Application of indocyanine green fluorescence angiography in evaluating blood flow in rotator cuff tears: a preliminary study.

BACKGROUND: The relationship between the degree of vascularization at the edge of a torn rotator cuff tendon and cuff healing remains unclear. The purpose of this study was to employ indocyanine green (ICG) fluorescence angiography to evaluate the blood flow at the edge of a torn rotator cuff tendon under the subacromial view. METHODS: Thirteen shoulders of 13 patients who underwent arthroscopic repair of full-thickness rotator cuff tears were included in this prospective study. Viewing from the posterolateral portal, ICG at 0.2 mg/kg body weight was intravenously administered, and the blood flow was recorded. After resecting the poorly vascularized torn edge of the tendon, ICG administration was repeated at the same volume. The fluorescence intensity and perfusion time of the tendon blood flow were evaluated using video analysis and modeling tools. Cuff integrity was evaluated using magnetic resonance imaging at 6 months postoperatively. Patients were divided into healed and retear groups, and the differences in the degree of blood flow were evaluated. RESULTS: ICG fluorescence angiography could visualize the blood flow in the rotator cuff tendon, and the torn edge of the tendon with poor blood flow was resected. The overall retear rate was 23.1 % (3/13). Based on quantitative analysis, the fluorescence intensity factors were significantly lower in the retear group than in the healed group before tendon débridement. The retear rate in the high blood flow group was 0% (0/7), while that in the low blood flow group was 50.0% (3/6). CONCLUSIONS: ICG fluorescence angiography may play a role in the future of shoulder arthroscopy. Further study is needed to determine the effect of blood flow on tendon healing.

Real-World Evidence for Risk Factors of Bruises and Fractures from Falls in Patients with Overactive Bladder: A Medical Record Analysis.

Aim: To identify the risk factors for bruises and fractures from falls in patients with overactive bladder (OAB). Methods: We evaluated 1136 patients with OAB and aged ≥50 years who visited our hospital. Age, sex, frequency of nocturnal urination, and urinary incontinence type were investigated in the 360 eligible patients. Patients were divided into three groups: those patients without falls (no-fall group), those with fall bruises (bruise group), and those with fall fractures (fracture group). The risk factors for bruises and fractures in patients with OAB were evaluated using the logistic regression analysis. In addition, association between the bruises or fractures from falls and the behavior around urination during the night was investigated. Results: The multivariate logistic regression analysis showed that female sex (odds ratio (OR) 2.888, p = 0.030) and nocturnal urination frequency ≥3 times/night (OR vs. ≤2 times/night, 2.940; p = 0.040) were significantly associated with bruises. Nocturnal urination frequency ≥3 times/night (OR vs. ≤2 times/night, 2.835; p = 0.026) and urge incontinence (OR 3.415, p = 0.016) were significantly associated with fractures. Behavior around urination during the night was significantly associated with fractures (p = 0.009). Conclusion: In the real-world clinical setting, increasing nocturnal urination frequency is a common risk factor for bruises and fractures. Also, female sex and urge incontinence were the risk factors for bruises and fractures, respectively. OAB patients with urge incontinence would especially require aggressive intervention to prevent fractures during night-time voiding.

Efficacy of bone marrow stimulation for arthroscopic knotless suture bridge rotator cuff repair: a prospective randomized controlled trial.

BACKGROUND: The purpose of this study was to investigate the efficacy of bone marrow stimulation (BMS) on the repair integrity of the rotator cuff insertion treated with arthroscopic knotless suture bridge (K-SB) rotator cuff repair. We hypothesized that BMS during K-SB repair can improve the healing of the rotator cuff insertion. METHODS: Sixty patients who underwent arthroscopic K-SB repair of full-thickness rotator cuff tears were randomly allocated to 2 treatment groups. Patients in the BMS group underwent K-SB repair augmented with BMS at the footprint. Patients in the control group underwent K-SB repair without BMS. Cuff integrity and retear patterns were evaluated by postoperative magnetic resonance imaging. The clinical outcomes included the Japanese Orthopaedic Association score, University of California at Los Angeles score, Constant-Murley score, and Simple Shoulder Test. RESULTS: Clinical and radiological evaluations were completed in 60 patients at 6 months postoperatively, in 58 patients at 1 year postoperatively, and in 50 patients at 2 years postoperatively. Both treatment groups showed significant improvements in the clinical outcome from baseline to the 2-year follow-up, but no significant differences were found between the 2 groups. At 6 months postoperatively, the retear rate at the tendon insertion was 0.0% (0 of 30) in the BMS group and 3.3% (1 of 30) in the control group (P = .313). The retear rate at the musculotendinous junction was 26.7% (8 of 30) in the BMS group and 13.3% (4 of 30) in the control group (P = .197). All retears in the BMS group occurred at the musculotendinous junction, and the tendon insertion was preserved. There was no significant difference in the overall retear rate or retear patterns between the 2 treatment groups during the study period. CONCLUSIONS: No significant differences were detected in the structural integrity or retear patterns regardless of the use of BMS. The efficacy of BMS for arthroscopic K-SB rotator cuff repair was not proven in this randomized controlled trial.

Bone formation of the coracoid bone graft after the Bristow procedure assessed using three-dimensional computed tomography.

BACKGROUND: The Bristow procedure has been shown to be a reliable method to prevent recurrent anterior shoulder instability by compensating for glenoid bone loss and producing the sling effect. The degree of postoperative morphological change in the coracoid bone graft is speculated to influence glenohumeral joint stability; however, the details of these changes after the Bristow procedure remain unknown. This study was performed to quantify the postoperative change in the coracoid bone graft volume as assessed by three-dimensional computed tomography (3D-CT). METHODS: The Bristow procedure was performed on 17 shoulders in 17 patients from August 2018 to January 2020. All patients were men, and their mean age at surgery was 17.9 years. The mean follow-up duration was 21.4 months. Within the first week after the operation (Time 0) and at the final follow-up, 3D-CT was used to determine the total coracoid bone graft volume. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) shoulder score, the University of California Los Angeles (UCLA) shoulder score, and the Western Ontario Shoulder Instability Index (WOSI). RESULTS: The mean volume of the total coracoid bone graft was 1.26 ± 0.29 cm3 at Time 0 and 1.90 ± 0.36 cm3 at the final follow-up (p < 0.0001). The mean JOA score, UCLA score, and WOSI were significantly better at the final follow-up than preoperatively (p < 0.001). No postoperative infection, neurovascular injury, or recurrent instability of the glenohumeral joint occurred. CONCLUSIONS: In the Bristow procedure, the volume of the total coracoid bone graft as shown by 3D-CT was significantly greater at the final follow-up than at Time 0, and bone formation of the coracoid bone graft was found after the Bristow procedure.

Influence of scapular neck length on the extent of impingement-free adduction after reverse total shoulder arthroplasty.

BACKGROUND: Following reverse total shoulder arthroplasty, a short scapular neck length (SNL) decreases postoperative impingement-free adduction, and impingement between the neck of the scapula and the humeral polyethylene cup may cause scapular notching. However, no reports have evaluated the influence of SNL on impingement-free adduction. The purposes of this study were to evaluate the influence of SNL on impingement-free adduction and to examine the effect of glenoid component lateralization and inferiorization on impingement-free adduction. METHODS: By use of 3-dimensional templating software, a virtual reverse total shoulder arthroplasty model was created in 15 patients who had no osteoarthritic change or any other bony deformity. We measured SNLs separately before implant placement (preoperative SNL) and after implant placement (postoperative SNL). The implant used was the Comprehensive Reverse Shoulder System (Zimmer Biomet, Warsaw, IN, USA), and baseplate bony lateralization of 0, 5, and 10 mm, with inferior eccentricity of 0.5 or 4.5 mm, was tested for impingement-free adduction. Correlations between the preoperative and postoperative SNLs and impingement-free adduction were analyzed. RESULTS: The mean preoperative SNL was 8.2 ± 1.9 mm (range, 5.0-11.7 mm), and the mean postoperative SNL was 6.0 ± 2.0 mm (range, 2.1-9.8 mm). There was a moderate correlation between the preoperative SNL and impingement-free adduction (r = 0.628, P = .12) and a strong correlation between the postoperative SNL and impingement-free adduction (r = 0.771, P = .001). Use of the model with 10 mm of bony lateralization and 4.5 mm of inferior eccentricity provided the best results in terms of impingement-free adduction. CONCLUSION: There were correlations between both the preoperative and postoperative SNLs and impingement-free adduction. Although the lateralized and inferiorized center of rotation may increase the risk of loosening of the glenoid component, this offset significantly increased impingement-free adduction.

Where and what damage occurs at the acromial undersurface in patients with rotator cuff tears?

BACKGROUND: The gross pathology of the acromial undersurface in shoulders with rotator cuff tears with subacromial impingement is not completely understood. Many researchers have focused on damage to the anterior one-third area of the acromial undersurface, but few have studied the middle and posterior one-third areas. The purpose of this study was to clarify where and what damage occurs at the acromial undersurface in patients with rotator cuff tears. METHODS: We performed arthroscopic shoulder (n = 182, all with rotator cuff tears; mean age, 64.9 ± 8.4 years) and cadaveric shoulder (n = 23, 14 intact cuffs and 9 rotator cuff tears; mean age, 74.8 years) evaluations to observe the extent and degree of damage to the acromial undersurface. We statistically analyzed the association between the severity of the damage to the acromial undersurface (assessed using the Copeland-Levy classification as A0, normal; A1, minor scuffing; A2, major damage; or A3, visualization of bare bone area) and rotator cuff tear size (assessed using the classification of DeOrio and Cofield as partial; small, <1 cm; medium, 1-3 cm; or large or massive, >3 cm). RESULTS: The anterior, middle, and posterior one-thirds of the acromial undersurface were somewhat damaged (class A1-A3) in 92.6%, 90.1%, and 78.6% of shoulders with rotator cuff tears, respectively, according to arthroscopic evaluation. Increasing cuff tear size was significantly associated with worsening degree of damage to the acromial undersurface (P < .001). In the 9 cadaveric shoulders with rotator cuff tears, class A1-A3 damage was identified in the anterior one-third area in 100%, in the middle one-third area in 88.9%, and in the posterior one-third area in 33.3%. In the 14 cadaveric shoulders with a normal rotator cuff, class A1-A3 damage was identified in the anterior one-third area in 35.7%, in the middle one-third area in 14.3%, and in the posterior one-third area in 0.71%. CONCLUSION: Damage to the acromial undersurface in patients with rotator cuff tears occurred at the middle, posterior, and anterior one-third areas, and the degree of damage was related to cuff tear size. Surgeons should evaluate the entire acromial undersurface to check for subacromial impingement damage at the middle and posterior one-third areas as well as the anterior one-third area of the acromial undersurface; this might aid in the treatment of patients with rotator cuff disease or subacromial impingement syndrome.

Arthroscopic margin convergence of large-sized rotator cuff tears does not lead to better clinical outcome compared with conventional repair.

Background: The margin convergence (MC) technique is used to repair longitudinal-type tears as direct repair of the apex of the longitudinal-type tear from medial to lateral is challenging. Few studies have compared the postoperative clinical outcomes and retear rates of arthroscopic rotator cuff repair (ARCR) using the MC technique with those of conventional ARCR without using the MC technique. Therefore, this study aimed to investigate the efficacy of MC on the clinical outcome and retear rates of patients with large-sized rotator cuff tears. It was hypothesized that ARCR using the MC technique would yield clinical outcome and retear rates similar to those of ARCR without using the MC technique. Methods: The medical records of consecutive patients who underwent ARCR for large-sized rotator cuff tears were retrospectively evaluated. Forty-four and 35 shoulders were repaired using MC (MC group) and not using MC (non-MC group), respectively. The range of motion (ROM) and the Japanese Orthopaedic Association (JOA) score were assessed preoperatively and after a minimum follow-up period of 12 months postoperatively. Magnetic resonance imaging was performed at least 3 months postoperatively to determine whether the tendons had healed. Results: The average postoperative follow-up duration was 26.6 months and 24.3 months in the MC and non-MC groups, respectively. The mean ROM and JOA score improved significantly in both groups postoperatively; however, the postoperative range of external rotation and the total JOA score was significantly lower in the MC group. The overall retear rate did not differ significantly between the MC (13/44, 29.5%) and non-MC (7/35, 20.0%) groups, respectively (P = .332). No significant differences were observed between the cases with retears in the 2 groups in terms of the postoperative ROM and the total JOA score. In contrast, the postoperative range of external rotation and the total JOA score of the patients with healed tendons in the MC group were significantly poorer than those of the patients with healed tendons in the non-MC group. Conclusion: ARCR using MC of large-sized longitudinal-type tears does not lead to better postoperative range of external rotation and clinical outcome compared with those of conventional repair.

Serial Magnetic Resonance Arthrography for a Midsubstance Capsular Tear in a Patient With Traumatic Anterior Shoulder Instability.

The natural history of midsubstance capsular tears (MCTs) is unclear. We herein describe a case of MCT observed using serial magnetic resonance (MR) arthrography. A 46-year-old woman presented with excessive external rotation of the left glenohumeral joint, resulting in an initial anterior dislocation of the left shoulder. She subsequently developed recurrent shoulder joint dislocations. MR arthrography revealed an MCT without a Bankart lesion three months after the initial dislocation. She opted for nonoperative treatment, but the shoulder instability did not improve. The second MR arthrography, nine months after the initial dislocation, showed no natural healing of the MCT. The third MR arthrography, 12 months after the initial dislocation, also showed no natural healing. Her shoulder instability remained persistent. The patient then decided to have surgery. Arthroscopy revealed a large capsular defect extending from the glenoid to the humeral head in the anterior inferior glenohumeral ligamentous complex. The MCT was repaired with the placement of nonabsorbable sutures in a side-to-side fashion. At the final follow-up, three years postoperatively, the patient had no anterior shoulder instability. The Rowe score was 100 points. MR arthrography showed good repair integrity of the MCT at one year postoperatively. Serial MR arthrography was useful for both the patient and the shoulder surgeon in considering the treatment of the MCT, facilitating an accurate and qualitative assessment of whether natural healing of the MCT had been achieved.

Passive Ankle Plantarflexion Position and Skin Surface Blood Flow Adjacent to the Achilles Tendon.

BACKGROUND: Open repair of the Achilles tendon carries a risk of wound complications and infection. The Achilles tendon is covered by a thin layer of skin and subcutaneous tissue, which has a fragile blood supply. The full plantarflexion position may cause sustained blanching of the skin above the Achilles tendon. However, no reports have described the in vivo blood flow (BF) changes at the skin surface with ankle position. This study aimed to use laser Doppler flowmetry to evaluate the in vivo BF at the skin surface and thereby clarify the changes in BF with ankle position. METHODS: The study cohort comprised 30 feet in 15 participants with no history of Achilles tendon rupture. Laser Doppler flowmetry was used to measure the BF at the skin surface above the medial Achilles tendon in the natural plantarflexion (NP) and full plantarflexion (FP) positions. RESULTS: In the NP and FP positions, the BF at 5 cm proximal to the calcaneal insertion (frequent site of Achilles tendon rupture) was 1.50 ± 0.32 and 0.97 ± 0.28 mL/min/100 g, respectively (P < .0001). CONCLUSION: The BF at the skin surface adjacent to the medial Achilles tendon at 5 cm proximal to the calcaneal insertion was significantly less in the FP position than the NP position.

Disseminated gonococcal infection of the shoulder mimicking rheumatoid arthritis.

Introduction: Gonococcal arthritis is a characteristic of disseminated gonococcal infection (DGI). DGI arthritis is one of the most serious orthopedic emergencies because it can result in rapidly progressive joint damage, but it is often difficult to diagnose. Delayed treatment can result in the development of osteomyelitis in the adjacent bone, similar to other types of bacterial arthritis. Method: We report a case of gonococcal osteomyelitis associated with DGI that was initially treated as rheumatoid arthritis. The diagnosis was confirmed by DNA testing of synovium collected during arthroscopic debridement. Results: Seven years after the initial consultation, there was no acute-phase reactant, the arthritic changes had improved over time and the range of motion had increased. DGI may be difficult to confirm, but it is one of the most important entities that should be differentiated in the treatment of arthritis. Conclusion: Clinicians need to keep in mind that blood and synovial fluid cultures often do not lead to a definitive diagnosis.

Radiologic foot alignment and clinical outcome after percutaneous drilling for symptomatic accessory navicular in skeletally immature children.

Various surgical treatments are available for a symptomatic AN, including percutaneous drilling (PD). PD is reportedly effective for ANs in skeletally immature children. However, no reports have described the foot alignment after PD in skeletally immature children. This study was performed to compare the radiographic parameters between the preoperative period and the final follow-up after PD for symptomatic ANs in skeletally immature children. From October 2013 to December 2020, PD was performed on 13 feet in 10 skeletally immature children. The patients comprised 5 boys and 5 girls with a mean age at surgery of 11.9 years. The mean follow-up period was 14.8 months. We measured 5 radiographic findings preoperatively and at the final follow-up: calcaneal pitch angle (CPA), talocalcaneal angle (TCA), talonavicular coverage angle (TNCA), anteroposterior talo-first metatarsal angle (ATMA), and lateral talo-first metatarsal angle (LTMA). Ten feet were assessed as excellent, 1 as fair, and 2 as poor. Ten unions (76.9%) were achieved among the 13 feet. The mean CPA improved from 16.4 ±â€…4.1 degrees preoperatively to 18.2 ±â€…3.4 degrees at the final follow-up, the TCA improved from 43.0 ±â€…3.7 to 45.2 ±â€…4.4 degrees, and the TNCA improved from 19.9 ±â€…4.4 to 15.4 ±â€…5.0 degrees (P < .05). The ATMA and LTMA were not significantly different between the preoperative period and final follow-up. We found that PD for symptomatic ANs in skeletally immature children was effective treatment, and some radiographic parameters showed significant differences between the preoperative period and final follow-up.

Alteration of coracoacromial ligament thickness at the acromial undersurface in patients with rotator cuff tears.

Background: Some researchers have stated that magnetic resonance imaging (MRI) is useful for assessing the coracoacromial ligament (CAL) at the acromial undersurface. However, few studies have investigated the reliability and clinical significance of MRI findings for the CAL at the acromial undersurface. The purpose of this study was to determine the association between CAL thickness at the acromial undersurface and rotator cuff tear size. Methods: The CAL thickness at the acromial undersurface was evaluated in 182 patients with rotator cuff tears (mean age: 64.9 ± 8.4 years) using a 3.0-Tesla MRI system. The association between CAL thickness at the acromial undersurface and rotator cuff tear size determined by the DeOrio and Cofield classification (partial; small: <1 cm; medium: 1-3 cm; and large or massive: >3 cm) was analyzed statistically. The intraobserver and interobserver reliabilities for MRI measurements of CAL thickness at the acromial undersurface were determined by calculation of intraclass correlation coefficients and their 95% confidence intervals. Results: The mean CAL thickness at the acromial undersurface was 2.7 ± 1.4 mm (range: 0-6.5 mm). Increasing rotator cuff tear size was significantly associated with decreasing CAL thickness at the acromial undersurface (P = .004). The intraobserver and interobserver intraclass correlation coefficients for CAL thickness at the acromial undersurface were almost perfect (0.98 and 0.91, respectively). Conclusion: The present study clarified that (1) MRI was a reliable tool for evaluation of CAL thickness at the acromial undersurface and (2) increasing rotator cuff tear size was significantly associated with decreasing CAL thickness at the acromial undersurface. These findings may assist toward understanding the progressive pathology in rotator cuff disease.

Excessively High Repair Tension Decreases Microvascular Blood Flow Within the Rotator Cuff.

BACKGROUND: Repair tension and microvascular blood flow within the rotator cuff has a critical impact on tendon healing after rotator cuff repair. However, the relationship between repair tension and microvascular blood flow within the rotator cuff remains unclear. PURPOSE/HYPOTHESIS: The purpose of this study was to determine how much tension adversely affects microvascular blood flow within the rotator cuff. The hypothesis was that as the repair tension increases, the microvascular blood flow within the rotator cuff decreases. STUDY DESIGN: Controlled laboratory study. METHODS: Repair tension and microvascular blood flow within the rotator cuff of 30 patients with full-thickness rotator cuff tears were simultaneously measured using a digital tension meter and a contact-type laser Doppler flowmeter, respectively. Microvascular blood flow was measured under 4 levels of tension (0, 10, 20, and 30 N) at 5 points on the rotator cuff. The obtained values were statistically analyzed by a linear mixed-effects model to clarify the effect of tension on microvascular blood flow within the rotator cuff. RESULTS: There was no statistically significant difference in microvascular blood flow (mL/min/100 g) within the rotator cuff between 0 N (mean, 3.51; 95% CI, 3.0-4.0) and 10 N (mean, 3.74; 95% CI, 3.2-4.3) of tension (P = .716). However, there were statistically significant differences in microvascular blood flow within the rotator cuff between 0 and 20 N of tension (mean, 2.84; 95% CI, 2.3-3.4) (P = .002) and between 0 and 30 N of tension (mean, 2.45; 95% CI, 1.9-3.0) (P < .001). CONCLUSION/CLINICAL RELEVANCE: Our findings indicate that tension of ≥10 N during rotator cuff repair significantly decreases the microvascular blood flow within the rotator cuff. These data will contribute to determining the optimal repair tension during rotator cuff repair.

Are there differences in arthroscopic and histological features between traumatic and degenerative rotator cuff tears in elderly patients? A prospective dual-center analysis.

BACKGROUND: Discriminating traumatic rotator cuff tears (RCTs) from degenerative RCTs is sometimes difficult in elderly patients because the prevalence of asymptomatic RCTs increases with age. Little intraoperative information is available on the characteristics of traumatic and degenerative RCTs in elderly patients. The purpose of this study was to compare the arthroscopic findings and histological changes of the coracoacromial ligament (CAL) between traumatic and degenerative RCTs in elderly patients. METHODS: Forty-two shoulders of 42 patients aged ≥ 65 years underwent arthroscopic rotator cuff repair. Nineteen patients had traumatic full-thickness RCTs (Group T), and 23 had degenerative full-thickness RCTs (Group D). The quality of the rotator cuff tissue and the condition of the long head of the biceps were examined. The grade of CAL was evaluated both arthroscopically and histologically. The stiffness of the musculotendinous unit was calculated by measuring the force and displacement using a tensiometer. The arthroscopic and histological findings of the two groups were compared. RESULTS: Although the mean tendon displacement was comparable, the stiffness was different between Group T and Group D (0.56 ± 0.31 and 1.09 ± 0.67 N/mm, respectively; p < 0.001). Both arthroscopic and histological analysis of the CAL showed that the degenerative changes in the CAL were milder in Group T than in Group D (p < 0.001 and p < 0.001, respectively). There was a moderate positive correlation between the arthroscopic findings of CAL degeneration and the histopathological changes in this ligament (r = 0.47, p = 0.002). CONCLUSIONS: Traumatic RCTs were characterized by preserved elasticity of the musculotendinous unit and milder CAL degeneration compared with degenerative RCTs even in elderly patients.

A comparative study of surgical invasion in arthroscopic and open rotator cuff repair.

SUMMARY: This study investigated the degrees of surgical invasion for arthroscopic rotator cuff repair and open rotator cuff repair by evaluating the serum levels of C-reactive protein, hemoglobin, and interleukin-6. The study participants were 17 patients (group A) who underwent arthroscopic rotator cuff repair and 15 patients (group O) who underwent open rotator cuff repair by the same surgeon. The difference in the size of the rotator cuff tear between the 2 groups was not significant (P > .05). No significant differences were recorded in the postoperative serum levels of C-reactive protein and hemoglobin between the 2 groups (P > .05). The mean postoperative serum level of interleukin-6 was significantly lower in group A than in group O (P < .01). Our findings indicate that arthroscopic rotator cuff repair is less invasive than open rotator cuff repair.

Anatomical study of the position and orientation of the coracoclavicular ligaments: Differences in bone tunnel position by gender.

BACKGROUND: Reconstructing both coracoclavicular ligaments following acromioclavicular dislocation has recently been reported to restore the function of the acromioclavicular joint better than traditional procedures. Knowing the appropriate position and orientation of the bone tunnels and the potential risks of neurovascular injuries leads to safe reconstruction. We aimed to answer the following questions: what is the difference in the accurate clavicular bone tunnel positions (BTPs) during coracoclavicular ligament reconstruction between sex, and what are the potential risks for neurovascular injuries? HYPOTHESIS: The BTPs differ by sex at the site of coracoclavicular ligament reconstruction. PATIENTS AND METHODS: We introduced two Kirschner wires into 25 cadaver shoulders (17 male, 8 female), one through the insertion center of the trapezoid ligament and one through the conoid ligament, and measured the distance from the respective Kirschner wire insertion points to the bony landmarks of the clavicle and the oblique angle of each Kirschner wire. The shortest distance from the insertion point of each Kirschner wire to the suprascapular nerve and artery was also measured. RESULTS: While the distance from the acromioclavicular joint to the respective Kirschner wire insertion points tended to be longer in males, the ratio of these insertion points to total clavicle length was constant. Other measurements for respective Kirschner wire insertions to the bony landmarks and neurovascular structures were comparable, as were abduction and retroversion angles. The distance from the suprascapular nerve to the insertion point of the conoid ligament at the coracoid process was 13.8±4.0mm, while the distance from the suprascapular artery was 7.1±3.3mm. DISCUSSION: Appropriate position and orientation of the bone tunnels, and the ratio of the BTPs to the total clavicular length, aid surgeons in performing the reconstruction. The conoid ligament insertion on the coracoid was just proximal to the suprascapular artery, so surgeons should be careful with conoid insertion. LEVEL OF EVIDENCE: V, cadaver study.

Predictors of safety margin for coracoid transfer: a cadaveric morphometric analysis.

BACKGROUND: The purpose of this study was to investigate the relationship between the bone length available for coracoid transfer without coracoclavicular ligament injury and the distance from the coracoid tip to the attachments of the coracoacromial ligament or pectoralis minor. We hypothesized that cadaver height and the soft tissue attachments on the coracoid process were predictive factors for sufficient bone length for coracoid transfer. METHODS: This study included 28 shoulders from Japanese cadavers: 19 male and 9 female. The distance from the coracoid tip to the distal attachment of the coracoclavicular ligament and the anterior and posterior margins of the coracoacromial ligament or pectoralis minor on the coracoid process were measured. RESULTS: The mean available length for coracoid transfer was 24.8 ± 3.4 mm. There was a significant difference in length between male and female subjects, being 26.0 ± 2.9 mm and 22.2 ± 3.0 mm, respectively (p = 0.004). High positive correlations were found between the length of the coracoid transfer and cadaver's height (r = 0.48, p = 0.009) and the distance from the coracoid tip to the anterior coracoacromial ligament attachment (r = 0.63, p < 0.001). The receiver operating characteristic curve area under the curve for cadaver height was 0.72 while that for distance from coracoid tip to anterior coracoacromial ligament was 0.88 when predicted for a sufficient length for coracoid transfer > 25 mm. CONCLUSIONS: Our findings will aid surgeons in preoperative planning and performing of osteotomy of the coracoid safely by predicting the available length of coracoid bone graft.

Combined measurement of nerve root blood flow and electrophysiological values: intraoperative straight-leg-raising test for lumbar disc herniation.

STUDY DESIGN: A total of 15 patients with lumbar disc herniation at the L5-S1 disc level who underwent microendoscopic discectomy were examined. The nerve root blood flow and electrophysiological values were measured during an intraoperative straight-leg-raising (SLR) test. OBJECTIVE: To investigate the relationships between nerve root blood flow changes and the electrophysiological values during an intraoperative SLR test. SUMMARY OF THE BACKGROUND DATA: It is unknown how the electrophysiological values are affected by nerve root blood flow changes during an SLR test. METHODS: We measured S1 nerve root blood flow and electrophysiologically evaluated the nerve root using the compound muscle action potentials (CMAPs) from the gastrocnemius muscle after S1 nerve root stimulation during an intraoperative SLR test. Subsequently, we analyzed the relationships between the nerve root blood flow changes and the electrophysiological values. RESULTS: Before discectomy, there were sharp decreases in the nerve root blood flow after 1 and 3 minutes of the SLR test (P < 0.001), and the amplitudes of the CMAPs deteriorated significantly (P < 0.001). Significant correlations were found between the decrease ratio for the nerve root blood flow during the SLR test and the deterioration ratio for the amplitude of the CMAPs. After discectomy, the blood flow increased significantly (P = 0.001). When the SLR test was performed again, the blood flow showed no significant decreases. The average amplitudes of the CMAPs were significantly ameliorated (P < 0.01). When the SLR test was performed again, no significant differences were found for the average amplitudes after 1 and 3 minutes of the test. CONCLUSION: Significant correlations were found between the decrease ratio for the nerve root blood flow and the deterioration ratio for the amplitude of the CMAPs. The present results demonstrate that temporary ischemic changes in the nerve root cause transient conduction disturbances.

Conehead wedging screw for distal radius fractures in elderly patients.

A retrospective study was done of the treatment of 76 distal radius fractures in patients older than 55 years, using intrafocal fixation with a conehead wedging screw or a threaded Kirschner wire. The average age of the 57 women and 19 men was 65.9 years. The fracture types classified according to Frykman were: 10 Type I, four Type II, two Type III, 11 Type IV, eight Type V, 10 Type VI, eight Type VII, and 23 Type VIII. The fixation materials used were a threaded Kirschner wire in 37 patients, and a conehead wedging screw in 39 patients. Followups for the two groups were 28 and 26 months, respectively. The conehead wedging screws were superior to the threaded Kirschner wires in maintaining postoperative reduction in displaced, moderately comminuted intraarticular fractures in elderly patients and had a lower complication rate. Intrafocal fixation using a conehead wedging screw may be indicated for treatment of intraarticular fractures with moderate comminution in elderly patients.