p < 0.001) were identified to be independently associated with surgical treatment. Gender was the most important risk factor with men being 2.39 times more likely to have surgical treatment, while patients with instability were 2.31 times more likely to receive surgery.ConclusionThe prevalence of patients with Klippel–Feil syndrome requiring surgery was 18.5%, with the majority undergoing posterior cervical surgery. Gender and instability were indemnified as independent risk factors leading to surgical treatment.

Evaluation of Safety and Efficacy of Traction, Closed Reduction, and Subsequent Hip Fixation in Hilgenreiner Brace in Patients with Severe Forms of Hip Developmental Dysplasia.

Background Hilgenreiner brace (Hb) was developed to improve hip reduction rate and reduce the incidence of femoral head avascular necrosis (AVN). In children under the age of 18 months with unstable hip joints or a dislocated hip joint, the treatment method involves nonsurgical treatment in most cases. Objectives To evaluate the effectiveness and safety of traction, closed reduction, and hip fixation in Hb in patients with severe forms of hip developmental dysplasia (DDH) in follow-up. Materials and Methods Prospective, clinical, cohort observation and retrospective matched-pair analysis. Analysis of medical records was conducted to evaluate the effectiveness of using Hb for treatment of dislocated hip joints in <18-month-old children. The investigated cases were of the dislocated hip joint since DDH was confirmed through clinical and imaging diagnosis and treated by the application of the close reduction method together with Hb, in a nonhuman position (hip joint in 90 degrees of flexion and 80 degrees of abduction). Analysis was carried out using the modified Berkeley's Mckay criteria and hip joint centralization, and evaluation was done using X-ray images according to the basic modified Severin classification system. Results The use of Hb applied after overhead traction to (mean 22.8 days, confidence level (95%)) 68 hip joints showed a significant improvement (92%) in the treated hips. In summary, only one brace replacement was performed due to swelling of the thigh and fixation pressure, three cases suffered from hip joint redislocation after removing the Hb (5%), and one patient had bilateral avascular necrosis (2.8%). Conclusions The use of Hb reduced avascular necrosis of the femur head, maintained higher hygiene conditions, and lowered both the risk of cast breakage and skin complications over the use of hip spica as compared to Hb. Hb is more cost-effective, and radiolucency is an additional advantage for this technique. Closed reduction and application of Hb after oral administration of a bolus dose of chlorpromazine chloride or phenobarbital resulted in complication avoidance of total anaesthesia.

Kinematic and Radiographic Evaluation of Acromioclavicular Reconstruction with a Synthetic Ligament.

Purpose The optimal surgical technique for unstable acromioclavicular (AC) and coracoclavicular (CC) joint injuries has not yet been established. The biomechanical and radiographic effect of the LockDown device, a synthetic ligament for AC joint reconstruction, was evaluated to assess the optimal surgical technique for unstable AC and CC joint injuries. It was hypothesized that the LockDown device would restore AC joint kinematics and radiographic stability to near native values. Methods Three fresh frozen cadaveric torsos (6 shoulders) modelled CC joint motion in their “native,” “severed,” and “reconstructed” states. The effects of stressed and unstressed native, severed, and reconstructed conditions on AC separation and CC distances in anteroposterior, mediolateral, and inferosuperior directions during shoulder abduction, flexion, and scaption were assessed. The analysis of variance (p, 0.05) was used to compare CC distance and peak AC distance in anteroposterior, mediolateral, and inferosuperior directions during shoulder flexion, abduction, and scaption measurements among native, severed, and reconstructed states with unstressed and stressed Zanca radiographic views. Results From radiographic analyses, the CC distance was significantly greater (p=0.001) across the surgical state in stressed versus unstressed views. Mean difference between stressed and unstressed views was 1.8 mm in native state, 4.1 mm in severed state, and 0.9 mm in reconstructed state. The CC distance was significantly greater in the “severed” state (10.4 mm unstressed; 14.5 mm stressed) compared to the “native” state (p=0.016) (6.5 mm unstressed; 8.3 mm stressed) and compared to the “reconstructed” state (p=0.005) (3.1 mm unstressed; 4.0 mm stressed) and significantly less (p=0.008) in the “reconstructed” state compared to the “native” state. CC distances decreased from native to reconstructed, an average of 3.3 mm for unstressed and 4.3 mm for stressed. On average, peak AC joint separation distance in anteroposterior, mediolateral, and inferosuperior directions during shoulder-abduction, flexion, and scaption was shown to be restored to 11.5 mm of native values after reconstruction with LockDown device. Conclusion Reconstruction of AC joint with LockDown synthetic ligament restores motion of clavicle and acromion to near native values, thereby decreasing scapular dyskinesis and enhancing AC joint stability.

Superiorly and transversely orienting the bicortical suspension device provides optimal anterolateral stability to the proximal tibiofibular joint: a finite-element study.

Instability of the proximal tibiofibular joint (PTFJ) can be treated with bicortical suspension (BCS) fixation. However, the ideal location, orientation, and configuration to apply one or two BCS devices are not clear. A finite-element model of the PTFJ was created from a female adult's CT dataset. Anterior and posterior ligaments at the PTFJ were modeled and suppressed to simulate stable and unstable joints. Fifty-six models simulated 56 device placements along guiding tunnel lines that connect eight entry locations on the fibular head to seven exit points on the anteromedial tibia. Doubling device stiffness created 56 more models. Combing any two placements created 1176 double-device configurations which were categorized to be crossed, divergent or parallel. Displacement of the fibular head relative to the fixed tibia under 100N anterolateral and posteromedial forces was assessed. Different placements had 2.1-27.9mm translation with 0.7-8.9° internal rotation under anterolateral loading, and 1.8-5.2mm translation with 6.1-7.9° external rotation under posteromedial loading. More transverse and superior orientations were associated with smaller anterolateral translation; more posterior and superior entry locations were associated with smaller internal rotation. The median (IQR) reductions in anterolateral translation by doubling device stiffness and by adding a second device were 0.8 (IQR 0.5-1.0) and 0.8 (IQR 0-6.1) mm, respectively. The type of double-device configurations had no significant effect on fibular motion. Surgeons should drill the guiding tunnel superiorly and transversely to ensure the optimal restoration of the PTFJ anterolateral stability.

Primary traumatic shoulder dislocation associated with rotator cuff tear in the elderly.

Introduction and importanceThe shoulder is one of the most unstable joints of the body. Shoulder dislocation accounts for up to 60% of all major joint dislocations. This study reports two cases of primary traumatic shoulder dislocation and shows that in the elderly, primary traumatic shoulder dislocation is associated with a rotator cuff tear (RCT).Case presentationA case report and narrative review included two female patients, aged 63 and 100 years. Presenting symptoms were instability, pain, and restricted shoulder movement. Both were successfully treated by surgery. Arthroscopy was performed in the first patient and open reduction in the second patient.Clinical discussionIn the first case, we found synovitis around the rotator interval, long head of the biceps tendinitis, and tears of the subscapularis tendon, supraspinatus tendon, and subacromial bursitis. The anterior labrum was normal. In the second case, complete detachment of the infraspinatus tendon was found. In both cases, rotator cuff repair was performed. Primary traumatic shoulder dislocation in the elderly is often associated with rotator cuff injury. Therefore, a detailed evaluation and management of the rotator cuff injury is essential. Rotator cuff injuries cause loss of dynamic stabilization of the shoulder, leading to recurrent shoulder dislocation and chronic shoulder instability.ConclusionThe associated pathology of the primary traumatic shoulder dislocation in elderly are rotator cuff tear. The management of the rotator cuff tear in primary traumatic shoulder dislocation can prevent further shoulder instability events.

Sliding Corrosion Fatigue of Metallic Joint Implants: A Comparative Study of CoCrMo and Ti6Al4V in Simulated Synovial Environments

Mechanical contact in a corrosive synovial environment leads to progressive surface damage at the modular interface of the joint implants. The wear debris and corrosion products degrade the synovial fluids and change the lubrication mechanisms at the joints. Consequently, the unstable joint lubrication and corrosion products will further induce the undesirable performance of the joint implants. In this study, the two major joint materials, CoCrMo and Ti6Al4V, were tested during the course of reciprocal sliding contact in simulated synovial liquids. Open circuit potential and coefficient of friction were monitored to describe electrochemical and mechanical responses. Potentiostatic test results illustrated electrochemical damage on both surfaces that modified oxidation chemistry on both surfaces. However, more significant modification of the CoCrMo surface was detected during wear in the simulated joint liquid. Even with a reduced coefficient of friction on the CoCrMo surface in sodium lactate environments, fretting current density drastically increased in corrosive sodium lactate with pH 2. However, the test results from the Ti6Al4V surface presented less coefficient of friction values, and moderate change in fretting current. Therefore, the experimental study concluded that the biocompatibility of Ti6Al4V is superior to that of CoCrMo in the combined effect of mechanical loadings and an electrochemical environment.

Comparison of 3 Dynamic External Fixation Devices for Proximal Interphalangeal Joint Dorsal Fracture-Dislocations in a Cadaver Model

Several improvised dynamic external fixation devices are used for treating unstable dorsal proximal interphalangeal (PIP) joint fracture-dislocations. We compared the effectiveness of 3 constructs for simulated dorsal PIP joint fracture-dislocations in a cadaver model. We tested 30 digits from 10 fresh-frozen, thawed cadaver hands. We aimed to remove the palmar 50% of the base of each digit's middle phalanx (P2), simulating an unstable dorsal PIP joint fracture-dislocation. Each PIP joint was then stabilized via external fixation with either a pins-and-rubber-bands construct, pins-only construct, or tuberculin syringe-pins construct. We allocated 10 digits per fixation group. The finger tendons were secured to a computer-controlled stepper motor-driven linear actuator. Via this mechanism, all PIP joints were taken through 1,400 cycles of flexion-extension. With the PIP joint in neutral extension, we measured the P2 dorsal translation at baseline, after fixator stabilization, and after the motion protocol. The actual mean P2 palmar defect created was 48% of the base. All PIP joints were unstable after creating the defect, with a mean initial P2 dorsal displacement of 3.7 mm. After application of the fixators, all PIP joint dislocations were reduced. The median residual P2 dorsal displacements were 0.0 mm for the pins-rubber bands group, 0.1 mm for the pins-only group, and 0.5 mm for the syringe-pins group. There were no cases of PIP joint redislocation after flexion-extension cycling, and the median dorsal P2 displacements were 0.0 mm for the pins-rubber bands group; 0.0 mm for the pins-only group; and 0.5 mm for the syringe-pins group. All 3 external fixators restored PIP joint stability following simulated dorsal fracture-dislocation, with all reductions maintained after motion testing. The syringe-pins construct had significantly greater median residual P2 dorsal displacement after the initial reduction and motion testing, which is of unclear clinical importance. This study informs surgeon decision-making when considering dynamic external fixator options for dorsal PIP joint fracture-dislocations.