Hyperbaric Oxygen as an Adjunctive Therapy Postfasciotomy for Unilateral Supraspinatus Rhabdomyolysis and Compartment Syndrome.

We present a case of severe supraspinatus muscle rhabdomyolysis following overexertion in a young male. Preexisting risk factors included illicit drug use. Even single muscle rhabdomyolysis can cause significant renal failure, and in our case the use of intravenous flushing was used in conjunction with hyperbaric oxygen after muscle compartment fasciotomy to maximize muscle recovery and renal protection in a manual worker (musician). Clinicians should be alert to severe muscle pain requiring narcotics after strenuous use.

Early unprotected return to contact sport after metacarpal fixation in professional athletes.

AIMS: To determine whether an early return to sport in professional Australian Rules Football players after fixation of a non-thumb metacarpal fracture was safe and effective. PATIENTS AND METHODS: A total of 16 patients with a mean age of 25 years (19 to 30) identified as having a non-thumb metacarpal fracture underwent open reduction and internal plate and screw fixation. We compared the players' professional performance statistics before and after the injury to determine whether there was any deterioration in their post-operative performance. RESULTS: Of the 16, 12 sustained their fracture during the season: their mean time to return to unrestricted professional play was two weeks (1 to 5). All except two of the 48 player performance variables showed no reduction in performance post-operatively. CONCLUSION: Our data suggest that professional athletes who sustained a non-thumb metacarpal fracture can safely return to professional play without restriction two weeks after internal fixation. Cite this article: Bone Joint J 2017;99-B:1343-7.

Effect of interscalene anaesthesia on cerebral oxygen saturation.

Interscalene blockade (ISB) is commonly associated with Horner's syndrome, indicating spread of injectate to the cervical sympathetic chain. Cervical sympathetic nerve activity (SNA) is believed to influence cerebral autoregulation, and a decrease in sympathetic tone may alter cerebral blood flow (CBF). This study investigated whether ISB influenced CBF in patients undergoing shoulder surgery. Patients (n=30) scheduled for elective shoulder arthroscopy were recruited. Cerebral oxygen saturation (ScO(2)) of the left and right frontal cortices was continuously measured during ISB administration, sedation and anaesthetic induction. Baseline ScO(2) was similar in blocked and unblocked sides (74 ± 5% and 73 ± 5% respectively, P=0.70). ScO(2) decreased with sedation (-3 ± 3% and -4 ± 3%, P=0.93), and increased with pre-oxygenation and general anaesthesia (P <0.01). Following ISB there was no change in ScO(2) between blocked and unblocked sides (P=0.18), or any difference between right- or left-sided ISB. ISB is not associated with an increase in CBF as indicated by ScO(2), despite the presence of Horner's syndrome.

Combined joint fusion for index and middle carpometacarpal instability in elite boxers.

Isolated instability of the index and middle finger carpometacarpal joints is uncommon. An unpublished injury pattern in a consecutive series of 13 elite boxers is described, with mid-term radiological and functional results of two novel surgical treatments. All the boxers (from Australia and the UK) were unable to compete owing to pain and weakness. Four boxers were managed initially by open reduction and temporary K-wire fixation. Nine boxers underwent primary carpometacarpal arthrodesis. All were able to return to their previous level of competition. One boxer who had undergone a soft tissue reconstruction competed at international level but required an arthrodesis because of recurrent symptoms. In elite boxers, simple reduction and wiring may be appropriate for an acute injury causing index or middle finger carpometacarpal joint instability, however, arthrodesis is the treatment of choice when instability and degenerative changes are present.

Effect of phenylephrine on the haemodynamic state and cerebral oxygen saturation during anaesthesia in the upright position.

BACKGROUND: The upright sitting or beachchair position is associated with hypotension, risk of cerebral hypoperfusion, and cerebral injury. We hypothesized that by increasing arterial pressure with phenylephrine administration, cerebral perfusion, and postoperative recovery would be improved. METHODS: Thirty-four patients undergoing elective shoulder surgery were randomized to receive either saline or phenylephrine infusion (PE) 5 min before being placed in the upright position. Simultaneous measurements of mean arterial pressure, cerebral oxygen saturation, middle cerebral artery velocity, and cardiac function using transthoracic echocardiography were made. Postoperative neurocognitive function was assessed. RESULTS: At the commencement of PE, mean (SD) cerebral oxygen saturation significantly decreased from 77 (10) to 67 (13)% (P=0.02), and further to 59 (11) % on upright positioning. The level of cerebral saturation upright was not significantly different to patients receiving saline (P=0.07), with values remaining at room-air levels. Middle cerebral artery blood velocity increased by 20% (P=0.04). Phenylephrine prevented hypotension in the upright position primarily by maintaining preload and increasing systemic vascular resistance (P=0.01), and was associated with a decrease in cardiac output. No postoperative neurocognitive dysfunction was identified. CONCLUSIONS: Despite maintaining arterial pressure with phenylephrine, cerebral desaturation occurred with upright positioning. Cerebral oxygen saturation can provide a valuable endpoint when evaluating the effect of vasopressor therapy on cerebral perfusion.

The effect of the sitting upright or 'beachchair' position on cerebral blood flow during anaesthesia for shoulder surgery.

The sitting upright or 'beachchair' position is commonly used for shoulder arthroscopic surgery. There is a theoretical concern that anaesthetised patients placed in this posture are at risk of reduced cerebral blood flow (CBF), especially if there is associated hypotension. This study investigated the effect of anaesthetic-induced hypotension on estimated cerebral blood flow in patients placed in the beachchair position for shoulder surgery. Forty patients were randomised to either sedation (propofol infusion 10 to 20 mg x hour 1, n = 20) or general anaesthesia using sub minimum alveolar concentration of sevoflurane (n = 20). All patients received an interscalene brachial plexus regional block. Internal carotid artery blood flow was measured using the time averaged velocity of the spectral Doppler waveform, and was then used as an estimate of global CBF. Following a pre-anaesthesia study, measurement of internal carotid artery blood flow was made before and after beachchair positioning, and at five-minute intervals during surgery. Beachchair positioning during general anaesthesia significantly decreased the mean arterial pressure (34 +/- 10 mmHg) compared to sedation (4 +/- 2 mmHg, P < 0.01), and vasopressor therapy was required more often. However, CBF remained constant in both anaesthetised (P = 0.83) and sedated patients (P = 0.68) despite beachchair positioning, and the fall in mean arterial pressure in the anaesthetised patients. There was no significant difference in CBF between groups (P = 0.91). These findings indicate that in patients in the beachchair position receiving sevoflurane anaesthesia, CBF is maintained when mean arterial pressure is above 70 mmHg, consistent with intact autoregulation.

When physiology becomes pathology: the role of magnetic resonance imaging in evaluating bone marrow oedema in the humerus in elite tennis players with an upper limb pain syndrome.

Upper limb stresses are well recognised in tennis, and the normal physiological responses of the humerus to externally applied forces are well defined. Changes to both the microscopic and macroscopic bony architecture are often not apparent on plain radiographs in the early stages of a stress reaction. Bone scintigraphy is more sensitive, but not very specific to subtle changes, as is computer aided tomography. Magnetic resonance imaging (MRI) scans are now used to assess many musculoskeletal injuries, and may allow earlier recognition of changes. This study reports on eight high level tennis players (seven professionals, one highly ranked amateur), who all presented during the course of the 2002 Australian Open and its lead up events. All had an upper limb pain syndrome centred around the elbow. Each underwent an MRI scan. A group of asymptomatic players also had scans of the same area to serve as controls. All symptomatic patients had various levels of bone marrow oedema in their distal humerus, some with periosteal reactions, although most without. No scans revealed a cortical breach. The management of these reactions is problematic in players on an international circuit, as review is sporadic and not always coordinated. The timetabling of international tournaments means it is difficult for top players to obtain adequate rest to avoid injury. Awareness of this early overuse reaction needs to be raised to allow preventive and therapeutic options to be considered to reduce the incidence of this humeral stress response producing an upper limb pain syndrome.

A randomized trial of ultrasound-guided brachial plexus anaesthesia in upper limb surgery.

Ultrasound guidance allows real-time identification of relevant anatomy and needle position when performing brachial plexus regional anaesthesia. The aim of this investigation was to determine whether the use of surface ultrasound could improve the quality of brachial plexus anaesthesia for upper limb surgery. Forty patients were randomized to either conventional "landmark-based" plexus anaesthesia, or to an ultrasound-guided approach using a 13 mHz linear array transducer Both interscalene and axillary techniques were used. The use of ultrasound significantly improved the onset and completeness of sensory (P=0.011) and motor (P=0.002) block. Ultrasound guidance also significantly reduced (P=0.012) the incidence of paraesthesia during the performance of the blocks. Ultrasound guidance increases the quality of sensory and motor blockade in brachial plexus regional anaesthesia, and by reducing the incidence of paraesthesia during performance of the blocks, may confer greater safety.

MR imaging of thumb carpometacarpal joint ligament injuries.

This study describes the MR imaging appearances of the supporting ligaments of the thumb carpometacarpal joint in asymptomatic volunteers and in a group of patients following joint injury. Fourteen patients with 11 acute and three chronic injuries underwent MR imaging. The anterior oblique ligament was the most commonly injured ligament, usually on the metacarpal side where it was disrupted, or allowed dislocation because of subperiosted stripping from the base of the thumb metacarpal. The dorsal radial ligament was occasionally avulsed or partially torn from the trapezoid. Following chronic injury, MR imaging can evaluate ligamentous laxity, ganglion cyst formation or osteoarthritis. Accurate evaluation of ligament injury may identify patients who would benefit from surgery.

Extensor carpi ulnaris subluxation or dislocation? Ultrasound measurement of tendon excursion and normal values.

Dislocation or subluxation of the extensor carpi ulnaris (ECU) tendon is one of the differential diagnoses of ulnar-sided wrist pain. No data exists on the degree of subluxation occurring in normal wrists. Retrospective review of surgical cases revealed two patients with dorsal and four with volar instability. Magnetic resonance imaging and ultrasound were not always predictive of the direction of instability. A standardised ultrasound technique was used to evaluate ECU subluxation in 20 asymptomatic wrists. In normal subjects, as a percentage of the width of the osseous groove, the volar edge of extensor carpi ulnaris may displace by up to 40% beyond the volar lip of the osseous groove with wrist flexion and the dorsal edge by 33% beyond the dorsal lip with wrist extension. The effect of gender on normal range and the diagnostic use of the standardised ultrasound technique need further evaluation.

Sonographic examination of lateral epicondylitis.

OBJECTIVE: The purpose of this study was to describe the sonographic appearance of the common extensor origin in cadavers and asymptomatic volunteers, and to relate this appearance to the findings in patients with lateral epicondylitis. SUBJECTS AND METHODS: Seventy-two elbows in 71 patients with lateral epicondylitis were examined on sonography. Most of the patients (60/71) gave a history of repetitive microtrauma. The injuries were evaluated with respect to location and severity. Focal areas of degeneration, discrete cleavage tears, and involvement of the lateral collateral ligament were identified. Calcification and bony changes were noted. The appearance of the normal common extensor tendon was described, and cadaveric specimens were dissected. Twenty-one patients subsequently underwent surgery. RESULTS: The normal common extensor origin is composed of longitudinal fibrils bound closely with the extensor carpi radialis brevis constituting most of the deep fibers, with the extensor digitorum making up the superficial part. The lateral collateral ligament can be identified as a discrete and separate band. The most common appearance of lateral epicondylitis is a focal hypoechoic area in the deep part of the tendon (46/72). These focal areas were identified at surgery and corresponded histologically to collagen degeneration with fibroblastic proliferation. Often discrete cleavage planes traversing the tendon were manifest as partial (18/72) and complete (2/72) tears. The lateral collateral ligament was involved in eight of 72 elbows. CONCLUSION: Sonography of the common extensor origin can be used to confirm lateral epicondylitis in patients with lateral elbow pain and provide information about the severity of the disease.

Magnetic resonance imaging of the wrist ligaments.

The advent of small arthroscopes has enabled the hand surgeon to visualize the ligaments of the wrist directly with resultant increased accuracy in diagnosing and treating pathology. Orthopaedists are now demanding a preoperative assessment and this, in turn, has necessitated that radiologists have a comprehensive understanding of wrist anatomy. High resolution MR imaging can identify the wrist ligaments reliably and provide information concerning their integrity. Interpretation is not straightforward; there is considerable anatomic variation, and there are perforations, defects and degenerative tears that can be troublesome in diagnosing injury. However, with experience and attention to anatomic detail, the radiologist can provide useful information regarding structural abnormalities. When injured, the ligaments of the wrist behave as other joint ligaments do. Findings following injury include discontinuity of normal striated bands, incomplete disruption, irregularities and alteration in normal signal. Fluid pooling around a ligament and concomitant bone injury are other clues to injury. The identification of such structural abnormalities may help to explain altered biomechanics and improve the management of patients following wrist injury.

A safe technique for distal biceps repair using a suture anchor and a limited anterior approach.

We describe a safe and simple method of repairing an acute rupture of the distal biceps tendon using a single limited (3 cm) anterior approach, a suture anchor, and the use of a plastic sheath (arthroscopy cannula or barrel of a 2 ml syringe) to protect the adjacent neural structures and to remove the need for extensive dissection and retraction in order to protect these structures. We have used this technique on three patients to date and all have regained a full range of flexion and extension at the elbow and pronation and supination of the forearm at a minimum of 6 months follow-up. There have been no neurovascular complications.

Bone scan findings in Kienböck's disease. A case report with atypical findings and literature review.

The authors present an 18-year-old man who had a 5-month history of a painful left wrist. Despite the prolonged history, discrete photopenia on the blood-pool phase and photopenia relative to the remainder of the ipsilateral carpus on the delayed phase of a bone scan in the region of the lunate was shown. When Kienböck's disease is seen in its late phase, the bone scan findings may be atypical in that they may not show the usual three-phase bone scintigraphic evidence of bone remodeling expected in delayed diagnosis avascular necrosis. A review of the previous literature is presented.

Smoking, alcohol and the risk of Dupuytren's contracture.

We investigated the association of Dupuytren's contracture with smoking and with alcohol by a case-control study in which 222 patients having an operation for this condition were matched for age, operation date and gender with control patients having other orthopaedic operations. Fifty of the cases were also each matched with four community controls. Data were collected by postal questionnaire. Dupuytren's contracture needing operation was strongly associated with current cigarette smoking (adjusted odds ratio 2.8 (95% confidence interval (CI) 1.5 to 5.2)). The mean lifetime cigarette consumption was 16.7 pack-years for the cases compared with 12.0 pack-years for the controls (p = 0.016). Dupuytren's contracture was also associated with an Alcohol Use Disorders Test score greater than 7 (adjusted odds ratio 1.9 (95% CI 1.02 to 3.57)). Mean weekly alcohol consumption was 7.3 units for cases and 5.4 units for controls (p = 0.016). The excess risk associated with alcohol did not appear to be due to a confounding effect of smoking, or vice versa. Smoking increases the risk of developing Dupuytren's contracture and may contribute to its prevalence in alcoholics, who tend to smoke heavily.

Chronic fibrosing pancreatitis in childhood: report of a case and literature review.

Chronic fibrosing pancreatitis in childhood is an uncommon condition of unknown etiology with a variety of clinical presentations, histopathologic features, and outcomes. The diagnosis is one of exclusion (of hereditary or secondary pancreatitis), which should include histological assessment. The histological features of this condition have been described, to our knowledge, in nine published cases. We report a case in a 13-year-old male, who presented with obstructive jaundice and subsequently had evidence of endocrine and exocrine pancreatic insufficiency, despite a surgical decompression of the pancreatic-biliary duct system.

Revision of failed total elbow arthroplasty.

We reviewed 25 patients with rheumatoid arthritis who had failure of 26 primary total elbow arthroplasties causing pain and loss of function. Most revision cases required special custom implants to treat varying bone loss and soft-tissue disruption. Assessment showed satisfactory functional results in the patients treated by revision at a mean follow-up period of 35 months. Our review suggests that revision surgery produces short- to medium-term painfree function, and is the treatment of choice for a failed total elbow arthroplasty in the absence of infection.

The interaction between endothelium-derived relaxing factor (EDRF) and eicosanoids in the regulation of the mesenteric microcirculation.

Locally produced eicosanoids and endothelium-derived factors are believed to be the mediators of vascular tone of various vascular beds including the mesentery. Using a small vessel isometric myograph which allows direct measurement of microvascular reactivity, the interaction of eicosanoids and endothelium-derived relaxing factor (EDRF) in regulating vascular tone of mesenteric microcirculation of the rat was characterized. The microvascular response to various vasoactive agents before and after inhibition of prostacyclin production with indomethacin (INDO, 5 microM) and inhibition of EDRF synthesis with N omega-nitro-L-arginine methyl ester (L-NAME, 50 microM) was compared. Analysis of dose-response curves for prostaglandin F2 alpha (PGF2 alpha), U46619, a stable thromboxane analog, and norepinephrine (NE) after pretreatment with INDO demonstrated that inhibition of endogenous eicosanoids significantly attenuated the vasoconstrictor response to PGF2 alpha and U46619 but not to NE. Inhibition of EDRF synthesis with L-NAME potentiated the vasoconstrictor response to PGF2 alpha, U46619, and NE. These results suggest that EDRF acts as the primary mediator of vasodilator tone in the mesenteric microcirculation rather than vasodilator cyclooxygenase products such as prostacyclin. It also appears that the vasoconstrictor action of PGF2 alpha and U46619 may be mediated by a release of an endogenous indomethacin-sensitive factor.

Results of Watson-Jones ankle reconstruction for instability. The influence of articular damage.

We reviewed 32 ankles in 30 patients at an average of five years after a Watson-Jones tenodesis. All but one patient had had ankle pain before operation and 19 had had clicking, catching, or locking of the ankle. Eleven of these had an ankle arthrotomy at the time of ligament reconstruction for intraarticular pathology. At review seven of 23 ankles had a significant decrease in ankle motion, and five in subtalar motion, but only two were unstable on examination. Twenty-one ankles, however, caused some pain on activity and nine were tender on palpation. These findings indicate intra-articular degeneration or injury rather than simple instability. Radiographs of 16 ankles showed good varus and anterior-drawer stability. Seven had talocrural osteoarthritis, but only four showed grade-1 subtalar osteoarthritis. We found no correlation between follow-up time and long-term results. The Watson-Jones tenodesis provides good rotational and lateral ankle instability and does not appear to lead to subtalar degeneration.