Pre-operative planning for reverse shoulder arthroplasty in low-resource centres: A modified Delphi study in South Africa.

BACKGROUND: Pre-operative planning for reverse shoulder arthroplasty (RSA) poses challenges, particularly when dealing with glenoid bone loss. This modified Delphi study aimed to assess expert consensus on RSA planning processes and rationale, specifically targeting low-resourced institutions. Our objective was to offer pre-operative decision-making algorithms tailored for surgeons practising in resource-constrained hospitals with limited access to computed tomography (CT) scans. METHODS: A working group generated statements on pre-operative imaging and glenoid of glenoid morphology and intra-operative decision-making. The study was conducted in three stages, with virtual consensus meetings in between. Stages 2 and 3 consisted only of closed questions/statements. The statements with over 70% were considered consensus achieved and those with less than 10% were considered disagreement consensus achieved. RESULTS: Twelve shoulder surgeons participated, with 67% having over five years of experience in shoulder arthroplasty. In the absence of glenoid bone loss, the sole use of plain radiographs for pre-operative planning reached consensus and is recommended by these groups, while 100% advise using CT scans when bone loss is present. Most surgeons (70%) recommend using patient-specific instrumentation (PSI) in cases of structural bone loss. Most of the statements on intra-operative decision-making related to component placement and enhancing stability failed to reach consensus. CONCLUSION: While consensus was achieved on most aspects of pre-operative imaging and planning, technical aspects of surgery lacked consensus. Planning for patients with structural glenoid bone loss necessitates CT scans and planning tools.

Intention to use digital mental health solutions: A cross-sectional survey of university students attitudes and perceptions toward online therapy, mental health apps, and chatbots.

Background: Globally, the high prevalence of mental disorders among university students is a growing public health problem, yet a small minority of students with mental health problems receive treatment. Digital mental health solutions could bridge treatment gaps and overcome many barriers students face accessing treatment. However, there is scant evidence, especially in South Africa (SA), relating to university students' use of and intention to use digital mental health solutions or their attitudes towards these technologies. We aim to explore university 2students attitudes towards and perceptions of digital mental health solutions, and the factors associated with their intention to use them. Methods: University students from four SA universities (n = 17 838) completed an online survey to assess experience with, attitudes and perceptions of, and intentions to use, digital mental health solutions. We conducted an exploratory factor analysis to identify factors underlying attitudes and perceptions, and then used multivariate ordinal regression analysis was used to investigate the factors' association with students' intention to use digital mental health solutions. Results: Intention to use digital mental health solutions was high, and attitudes towards and perceptions of digital mental health solutions were largely positive. Importantly, our analysis also shows that 12.6% of users were willing to utilise some form of digital mental health solutions but were unwilling to utilise traditional face-to-face therapies. The greatest proportion of variance was explained by the factor 'Attitudes towards digital technologies' utility to improve student counselling services, provided they are safe'. Conclusion: SA university students are already engaging with digital mental health solutions, and their intention to do so is high. Certain attitudes and perceptions, particularly concerning the utility, effectiveness, and safety, underlie willingness to engage with these solutions, providing potential targets for interventions to increase uptake.

Moment arms of the coracobrachialis and short head of biceps following a Latarjet procedure: a modeling study.

BACKGROUND: The Latarjet procedure transfers the coracoid process to the anterior glenoid. This prevents recurrent anterior humeral dislocation but alters the origins of the coracobrachialis (CBR) and short head of the biceps (SHB). The impact of this alteration on the moment arms of these muscles has not been examined. METHODS: The Newcastle Shoulder Model was updated with 15 healthy cadaveric bone models to create customized shoulder models. The CBR and SHB muscles were attached to the anterior glenoid via an elliptical wrapping object. Muscle moment arms were calculated for abduction, forward flexion, scapular plane elevation, and internal rotation with 20° and 90° of abduction. Statistical comparison of moment arms between native and Latarjet shoulders was performed using spm1D. RESULTS: By transferring the origins of the CBR and SHB to the anterior glenoid, both muscles had extension moment arms during glenohumeral elevation in the coronal, sagittal, and scapular planes. Their average moment arms during abduction (-30.4 ± 3.2 mm for CBR and -29.8 ± 3.0 mm for SHB) and forward flexion (-26.0 ± 3.1 mm for CBR and -26.2 ± 3.2 mm for SHB) suggested that their role after the Latarjet procedure changed compared with their role in the native shoulder (P < .001). At higher abduction levels, both the muscles had higher internal rotation moment arms compared with the native shoulder. CONCLUSION: The Latarjet procedure affected the moment arms of the CBR and SHB. Both muscles had increased extension and internal rotation moment arms at higher degrees of elevation compared with the native shoulders. This finding suggests that these muscles act as dynamic stabilizers after the Latarjet procedure.

A narrative review of treatment strategies for major glenoid defects during primary reverse shoulder arthroplasty, with a focus on the use of structural bone graft.

Structural glenoid defects are common during primary reverse shoulder arthroplasty (RSA) and are often associated with poor outcomes. The lack of pre-operative imaging protocols for determining the depth and degree of glenoid wear hinders our ability to accurately plan and correct these defects. Although bone grafting has been reported to be effective in reducing glenoid wear during RSA, there is limited information on when to utilise it and how to prepare the graft. We conducted this review to assess the evidence for the management of glenoid defects, with an emphasis on bone grafts to treat structural glenoid bone loss in primary RSA patients.

Surgical management of distal humerus gunshot fractures: descriptive case series.

PURPOSE: The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa. METHODS: A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification. RESULTS: Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months. CONCLUSIONS: These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management. LEVEL OF EVIDENCE: IV.

Characterizing moment arms of the coracobrachialis and short head of biceps in native shoulders and after reverse total shoulder arthroplasty during elevation and rotation: a modeling study.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) alters the line of action of muscles around the glenohumeral joint. The effects of these changes have been well characterized for the deltoid, but there is limited information regarding the biomechanical changes to the coracobrachialis (CBR) and short head of biceps (SHB). In this biomechanical study, we investigated the changes to the moment arms of the CBR and SHB due to RTSA using a computational model of the shoulder. METHODS: The Newcastle Shoulder Model, a pre-validated upper-extremity musculoskeletal model, was used for this study. The Newcastle Shoulder Model was modified with bone geometries obtained from 3-dimensional reconstructions of 15 nondiseased shoulders, constituting the native shoulder group. The Delta XTEND prosthesis, with a glenosphere diameter of 38 mm and polyethylene thickness of 6 mm, was virtually implanted in all the models, creating the RTSA group. Moment arms were measured using the tendon excursion method, and muscle length was calculated as the distance between the muscle's origin and insertion points. These values were measured during 0°-150° of abduction, forward flexion, scapular-plane elevation, and -90° to 60° of external rotation-internal rotation with the arm at 20° and 90° of abduction. Statistical comparisons between the native and RTSA groups were analyzed using 1-dimensional statistical parametric mapping (spm1D). RESULTS: Forward flexion moment arms showed the greatest increase between the RTSA group (CBR, 25.3 ± 4.7 mm; SHB, 24.7 ± 4.5 mm) and native group (CBR, 9.6 ± 5.2 mm; SHB, 10.2 ± 5.2 mm). The CBR and SHB were longer in the RTSA group by maximum values of 15% and 7%, respectively. Both muscles had larger abduction moment arms in the RTSA group (CBR, 20.9 ± 4.3 mm; SHB, 21.9 ± 4.3 mm) compared with the native group (CBR, 19.6 ± 6.6 mm; SHB, 20.0 ± 5.7 mm). Abduction moment arms occurred at lower abduction angles in the RTSA group (CBR, 50°; SHB, 45°) than in the native group (CBR, 90°; SHB, 85°). In the RTSA group, both muscles had elevation moment arms until 25° of scapular-plane elevation motion, whereas in the native group, the muscles only had depression moment arms. Both muscles had small rotational moment arms that were significantly different between RTSA and native shoulders during different ranges of motion. CONCLUSION: Significant increases in elevation moment arms for the CBR and SHB were observed in RTSA shoulders; these increases were most pronounced during abduction and forward elevation motions. RTSA also increased the lengths of these muscles.

Evaluation of an Intensive Care Outreach Nurse Program in 4 UAE Hospitals.

BACKGROUND: Intensive care outreach nurses (ICONs) can reduce deterioration and death of patients in hospitals. PURPOSE: Evaluate outcomes associated with implementation of the ICON role across 4 UAE hospitals. METHODS: Trend analyses and χ 2 tests were used to measure changes before ICON program, during ICON year 1, ICON year 2, when the service coverage extended 24/7, and until the end of 2019. RESULTS: From year 1 to year 2, failures to escalate decreased from a rate of 14.8 to 5.6 episodes per 1000 admissions for all sites combined ( P < .001). The cardiac arrest rate went from 4.04 to 1.42 per 1000 admissions in year 2 and continued downward to 0.72 per 1000 ( P < .001). Transfer from ward or readmission to intensive care unit/high dependency unit varied by site, although there was a statistically significant trend for all hospitals combined. CONCLUSION: The ICON role contributed to fewer failure to escalate incidents and lower cardiac arrest rates.

Assessment and management of shoulder pain at primary care level.

Most patients with shoulder pain will initially visit their community health centre, private general practitioner or family physician, with various levels of experience in the assessment and management of shoulder conditions. Shoulder conditions will range from early, simple ailments that can be treated in the primary care setting, to post-traumatic injuries and complex pathologies requiring the expertise of an orthopaedic surgeon or a fellowship-trained shoulder surgeon. Correct assessment of the patient's shoulder condition at the index consultation is a prerequisite for appropriate management. This article sets out straightforward guidelines to help general practitioners confidently identify the patient's source of shoulder pain and initiate an appropriate management plan at primary care level. Criteria for urgent and elective referral for specialist care are also outlined.

Continuous pulse oximetry during skin-to-skin care: An Australian initiative to prevent sudden unexpected postnatal collapse.

AIM: To examine the use of continuous pulse oximetry monitoring (CPOM) of newborns as a non-invasive and non-intrusive standard of care for promoting early and safe skin-to-skin contact between mothers and newborns immediately after birth and to gather acceptability feedback from midwifery staff and mothers. METHODS: All babies receiving skin-to-skin contact (SSC) had continuous pulse oximetry monitoring (CPOM) for the first-hour postbirth. Staff were trained with education sessions before implementation. Midwives and mothers were surveyed post-implementation and again after distribution of an education brochure regarding CPOM. RESULTS: Seventy per cent of midwives and 66% of mothers responded to the survey. The majority of midwives received the practice positively and felt reassured by the use of CPOM in the immediate postpartum period. The survey identified gaps in maternal knowledge of the risk and benefits of SSC which improved significantly after the distribution of the educational brochure (P = .01). CONCLUSION: Continuous pulse oximetry monitoring with a compact monitor in the first-hour postbirth is a simple, non-invasive and innovative approach to enhance safe skin-to-skin care by improving vigilance of newborns. Our study confirmed the acceptance of such approach by midwives and mothers in our population.

A gender-based comparison of coracoid and glenoid anatomy: CT analysis and discussion of potential impact on the Latarjet procedure.

BACKGROUND: The success of the modified Latarjet procedure depends on proper sizing of the coracoid graft. There is no information available regarding the morphometric relationship between the glenoid cavity and the coracoid process for the South African population. This study aims at measuring the relationship between the glenoid and coracoid morphometries and investigates their gender-related differences. METHODS: Glenohumeral computerized tomography scans of 100 consecutive patients were considered for this study. Morphometric measurements were performed after aligning the coracoid and glenoid in their optimum orientation. These measurements were performed by 2 independent observers. The ratio between glenoid and coracoid measurements was calculated and statistically compared using the Mann-Whitney U test. Intraclass correlation coefficients were calculated to analyze interobserver reliability. All the statistical tests were performed in SPSS v.26, and power calculations in G∗Power v.3.1. RESULTS: An average intraclass correlation coefficient value of 0.79 suggested that the interobserver reliability was good. Except for coracoid length, statistically significant (P < .05) gender differences were observed for all the other morphometries. The coracoid width (16.5 ± 1.4 mm vs. 14.7 ± 1.4 mm) and height (13.6 ± 1.6 mm vs. 10.5 ± 1.5 mm) differed between genders by 1.8 and 3.1 mm, respectively. The glenoid anteroposterior (AP) (25.3 ± 2.9 mm vs. 23.2 ± 2.4 mm) and superioinferior (36.9 ± 1.9 mm vs. 33.7 ± 2.6 mm) measurements differed by 2.1 and 3.3 mm, respectively, between the males and the females. The ratio between the AP width of the glenoid and the coracoid height was also found to be significantly different (P < .05) between the gender groups. These morphometric ratios for the coracoid width (0.66 ± 0.09 mm vs. 0.64 ± 0.08 mm) and the coracoid height (0.55 ± 0.09 mm vs. 0.46 ± 0.07 mm) differed between genders by 0.02 and 0.09, respectively. CONCLUSION: Measurements taken from computerized tomography scans showed significant differences between genders in absolute measurements and in the ratio of the coracoid height to the glenoid AP distance. This could have implications on the ability of the Latarjet procedure to compensate for bone loss in female patients.

Staff's Perception of the Intensive Care Outreach Nurse Role: A Multisite Cross-sectional Study.

BACKGROUND: Rapid Response Systems are emerging internationally to provide a patient-focused approach to prevent potentially avoidable deaths and serious adverse events. LOCAL PROBLEM: This study focused on ward nurses in the United Arab Emirates (UAE) government hospitals who were perceived to lack the confidence and knowledge to detect and/or respond to deteriorating patients. METHOD: A cross-sectional study design was used to evaluate the Intensive Care Outreach Nurse (ICON) role from the perspectives of the ICONs, their managers/educators, and ward-based physicians and nurses. ICONs are intensive care experienced nurses with additional education in the role of rapid responder to the deteriorating patient. INTERVENTIONS: An ICON role was implemented across 4 hospitals to respond to and support clinicians in the recognition and management of the deteriorating patient on general inpatient wards. RESULTS: ICON skills perceived as most beneficial by respondents included staff education, respiratory therapy, medication administration, and intravenous access. CONCLUSIONS: The ICON role is able to support recognition and management of the deteriorating patients.

Exertional hypoxemia is more severe in fibrotic interstitial lung disease than in COPD.

BACKGROUND AND OBJECTIVE: Despite its clinical and prognostic significance, few studies have evaluated the severity of exertional oxygen desaturation in fibrotic interstitial lung disease (ILD). Our objectives were to identify clinical and physiological variables that predict the extent of exertional oxygen desaturation in fibrotic ILD and to quantify the severity of desaturation compared to chronic obstructive pulmonary disease (COPD). METHODS: This retrospective study compared the results of 6-min walk test (6MWT) performed while breathing room air in fibrotic ILD patients and COPD patients eligible for pulmonary rehabilitation. Outcomes included the oxygen saturation (SpO2 ) nadir and the change in SpO2 from rest during a 6MWT. Predictor variables were identified on unadjusted analysis, followed by multivariate analysis to identify independent predictors of desaturation. RESULTS: The study included 134 patients with fibrotic ILD and 274 patients with COPD. The ILD and COPD cohorts had similar age, sex, frequency of major comorbidities, walk distance, baseline SpO2 and baseline Borg dyspnoea scores. DLCO was the strongest predictor of desaturation in both cohorts. Compared to patients with COPD, ILD patients had significantly lower SpO2 nadir values (88.1 ± 6.4 vs 91.0 ± 4.6) and greater decrease in SpO2 from baseline (7.4 ± 5.2 vs 4.5 ± 3.7) after adjusting for demographic features and pulmonary physiology (P < 0.0005), with greater between-group differences at lower DLCO values. CONCLUSION: Patients with fibrotic ILD have greater oxygen desaturation during 6MWT compared to patients with COPD when adjusting for demographic features and pulmonary physiology. These findings suggest the need for disease-specific studies to evaluate the potential utility of ambulatory oxygen in fibrotic ILD.

The modified Latarjet procedure in female patients: clinical outcomes and complications.

BACKGROUND: The aim of this study was to assess the short- and medium-term complications and clinical outcomes of female patients after a modified Latarjet procedure. A review of the literature was also conducted for outcomes of the modified Latarjet procedure in female patients and differences reported between male and female patients. METHOD: We retrospectively reviewed the clinical notes of all female patients who had modified Latarjet procedures from 2001 with at least 1 year of follow-up. Patients were interviewed for an Oxford Shoulder Score, Western Ontario Shoulder Instability Index, Oxford Shoulder Instability Score, and subjective shoulder value. A literature review was performed of the electronic database PubMed; 343 papers were assessed for clinical outcomes based on gender. RESULTS: Twenty-nine patients were available for inclusion in the study. There were 13 complications in 11 patients (34%). The median postoperative Western Ontario Shoulder Instability Index score was 433; Oxford Shoulder Score, 42; and Oxford Shoulder Instability Score, 36. The median subjective shoulder value was 87%. Of these patients, 37.5% returned to sport. The reoperation rate was 13.8%. We found no literature reporting the outcomes of the modified Latarjet procedure in female patients. CONCLUSION: There are no published data comparing outcomes of the modified Latarjet procedure in male and female patients. Female patients had a lower postoperative return to sport and shoulder scores after the modified Latarjet procedure compared with literature reports. Whereas female gender should not be a contraindication to the Latarjet procedure, selection of patients in this group may need to be more stringent.

Amniotic Band Syndrome With Pseudoarthrosis of Tibia and Fibula: A Case Report.

Constriction of the lower limb by a congenital amniotic band has been proposed to explain the development of pseudoarthrosis of the tibia and fibula. We report a case of amniotic band syndrome in a preterm female infant with pseudoarthrosis of the tibia and fibula. She was born at 29 weeks of gestation with congenital amniotic bands and was noted to have a severely edematous left foot distal to the constricting band with rudimentary digits. The skin was pink and well perfused with palpable pulses. Radiography demonstrated pseudoarthrosis of the tibia and fibula. The limb deformities were managed with splints, positioning, and physiotherapy. She underwent Z-plasty with soft tissue release on the left lower leg on day 7 of life. At 36 weeks of postmenstrual age, a repeat radiograph showed markedly improved growth of the tibia and fibula with mature new bone formation, which avoided the need for further surgical intervention. During the follow-up period, she underwent left Syme's amputation at 18 months. At 29 months of age, the child was able to walk and run without support. The findings from our case confirm the potential for bone growth in patients with amniotic band syndrome, once the constricting band has been released. Simple release of the constriction band with Z-plasty resulted in growth of mature bone, replacing the pseudoarthrosis and, hence, the patient did not require surgical amputation. Thus, one should be cautious when deciding on surgical amputation, even in the presence of pseudoarthrosis, especially in preterm infants. Early limb-preserving surgery with release of the constricting band with an intention to salvage the limb appears appropriate.

Outcomes After Ulnar Nerve In Situ Release During Total Elbow Arthroplasty.

PURPOSE: Ulnar nerve (UN) lesions are a significant complication after total elbow arthroplasty (TEA), with potentially debilitating consequences. Outcomes from a center, which routinely performs an in situ release of the nerve without transposition, were investigated. METHODS: Eighty-three primary TEAs were retrospectively reviewed for the intraoperative management of the UN and presence of postoperative UN symptoms. RESULTS: Three patients had documented preoperative UN symptoms. One patient had a prior UN transposition. The nerve was transposed at the time of TEA in 4 of the remaining 82 elbows (5%). The indication for transposition in all cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. Of the 4 patients who underwent UN transposition, 2 had postoperative UN symptoms. Both were neuropraxias, which resolved in the early postoperative period. The remaining 78 TEAs received an in situ release of the nerve. The incidence of postoperative UN symptoms in the in situ release group was 5% (4 of 78). Two patients had resolution of symptoms, whereas 2 continued to experience significant UN symptoms requiring subsequent transposition. Seven patients had preoperative flexion of less than 100°. Of these, 2 had a UN transposition at the time of TEA. Of the remaining 5 elbows with preoperative flexion less than 100°, 2 had postoperative UN symptoms after in situ release, with 1 requiring subsequent UN transposition. CONCLUSIONS: A 3% incidence of significant UN complications after TEA compares favorably with systematic reviews. We do not believe that transposition, which adds to the handling of the nerve and increases surgical time, is routinely indicated and should rather be reserved for cases with marked limitation of preoperative elbow flexion or when intraoperative assessment by the surgeon deems it necessary. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Total elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches.

BACKGROUND: Total elbow arthroplasty (TEA) is associated with high complication rates compared with other large-joint arthroplasties. The frequency and type of complication may differ, depending on the surgical approach. A comparison of outcomes with triceps-off and triceps-on approaches was investigated. METHODS: Seventy-three patients underwent 83 primary TEAs between 2003 and 2012. Forty-six elbows had a triceps-off approach, and 37 had a triceps-on approach. Results were reviewed at a mean of 4.2 years. Cementing technique was graded according to Morrey's criteria, and clinical outcomes were assessed by means of the Mayo Elbow Performance Score. RESULTS: There was no statistically significant difference between the triceps-off and triceps-on groups with regard to the patient's age, gender, preoperative Mayo Elbow Performance Score or range of motion, or previous surgery on the affected elbow. Among patients who underwent a TEA for an inflammatory arthropathy, there was a significant difference in outcome between groups with regard to final flexion, extension, arc of motion, and pronation. Cementing technique in the triceps-off group was adequate in 70%. In the triceps-on group, cementing technique was adequate in 92%. The complication rate in the triceps-off group was 32.6% and included 7 triceps ruptures. Three patients who had attempted repairs of the triceps rupture developed deep infections requiring multiple further surgeries. The complication rate in the triceps-on group was 8.1%. CONCLUSION: A triceps-on approach in TEA results in consistently good clinical outcomes with no risk of triceps rupture, and the approach does not compromise the cement mantle. We believe that this approach will reduce complication rates in TEA.

Angular stable fixation of displaced distal-third clavicle fractures with superior precontoured locking plates.

HYPOTHESIS: We reviewed the outcome of angular stable plates in addressing displaced lateral-third clavicle fractures. We investigated union, shoulder function, request for implant removal, and return to sport. Our hypothesis was that these implants provide predictable union and return to sports without the negative consequence of leaving plates in situ, reducing the requirement for a second surgery. METHODS: We undertook a retrospective review of a consecutive series of patients who underwent this surgery between 2007 and 2010. Nineteen patients with a mean follow-up of 25 months were included. Postoperative follow-up was performed at 2 weeks and monthly thereafter until union was assessed as achieved clinically and radiographically. Two telephone interviews at a mean of 7 months and 25 months postoperatively assessed shoulder function by Oxford Shoulder Score, presence of any plate or scar discomfort, need for implant removal, and return to sport. RESULTS: Nineteen patients achieved union by 4 months (median, 12 weeks; range, 6-16 weeks). The mean Oxford Shoulder Score was 46 (range, 41-48) at a mean of 7 months (range, 3-18 months) and 47 (range, 44-48) at 25 months (range, 18-48 months). Initially, 2 patients requested implant removal; later, however, both declined surgery. No plates have been removed. Four patients complained of mild plate discomfort but did not wish removal. All patients had returned to sporting activities. CONCLUSION: Angular stable plate fixation of Neer group II, type II clavicle fractures resulted in a 100% union rate with excellent return of function with no mandatory need for removal.

Pediatric atlanto-occipital dissociation: radiographic findings and clinical outcome.

STUDY DESIGN: Retrospective diagnostic feasibility study and clinical review. OBJECTIVES: To evaluate the feasibility of making an initial atlanto-occipital dissociation (AOD) diagnosis from four radiological measurements of the craniocervical relationship on lateral cervical spine x-rays and to assess the AOD patients' clinical outcomes relative to their magnetic resonance imaging (MRI) findings. METHODS: The Powers ratio, Wackenheim line, basion-dens distance (BDD), and the C1/2:C2/3 interspinous ratio were measured in 58 pediatric controls and ten MRI-confirmed patients with AOD. The ability to identify the required anatomical landmarks and make the measurements was noted and sensitivity and specificity calculated. The correspondence between the clinical presentation and outcomes for patients with AOD and their MRI features was investigated. RESULTS: Clear landmarks for measuring interspinous ratio and Wackenheim line were confirmed by all x-rays. The BDD was measureable in 90% and the Powers ratio could be calculated in only possible in 59%. The interspinous ratio and BDD offered high sensitivities and specificity. Although the Wackenheim line was consistantly measured, it conferred a low sensitivity but reasonable specificity. The Powers ratio offered high specificity with low sensitivity. On MRI, all patients with AOD had apical ligament disruption, with a high rate of interspinous ligamentous injury (8/9); prevertebral swelling (7/9); retroclival hematoma (6/9); and tectorial membrane injury (4/9). The only MRI feature associated with poor outcome was that of altered cord signal. Both patients who died had cord signal changes on T1- and T2-weighted images. The third patient with cord signal change was limited to T2 changes with a normal T1. He had a C5-L3 sensory deficit that resolved. The degree of tectorial membrane injury did not appear to influence outcome. CONCLUSIONS: The BDD and interspinous ratio offer the best measures for initial x-ray diagnosis of AOD. This will alert the surgeon to the need for MRI. These patients often have a reduced level of consciousness, thus making clinical evaluation difficult. The MRI findings, although apparently indicative of severe abnormality, did not actually correspond to outcomes except for the presence of T1 cord signal changes that matched with severe neurological impairment and subsequent death.

Emergency use of a size 1 laryngeal mask airway in a ventilated neonate with an undiagnosed type IV laryngotracheo-oesophageal cleft.

The perioperative management of a neonate with a type IV laryngotracheo-oesophageal cleft and exomphalos major is described. Following an otherwise uncomplicated exomphalos repair, this baby became increasingly and inexplicably difficult to ventilate through an endotracheal tube. The emergency use of a laryngeal mask airway as a rescue maneuver allowed positive pressure ventilation, and subsequent diagnosis of the airway abnormality. The difficulties in management of the two co-existing conditions are discussed.