Biomechanical study: determining the optimum insertion angle for screw-in suture anchors-is deadman's angle correct?

PURPOSE: To assess the effect of the insertion angle and the angle of applied load on the pullout strength of screw-in suture anchors. METHODS: Screw-in metallic suture anchors were inserted into a 10-lb/cu ft synthetic cancellous bone block at 30°, 45°, 60°, and 90° to the surface. The suture pull angle was then varied in 30° increments between 0° and 180°. Five constructs were tested to failure (anchor pullout) for each combination of angles using a Zwick tensile testing machine (Zwick Roell, Ulm, Germany). RESULTS: There were a total of 25 combinations. The greatest pullout strength was seen with a suture anchor inserted at 90° to the bone block with a pull angle of 90° to the bone (mean, 306 N; standard deviation [SD], 9 N). The weakest pullout strength was seen with a suture anchor inserted at 30° with the angle of pull at 120° (i.e., opposite to the direction of insertion of the anchor) (mean, 97 N; SD, 11 N). A simulated deadman's angle of 45° with an angle of pull of 150° produced a pullout strength of 127 N (SD, 4 N). The pullout strengths for each insertion angle were greatest when the angle of pull was similar to the angle of insertion (P < .0001, repeated-measures analysis of variance). CONCLUSIONS: The angle of applied load to a suture anchor and the insertion angle significantly influence the biomechanical pullout strength of screw-in suture anchors. The insertion angle of the suture anchor should replicate the angle of applied load to ensure the optimum pullout strength. CLINICAL RELEVANCE: The screw-in anchor insertion angle and angle of applied load may have an influence on pullout strength.

Pectoralis minor syndrome: diagnosis with Botulinum injection and treatment with tenotomy - a prospective case series.

Background: Pectoralis minor syndrome involves pain, paraesthesia and weakness in the arm due to compression of the brachial plexus passing beneath pectoralis minor; this paper reports the results of a single centre's treatment pathway in affected patients. Methods: During a four-year period, patients exhibiting symptoms of pectoralis minor syndrome without significant improvement following physiotherapy proceeded to Botulinum injection. Those with good response to injection but subsequent recurrence of symptoms were offered pectoralis minor tenotomy. Oxford shoulder Scores were collected at baseline and after interventions. Results: Twenty-one patients received Botulinum injection; at six weeks following injection, mean change in Oxford Shoulder Score was +12.4, with only one patient reporting a worsening of symptoms. Of the 17 patients with clinically significant response to injection, 12 have subsequently undergone tenotomy; three months following tenotomy, mean change in Oxford Shoulder Score from baseline was +22.3. Improvement was maintained in all patients at prolonged follow-up (average 20 months post-tenotomy). Discussion: This pathway has shown to be extremely effective in patients not responding to first-line treatment for pectoralis minor syndrome, with 85% of patients post-injection and 100% of patients post-tenotomy showing significant (greater than published minimal clinically important difference value of six points) improvements in Oxford Shoulder Score, maintained at follow-up.

Systematic Review With Meta-Analysis: Are Muscle Transfers a Satisfactory Treatment Option to Restore Shoulder Abduction in Delayed Adult Brachial Plexus Injuries?

Brachial plexus injuries usually result in significant upper limb disabilities and shoulder joint instability. Primary nerve reconstruction procedures are more effective if performed within six months from the injury. Secondary procedures, including muscle transfers, are usually indicated for delayed presentation (>6 months) or when the outcomes of primary procedures are unsatisfactory. A comprehensive systematic search of the MEDLINE, EMBASE, AMED, PubMed, and Cochrane databases was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data, including demographic information, time to surgery, the extent of brachial plexus injury, surgical techniques, follow-up duration, and functional outcomes were collected and tabulated. Meta-analysis was conducted using Review Manager (RevMan) 5.4 software ([Computer program]. Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014). Seven studies were eligible to be included in this review, with a total of 218 patients. The average patient age was 28.39 ± 3 years, with a mean time to surgery of 29.87 ± 18 months. Forty-six (46) patients (21.10%) were treated as delayed presentation and 172 patients (78.89%) had muscle transfer performed as a secondary procedure. The mean time at follow-up was 18.86 ± 13.5 months. Upper trapezius muscle transfer was the most common transferred muscle (100%) either in isolation (n=159, 72.93%) or in combination with lower trapezius transfer (n=59, 27.06%). The mean preoperative and postoperative shoulder abduction were 12.22 ± 10.09 degrees and 58.36 ± 32.33 degrees, respectively (p < 0.05). Meta-analysis shows a statistically significant difference (CI at 95%, p<0.05) favoring postoperative shoulder abduction. Muscle transfers especially upper trapezius transfer could be a satisfactory secondary procedure to restore shoulder abduction and enhance shoulder joint stability.

Rationalization of Orthopaedic Surgical Instrument Trays: Three Years' Experience of a Practical Approach to Cut Down Unnecessary Costs.

Background This study aimed to rationalize the surgical instrument trays (SITs) used in some trauma and orthopedic (T&O) procedures to reduce unnecessary costs. Methods SITs for several T&O procedures at our trust were assessed to judge the utility of each instrument. SITs for hip, knee, and shoulder arthroscopy, dynamic hip screw (DHS), rotator cuff repair, shoulder stabilization, total shoulder arthroplasty (TSR), and proximal humerus fracture fixation were reviewed. Infrequently used and irrelevant instruments were removed to minimize the number of used trays for each procedure. A qualitative survey was conducted following SIT rationalization to assess the practicality and suitability of these changes. Results The number of SITs was rationalized from four to two for DHS, three to one for hip, knee, and shoulder arthroscopy, five to two for rotator cuff repair and shoulder stabilization, three to one for TSR, and proximal humerus fracture fixation. Based on the local database figures for these procedures, the estimated number of used trays reduced from 2,785 to 1.015 (36.4%) trays per year. Based on the sterilization cost of £35 per tray, annual savings amounted to about £61,950. Qualitative analysis of theatre staff feedback showed increased time efficiency and a positive feeling of practicality. Conclusion The critical appraisal of the departmental operating practice is an effective tool to achieve cost-efficient practice. The rationalization of SITs for orthopedic procedures can result in significant savings by reducing sterilization costs alone.

Does a delay in surgery for distal radial fractures affect patient outcome?

Current guidelines from the British Orthopaedic Association state that if fractures of the distal radius are operated on then this should take place within 3 days of injury for intra-articular fractures, 7 days for extra-articular fractures and 3 days when a trial of conservative management has failed. This retrospective cohort study aimed to assess whether there was any difference in outcome between patients receiving timely or delayed surgery, using the Patient-Rated Wrist Evaluation score at >12 months after injury as the primary outcome measure. Data from 380 patients treated at two district general hospitals over a 5-year period were obtained using electronic databases to capture the demographics and treatment details and postal questionnaires to assess current function. The study showed no statistical or clinical differences in outcome measures between the timely or delayed cohorts in any of the three treatment groups.Level of evidence: III.

Total Elbow Arthroplasty Survey 2015: Current Service Provision and Future Improvements (England and Wales).

BACKGROUND: The number of total elbow replacement (TER) procedures conducted is relatively low compared to other joint arthroplasties. We have established a survey about current service provision and possible future improvements in the UK. METHODS: A British Elbow and Shoulder Society (BESS) approved online survey was circulated to its surgical members. RESULTS: In total, 153 members of BESS responded. Almost 31% of respondents performed two to five TER in 2014; 28% performed none and 22.7% performed five to ten. Two-thirds of respondents did not perform any revision surgery. The main indication for TER was rheumatoid arthritis (33%), followed by acute trauma (28.5%). In addition, 67% of surgeons have an available 'network' for advice, either locally or regionally. Most primary procedures (93%) were carried out within the local units. However, 34% of complex primary or revision procedures were referred to another centre. Furthermore, 52% of respondents agree that, to be proficient in TER, a minimum number of procedures per annum should be performed: 62% stated that five procedures per annum should be considered as the minimum required. Suggestions for improvement included a hub and spoke model (48%) and a dedicated TER surgeon within the unit (45%). CONCLUSIONS: The survey highlights the interest in exploring options for improving TER provision in the UK.

Treating osteomyelitis of major limb amputations with a modified Lautenbach technique.

INTRODUCTION: Major lower limb amputation significantly increases the energy cost of walking for patients. Complications such as osteomyelitis may require further surgery, and can lead to shortening of the stump. In these cases, the aim should be to treat infection without shortening the limb further. We present a series of patients with established osteomyelitis of the amputation stump, managed using a modified Lautenbach technique. METHOD: Six patients with either above or below knee amputations, in the practice of a single orthopaedic surgeon, were studied. Ages range from 39 to 64 years, and reasons for amputation included infection, pain, and necrosis. All patients had osteomyelitis in the amputation stump confirmed on MRI. RESULTS: At a mean follow-up of 3.75 years (range 7 months to 6 years) all six patients had no clinical or haematological evidence of infection, and had returned to independent living. Stump length was preserved in all cases, including in one patient who underwent two procedures to ensure complete debridement. CONCLUSIONS: We believe that this case series is the largest so far published regarding this modification of the Lautenbach Procedure. This operation treats infection effectively without further loss of bone length, and no patients so far have developed significant complications.

Tendinopathies Around the Elbow Part 2: Medial Elbow, Distal Biceps and Triceps Tendinopathies.

In the second part of this review article the management of medial elbow tendinopathy, distal biceps and distal triceps tendinopathy will be discussed. There is a scarcity of publications concerning any of these tendinopathies. This review will summarise the current best available evidence in their management. Medial elbow tendinopathy, also known as Golfer's elbow, is up to 6 times less common than lateral elbow tendinopathy. The tendinopathy occurs in the insertion of pronator teres and flexor carpi radialis. Diagnosis is usually apparent through a detailed history and examination but care must be made to exclude other conditions affecting the ulnar nerve or less commonly the ulnar collateral ligament complex. If doubt exists then MRI/US and electrophysiology can be used. Treatment follows a similar pattern to that of lateral elbow tendinopathy. Acute management is with activity modification and topical NSAIDs. Injection therapy and surgical excision are utilised for recalcitrant cases. Distal biceps and triceps tendinopathies are very rare and there is limited evidence published. Sequelae of tendinopathy include tendon rupture and so it is vital to manage these tendinopathies appropriately in order to minimise this significant complication. Their management and that of partial tears will be considered.