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Cureus Nov 2021Different studies on reverse shoulder arthroplasty (RSA) have proposed changes to the humeral design to lateralise the humeral centre of rotation (COR), with humeral... (Review)
Review
Different studies on reverse shoulder arthroplasty (RSA) have proposed changes to the humeral design to lateralise the humeral centre of rotation (COR), with humeral inclination to 135 or 145 from 155 degrees or to switch to onlay humeral trays from inlay design; with both having also been used in combination. There have been many studies and systematic reviews to show the difference in outcomes and complications to the variations in glenoid design but to date, there have been no systematic studies to compare different humeral inclinations for RSA implants. Searches using keywords were used in common medical search engines in a systematic fashion. The article was reviewed for the class of evidence and bias, summarised and compared in meta-analysis. Inclusion criteria included studies on adults with RSA that compared lateralised humeral implants to medialised. The search produced 349 articles; of these, we identified nine studies that met the inclusion criteria. Our review identified a total of 562 patients who had been included in studies directly comparing lateralised humerus to a more medial design. Meta-analysis showed a significantly reduced risk of scapular notching in lateralised humerus compared to the standard medialised component. The external rotation range of motion in the lateralised group was statistically significant. The improvement in scapular notching and gain in the range of motion without any apparent downside in the form of reduced patient-reported outcome measures or complications suggest a lateralised humeral component is superior to the more medialised design in RSA. A large RCT with a longer-term follow-up is needed to confirm whether there is clinically significant benefit from the lateralisation of the humerus.
PubMed: 34824955
DOI: 10.7759/cureus.19845 -
Rambam Maimonides Medical Journal Apr 2022Patellar instability comprises a group of pathologies that allow the patella to move out of its trajectory within the trochlear groove during walking. Symptomatic...
BACKGROUND
Patellar instability comprises a group of pathologies that allow the patella to move out of its trajectory within the trochlear groove during walking. Symptomatic patients who need surgery commonly undergo soft tissue procedures such as medial patellofemoral ligament repair to strengthen the ligaments that hold the patella in place. However, soft-tissue repairs may be insufficient in patients suffering from patellar maltracking, which is characterized by an unbalanced gliding of the patella within its route. In these patients, a different approach is advised. We aim to provide the mid-term clinical outcomes of the Fulkerson distal realignment operation in selected patients with non-traumatic patellar maltracking.
METHODS
The clinical outcomes of the Fulkerson distal realignment operation performed in 22 knees of 21 patients were evaluated by a self-administered subjective International Knee Documentation Committee (IKDC) score and the Tegner-Lysholm knee scoring scale.
RESULTS
Before surgery, the median IKDC score was 52, and the median Tegner-Lysholm score was 56. Following surgery (mean follow-up 48 months, range 24-156), the median IKDC and the Tegner-Lysholm scores were 67 and 88, respectively. The improvement was statistically significant (P=0.001 and P=0.002 for IKDC and Tegner-Lysholm scores, respectively). Associated procedures included patella microfracture due to grade III-IV cartilage lesion (International Cartilage Repair Society grading system) in four patients, retinacular releases in three patients, medial capsular augmentations in two patients, and medial patellofemoral ligament reconstruction in two patients. One patient with Ehlers-Danlos disease required excessive medialization of the tibial tuberosity. Surgery-related complications occurred in three patients.
DISCUSSION
Surgical correction of patellar maltracking with Fulkerson distal realignment combined with associated procedures in individual patients was associated with an increase in subjective and functional clinical scores at medium-term follow-up. Particular attention should address pathologies associated with patellar maltracking and managed accordingly.
LEVEL OF EVIDENCE
4c (case series).
PubMed: 35290178
DOI: 10.5041/RMMJ.10465 -
Orthopaedic Surgery Nov 2022How to restrict sliding of cephalomedullary nail and rigid reconstruct medial support for unstable intertrochanteric fractures remains a challenge. This study aims to...
OBJECTIVE
How to restrict sliding of cephalomedullary nail and rigid reconstruct medial support for unstable intertrochanteric fractures remains a challenge. This study aims to explore the feasibility of a novel cephalomedullary nail for restriction sliding and reconstruction of medial femoral support to prevent failure in unstable trochanteric fractures through finite element analysis.
METHODS
The DICOM files of a unilateral femur spiral computed tomography (CT) scans from a elderly female were converted into STL files, and the most common clinical trochanteric fracture model with the absence of medial support, AO/OTA 31-A2.3 was simulated by removing the posterior medial femur. The model of a novel medial sustain nail (MSN-II) and a widely used nail (proximal femoral nail anti-rotation PFNA-II) were modeled according to the manufacturer-provided engineering drawing. Different loads were applied to the femoral head to simulate the postoperative weight bearing gait. The sliding distance of helical blade in femoral neck, maximum stress of femur and nail, displacement of proximal fragment were analyzed to revealing the mechanical stability of unstable trochanteric fracture stabilized by different implant.
RESULTS
The sliding distance of helical blade in the femoral neck, the maximum stress on the femur and nail, the displacement of proximal fragment in MSN-II under 2100N axial load were 0.65 mm, 689 MPa, 1271 MPa, 16.84 mm respectively, while that were 1.43 mm, 720.8 MPa, 1444 MPa, 18.18 mm, respectively in PFNA-II. The difference between the two groups was statistically significant (P < 0.05) and the stress was mainly distributed in medial distal side of nail but helical blade and the proximal aperture for the nail in MSN-II. Compared to PFNA-II, MSN-II demonstrates biomechanical merit against femur medialization, cut-out and coax varus.
CONCLUSION
The sliding distance of helical blade in femoral neck, the maximum stress on the femur and nail, and the displacement of proximal fragment of MSN-II were less than those of PFNA-II in the treatment of unstable intertrochanteric fractures. Therefore MSN-II has better stability than PFNA-II and it may have the potential to avoid femur medialization and cut out. It might be an option in unstable trochanteric fracture because of its superiority in restricted sliding and medial support reconstruction.
Topics: Female; Humans; Aged; Bone Nails; Finite Element Analysis; Hip Fractures; Femur; Femur Head
PubMed: 36120825
DOI: 10.1111/os.13497 -
Orthopaedic Journal of Sports Medicine Aug 2022Increased tibial tuberosity-trochlear groove (TT-TG) distance is an important indicator of medial tibial tubercle transfer in the surgical management of lateral patellar...
BACKGROUND
Increased tibial tuberosity-trochlear groove (TT-TG) distance is an important indicator of medial tibial tubercle transfer in the surgical management of lateral patellar dislocation (LPD). Changes to TT-TG distance are determined by a combination of several anatomical factors.
PURPOSE
To (1) determine the anatomical components related to increased TT-TG distance and (2) quantify the contribution of each to identify the most prominent component.
STUDY DESIGN
Case-control study; Level of evidence, 3.
METHODS
Included were 80 patients with recurrent LPD and 80 age- and body mass index-matched controls. The 2 groups were compared in TT-TG distance and its related anatomical components: tibial tubercle lateralization (TTL), trochlear groove medialization, femoral anteversion, tibiofemoral rotation (TFR), tibial torsion, and mechanical axis deviation (MAD). The Pearson correlation coefficient () was calculated to evaluate the association between increased TT-TG distance and its anatomical parameters, and factors that met the inclusion criteria of < .05 and ≥ 0.30 were analyzed via stepwise multivariable linear regression analysis to predict TT-TG distance.
RESULTS
The LPD and control groups differed significantly in TT-TG distance, TTL, TFR, and MAD ( < .001 for all). Increased TT-TG distance was significantly positively correlated with TTL ( = 0.376; < .001), femoral anteversion ( = 0.166; = .036), TFR ( = 0.574; < .001), and MAD ( = 0.415; < .001), and it was signficantly negatively correlated with trochlear groove medialization ( = -0.178; = .024). The stepwise multivariable analysis revealed that higher TTL, excessive knee external rotation, and excessive knee valgus were statistically significant predictors of greater TT-TG distance ( < .001 for all). The standardized estimates that were used for evaluating the predictive values were larger for TFR compared with those for TTL and MAD.
CONCLUSION
TTL, TFR, and MAD were the main independent anatomical components associated with increased TT-TG distance, with the most prominent component being TFR. The association of TT-TG distance to each component analyzed in our study may help guide surgical planning.
PubMed: 36003969
DOI: 10.1177/23259671221113841 -
Surgical Neurology International 2012Posterior clinoidectomy is a useful procedure for maximizing exposure to the interpeduncular cistern via transcranial approaches for basilar tip aneurysms and select...
BACKGROUND
Posterior clinoidectomy is a useful procedure for maximizing exposure to the interpeduncular cistern via transcranial approaches for basilar tip aneurysms and select intracranial tumors. The value of posterior clinoidectomy during endonasal endoscopic transclival surgery is not well described.
METHODS
We performed endoscopic endonasal transsphenoidal extradural bilateral posterior clinoidectomy and dorsum sella removal on five silicon-injected cadaveric heads. The dorsum sella was split in the midline and removed from medial to lateral until the posterior clinoids were encountered. The posterior clinoid was dissected from the medial wall of the cavernous sinus and mobilized medially in order to detach it from the ligaments and carefully fractured it from the bony attachment to the petrous apex and carotid canal. Following this, the clival and dorsum sella dura was opened to expose the interpeduncular cistern and its contents.
RESULTS
The technical feasibility of endoscopic endonasal extradural posterior clinoidectomy was reproduced in all five cadaveric specimens. This technique was performed without damaging the vital structures, including preservation of the pituitary gland. After performing bilateral posterior clinoidectomy, the retrosellar dura was opened, allowing good visualization of the contents of the prepontine and interpeduncular cistern.
CONCLUSION
We describe the technique of endoscopic endonasal extradural posterior clinoidectomy. We believe this approach is best suited for retrosellar pathology located in the interpeduncular cistern and is a useful adjunct to the transclival approach to increase the field of view and maximize the extent of resection.
PubMed: 22754729
DOI: 10.4103/2152-7806.97008 -
Orthopaedic Journal of Sports Medicine Jan 2022Reverse total shoulder arthroplasty (rTSA) is an established procedure for cuff tear arthropathy. More lateralized prostheses have been designed to overcome the reported... (Review)
Review
BACKGROUND
Reverse total shoulder arthroplasty (rTSA) is an established procedure for cuff tear arthropathy. More lateralized prostheses have been designed to overcome the reported adverse outcomes of Grammont-style rTSA.
PURPOSE
To compare the clinical and radiological outcomes of medialized and lateralized center of rotation (COR) in rTSA.
STUDY DESIGN
Systematic review; Level of evidence, 3.
METHODS
This review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies with a level of evidence ≥3 that compared medialized and lateralized rTSA with a minimum follow-up of 12 months. Functional scores including the American Shoulder and Elbow Surgeons (ASES) score and Constant score (CSS), range of motion at final follow-up, gain of external rotation (ER), visual analog scale (VAS) pain score, scapular notching, and heterotopic ossification (HO) were compared. Data were analyzed using random-effects or fixed-effects models in accordance with heterogeneity.
RESULTS
Five retrospective cohort studies and 1 randomized controlled study (n = 594 patients) were included. Lateralized rTSA resulted in greater improvement in ER degree ( < .001), a lower VAS pain score (standardized mean difference [SMD], -0.39; = .002), and a lower rate of scapular notching (risk ratio [RR], 0.40; < .001) and HO (RR, 0.52; < .001). Final forward flexion (SMD, -0.14; = .629) and ER (SMD, 0.21; = .238) did not differ significantly between the 2 groups. Overall functional scores, including ASES score (SMD, 0.22; = .310) and CSS (SMD, 0.37; = .077), also did not differ significantly (SMD, 0.28; = .062). The overall complication rate did not differ significantly between the 2 groups (RR, 0.71; = .339).
CONCLUSION
Compared with medialized rTSA, lateralized COR rTSA results in greater improvement in ER and the VAS pain score, decreased rates of scapular notching and HO, and no significant changes in functional outcome scores or the complication rate.
PubMed: 35005051
DOI: 10.1177/23259671211063922 -
Translational Neuroscience 2018Although there are a few studies of portions of the vestibular system such as the vestibulocerebellar tract and the neural connectivity of the vestibular nuclei (VN), no...
Although there are a few studies of portions of the vestibular system such as the vestibulocerebellar tract and the neural connectivity of the vestibular nuclei (VN), no study of the ipsilateral vestibulothalamic tract (VTT) (originating from the VN and mainly connecting to the lateral thalami nuclei) has been reported. In the current study, using diffusion tensor tractography (DTT), we investigate the reconstruction method and characteristics of the ipsilateral VTT in normal subjects. Thirty-three subjects were recruited for this study. For the ipsilateral VTT, the seed region of interest (ROI) was placed on the VN, which was isolated on the FA map using adjacent structures as follows: the reticular formation (anterior boundary), posterior margin of medulla and pons (posterior boundary), medial lemniscus (medial boundary) and restiform body (lateral boundary). The target ROI was placed at the lateral thalamic nuclei using known anatomical locations. The DTT parameters of the ipsilateral VTT were measured. The ipsilateral VTTs that originated from the vestibular nuclei ascended postero-laterally to the upper pons and antero-medially to the upper midbrain via the medial longitudinal fasciculus, and terminated the lateral thalamic nuclei. No significant differences were observed in DTT parameters of the ipsilateral VTT between the right and left hemispheres (p > 0.05). Using DTT, we reconstructed the ipsilateral VTT and observed the anatomical characteristics of the ipsilateral VTT in normal subjects. We believe that the methodology and results in this study could be helpful to researchers and clinicians in this field.
PubMed: 29662702
DOI: 10.1515/tnsci-2018-0005 -
Postgraduate Medical Journal Nov 1981One hundred consecutive recurrences following repair of inguinal hernias have been studied; 62 were direct, 30 indirect, 7 pantaloon and one a femoral hernia. Half the...
One hundred consecutive recurrences following repair of inguinal hernias have been studied; 62 were direct, 30 indirect, 7 pantaloon and one a femoral hernia. Half the indirect recurrences occurred within a year of repair and probably represented failure to detect a small indirect sac. Later indirect recurrences probably represented failure to repair the internal ring. Nine of the direct hernias were medial funicular recurrences and represented failure to anchor the darn medially. The rest of the direct recurrences were attributable to tissue insufficiency and could probably have been averted by larger tissue bites. Recurrences following inguinal herniorrhaphy remain an all too common problem but can be reduced by meticulous surgical technique.
Topics: Adult; Female; Hernia, Inguinal; Humans; Male; Middle Aged; Recurrence; Time Factors
PubMed: 7339602
DOI: 10.1136/pgmj.57.673.702 -
Acta Ophthalmologica Mar 2020To establish a linear measuring method in computed tomographic (CT) images to predict the displacement of the globe late after orbital blowout fracture.
PURPOSE
To establish a linear measuring method in computed tomographic (CT) images to predict the displacement of the globe late after orbital blowout fracture.
METHODS
Subjects were retrospectively included. Inclusion criteria were as follows: (1) adult subjects (≥18 years old at the time of trauma); (2) unilateral orbital medial-wall and/or floor fractures; (3) CT examination at least 30 days after trauma. Exclusion criteria were as follows: (1) facial or orbital fracture extending to other parts of the orbit than medial-wall and/or floor; (2) history of orbital or ocular abnormality other than the orbital trauma; (3) severe ocular trauma accompanied by the orbital trauma; (4) orbital fracture treated surgically before the CT examination. A co-ordinate system was built based on the orbital CT scans. Displacements of orbital walls, displacement of the globe and relative location of the fracture site were measured. Correlations between the variables were investigated.
RESULTS
Ninety-nine per cent of fracture sites of the medial wall and 100% of fracture sites of the floor were posterior to the centre of the unaffected globe. The affected globe moved significantly medially (p < 0.001) and backwards (p < 0.001) in pure medial-wall fracture; backwards (p < 0.001) and downwards (p = 0.017) in pure floor fracture; and medially (p < 0.001), backwards (p < 0.001) and downwards (p < 0.001) in medial-wall and floor fractures. Displacement of the globe was correlated with displacements of the orbital walls, and the regression formulae were therefore fitted. Application of the formulae revealed that the same extent of orbital wall displacement caused more displacement of the globe in female patients than in male patients.
CONCLUSIONS
A linear measuring method in a three-dimensional co-ordinate system was established to identify the displacements of orbital walls and the displacement of the globe in orbital blowout fractures. The regression formulae generated in this study might be used in clinical practice to predict late displacement of the globe by measuring the displacements of orbital walls.
Topics: Adult; Aged; Eye Injuries; Female; Humans; Imaging, Three-Dimensional; Male; Middle Aged; Orbital Fractures; Retrospective Studies; Tomography, X-Ray Computed; Young Adult
PubMed: 31421032
DOI: 10.1111/aos.14226 -
The American Journal of Sports Medicine Jul 2021Little scientific evidence is available regarding the effect of knee joint line obliquity (JLO) before and after coronal realignment osteotomy.
BACKGROUND
Little scientific evidence is available regarding the effect of knee joint line obliquity (JLO) before and after coronal realignment osteotomy.
HYPOTHESES
Higher JLO would lead to abnormal relative position of the femur on the tibia, a shift of the joint contact areas, and elevated joint contact pressures.
STUDY DESIGN
Descriptive laboratory study.
METHODS
10 fresh-frozen human cadaveric knees (age, 59 ± 5 years) were axially loaded to 1500 N in a materials testing machine with the joint line tilted 0°, 4°, 8°, and 12° varus ("downhill" medially) and valgus, at 0° and 20° of knee flexion. The mechanical compression axis was aligned to the center of the tibial plateau. Contact pressure and contact area were recorded by pressure sensors inserted between the tibia and femur below the menisci. Changes in relative femoral and tibial position in the coronal plane were obtained by an optical tracking system.
RESULTS
Both medial and lateral JLO caused significant tibiofemoral subluxation and pressure distribution changes. Medial (varus) JLO caused the femur to subluxate medially down the coronal slope of the tibial plateau, and vice versa for lateral (valgus) downslopes ( < .01), giving a 6-mm range of subluxation. The areas of peak pressure moved 12 mm and 8 mm across the medial and lateral condyles, onto the downhill meniscus and the "uphill" tibial spine. Changes in JLO had only small effects on maximum contact pressures.
CONCLUSION
A 4° change of JLO during load bearing caused significant mediolateral tibiofemoral subluxation. The femur slid down the slope of the tibial plateau to abut the tibial eminence and also to rest on the downhill meniscus. This caused large movements of the tibiofemoral contact pressures across each compartment.
CLINICAL RELEVANCE
These results provide important information for understanding the consequences of creating coronal JLO and for clinical practice in terms of osteotomy planning regarding the effect on JLO. This information provides guidance regarding the choice of single- or double-level osteotomy. Excessive JLO alteration may cause abnormal tibiofemoral joint articulation and chondral or meniscal loading.
Topics: Biomechanical Phenomena; Cadaver; Femur; Humans; Knee Joint; Meniscus; Middle Aged; Tibia
PubMed: 34125619
DOI: 10.1177/03635465211020478