The application of inverted lateral clavicle locking compression plate for medial clavicle fractures: biomechanical study and clinical implementation.

BACKGROUND: There has been no absolute consensus on the optimal implant for fixation of medial clavicle fracture. The purpose of the present study was to test the biomechanical efficacy of inverted lateral clavicle locking compression plate (LCP-LC) in fixation of this specific fracture location by finite element analysis. METHODS: Transverse and comminuted medial clavicle fracture simulated models stabilized by three different devices including inverted LCP-LC, superior clavicle LCP (LCP-SC), and dual reconstruction (LCP-RP) with LCP-SC were investigated biomechanical performance under three loading conditions, i.e., axial compression, inferior bending, and axial torsion. RESULTS: EQV stress exhibited on implant and elastic strain at fracture site under inferior bending was greater than other loading cases. LCP-SC construct represented the greatest EQV stress and elastic strain. The inverted LCP-LC construct demonstrated lower EQV stress than the LCP-SC construct and was comparable to dual plating. Under axial compression and axial torsion, elastic strain produced from the inverted LCP-LC construct was comparable to dual plating, but greater than dual plating when subjected to inferior bending. CONCLUSION: By the results of FE analysis, inverted LCP-LC could be a potential application for fixation of clavicle fracture with short medial fragment.

Looping a suture under the coracoid process using a modified pelvic suture needle in coracoclavicular stabilization.

A distal clavicle fracture is a common shoulder injury. Coracoclavicular (CC) stabilization is a popular procedure for treating this injury. However, with this method, there is a technical difficulty in looping the suture under the coracoid base with instruments normally available in the operating room (OR). Herein, the authors describe modifying a pelvic suture needle to ease this process. Case presentation: An 18-year-old Thai female presented with left shoulder pain after a fall while cycling. The physical examination showed tenderness at the prominent distal clavicle. The radiograph of both clavicles showed a displaced distal clavicle fracture of the left shoulder. After discussing the treatment, she decided to have CC stabilization as the authors recommended. Clinical discussion: CC stabilization is one of the main surgical techniques used in treating an acute displaced distal clavicle fracture. The most important but difficult step of the CC stabilization is passing a suture under the coracoid base. To make this step easier, various commercial tools have been created, however, they are expensive ($1400-1500 per piece), and most operating rooms in resource-limited countries do not have them available. The authors modified a pelvic suture needle specifically for use in looping a suture under the coracoid process, which is hard to do with standard surgical tools.

Using a right-angle forceps clamp to pass a suture under the coracoid base in coracoclavicular stabilization: a technical note.

A distal clavicle fracture is a common injury of the shoulder joint. Coracoclavicular (CC) stabilization is one of the recommended procedures for treating the distal clavicle fracture. However, it is difficult to pass the suture under the coracoid process with instruments normally available in the operating room (OR). Herein, the authors describe a simple technique to accomplish this suture passing quickly and easily using tools available in the OR. Case presentation: A 59-year-old Thai female presented with right shoulder pain after a fall. The physical examination showed a prominent bulge and tenderness at the right distal clavicle. A radiograph of both clavicles showed a right displaced distal clavicle fracture. After discussing the possible treatments with her, she decided to have CC stabilization as we recommended. Clinical discussion: In CC stabilization, the most important but difficult step is passing a suture under the coracoid base. There are some specialized commercial instruments which are matched to the shape of the coracoid process to make it easy to perform this step, but all are highly expensive (~$1400-1500 per piece) and thus often not available in ORs in resource-limited settings. Conclusion: The authors devised a technique using standard surgical instruments and materials available in all ORs to enable them to pass a suture easily and quickly under the coracoid base.

Displaced varus proximal humerus fracture with conservative treatment: a case report.

The authors report a case of an elderly female with a displaced varus misalignment of a proximal humerus fracture which met the indications for surgery, but the patient was treated conservatively with an arm sling due to the wishes of the patient and her relatives. The clinical outcome was nearly full function compared with the right shoulder. Presentation of case: A 65-year-old Thai female presented with right shoulder pain 1 h after a fall during which her right shoulder hit the floor. Radiographs of the right shoulder in anteroposterior and lateral transcapular views showed a proximal humerus fracture with varus misalignment. The patient and her relatives decided on conservative treatment with an arm sling. At 12 weeks following the fall she was able to move her right shoulder nearly equally to the left shoulder. Intervention and outcome: The authors discussed the treatment options with the patient and her relatives and recommended open reduction and internal fixation with a locking plate and screw, but they decided on conservative treatment with an arm sling. At 12 weeks following the fall she was able to move her right shoulder nearly equally to the left shoulder. She had no pain and could do normal life activities with the right shoulder. Relevance and impact: Patients with severe varus deformity are usually treated with surgery. If there are contraindications for surgery, the stability of the fracture should first be evaluated through radiographs of the fracture in various arm positions.

Using a modified recycled corkscrew suture anchor to pass a suture under the coracoid base.

INTRODUCTION: A common shoulder injury is a distal clavicle fracture which can be treated with various methods such as coracoclavicular (CC) stabilization, fixation with a distal clavicular locking plate, hook plate or tension band wiring. In CC stabilization, the most difficult step is passing a suture under the coracoid base because there is no standard instrument matched to the shape of the coracoid process. We propose a technique using a modified recycled corkscrew suture anchor to pass a suture under the coracoid base. CASE PRESENTATION: A 30-year-old Thai female with a left clavicle fracture was scheduled for CC stabilization. In the step of passing a suture under the coracoid base, we used a modified recycled corkscrew suture anchor to quickly and easily perform this step. CLINICAL DISCUSSION: There are some specialized commercial tools which are designed to pass a suture under the coracoid base but all are very expensive (∼ $1400-1500 per piece). To overcome this problem, we modified a used sterilized corkscrew suture anchor to pass a suture under the coracoid base, normally done from the medial to lateral sides, recycling a device usually discarded after use.

Septic arthritis of shoulder joint following a COVID-19 vaccination: A case report.

Introduction: Septic arthritis of the shoulder joint is a serious condition which requires early diagnosis and treatment. This condition usually presents with shoulder pain, limited range of motion and/or fever, and is diagnosed by shoulder arthrocentesis with significant synovial fluid leukocytosis or positive synovial fluid gram stain or culture. There are some risk factors for septic arthritis, notably bacteremia, pre-existing joint pathology and an immunocompromised host such as poorly controlled type II diabetes mellitus. Case presentation: A 45-year-old Thai female developed left shoulder septic arthritis after an Astra-Zeneca COVID-19 vaccine administration. The clinical symptoms were left shoulder pain, limited range of motion and fever. The probable risk factors were underlying diabetes mellitus type II and vaccine administration technique. The joint fluid culture showed Staphylococcus aureus. This patient was treated with combined arthroscopic debridement and an intravenous antibiotic for 1 week which was then switched to an oral antibiotic for 5 weeks. Her clinical symptoms gradually improved over the 2 weeks following the initiation of treatment. Conclusion: Septic arthritis is a rare complication after a vaccination. Doctors should be especially careful with immunocompromised patients, and always use a correct injection technique.

Using a modified J-shaped Y-knot all-suture anchor to pass a suture under the coracoid process in coracoclavicular stabilization.

INTRODUCTION: The distal clavicle fracture is a common shoulder injury. There are several treatment methods which can achieve good outcomes, of which coracoclavicular (CC) stabilization is one of the most popular surgical options. In CC stabilization, the step of passing a suture under the coracoid base is the most difficult step because the standard surgical tool is not designed for passing a suture under the coracoid process. To solve this problem, there are commercial tools for use in this step but all of them are expensive, and thus of limited availability in developing or low-resource settings. We propose a modified J-shaped Y-knot all-suture anchor for use in passing a suture under the coracoid process. CASE PRESENTATION: A 45-year-old Thai male who had a left distal clavicle fracture was scheduled for CC stabilization. We modified a sterile Y-knot all-suture anchor to loop underneath the coracoid base which was easy to use and can design individually. DISCUSSION: In CC stabilization, there are many specialized commercial tools specially designed to easily pass the suture under the coracoid base but they are very expensive. The surgeon can use this technique to modify J-shaped Y-knot all-suture anchor for use in CC stabilization, recycling a Y-knot all-suture anchor normally discarded after use. CONCLUSION: A modified J-shaped Y-knot all-suture anchor can use in passing a suture under the coracoid process.

A COVID-19 vaccination precipitating symptomatic calcific tendinitis: A case report.

INTRODUCTION: Shoulder pathology may be symptomatic or asymptomatic depending on the patient. We report the first case of a COVID-19 vaccination administration precipitating symptomatic calcific tendinitis from pre-existing, asymptomatic calcific tendinitis. CASE PRESENTATION: A 50-year-old Thai male began experiencing left shoulder pain about 3 hours following a COVID-19 vaccination. He waited at home for the pain to improve, and when it did not improve in about 3 days he decided to see a doctor at the orthopedics clinic. He was sent for ultrasonography of his shoulder, which revealed calcific tendinitis of the subscapularis tendon. DISCUSSION: A SIRVA is normally considered if post-vaccination shoulder pain has not improved within a few days following a vaccination in a patient without shoulder pain prior to the vaccination. In our patient, a COVID-19 vaccination precipitated asymptomatic calcific tendinitis to symptomatic calcific tendinitis. CONCLUSION: Previously asymptomatic shoulder pathologies can be precipitated to symptomatic by a COVID-19 vaccination.

Shoulder injury related to Sinovac COVID-19 vaccine: A case report.

INTRODUCTION: After a vaccination, patients frequently have clinical symptoms of pain and swelling over the injection area which usually resolve 2-3 days after the injection. If the symptoms do not improve, a shoulder injury related to vaccine administration (SIRVA) will be considered, perhaps related to an improper injection technique. Herein we report our first case of a SIRVA after a Sinovac COVID-19 vaccination which occurred due to deep penetration and direction of the needle. The clinical symptoms of the patient improved after treatment with combined oral non-steroidal anti-inflammatory drugs and a short course of intravenous antibiotic. CASE PRESENTATION: A 52-year-old Thai male without prior shoulder pain had a Sinovac COVID-19 vaccination at his right shoulder. The injection was given by a nurse using a 27-gauge needle, 1.5 inches in length. The injection landmark was 3 finger breadths below the midlateral edge of the acromial process. The direction of the needle was 45° to the skin cephalad. Three days after receiving the vaccine the patient began to have right shoulder pain with limited range of motion and acute fever. He was admitted for medical treatment which his clinical symptoms gradually improved. CONCLUSION: We report a case of subacromial-subcoracoid-subdeltoid bursitis following a Sinovac COVID-19 vaccine injection. This condition is rare, and usually related to an incorrect vaccination technique. To avoid this complication, nurses should identify the correct landmark, use an appropriate needle length, and point the needle in the correct direction.

Combined proximal humerus fracture and acromioclavicular joint injury: A case report.

INTRODUCTION: Both the proximal humerus fracture and the acromioclavicular (AC) joint injury are commonly found in shoulder girdle injuries but there are no reports of them presenting together. The mechanism of the AC joint injury is similar to that of the proximal humerus fracture, a lateral impact to the shoulder girdle, but the arm positions are different, as the AC injury usually involves an adducted arm while the proximal humerus fracture normally occurs with the arm in a neutral position. Herein we report, to our knowledge, the first case of a combined proximal humerus fracture and AC joint injury. CASE PRESENTATION: A 40-year-old Thai male presented with right shoulder pain after a motorcycling accident. He was diagnosed as a proximal humerus fracture (Neer 4-part fracture). Open reduction and internal fixation with a Philos plate (Synthes®) in the supine position were then performed. However, an AC joint injury (Rockwood type III) was then noticed on the post-operative X-ray taken in the upright position. We had missed the AC joint injury because all pre-operative imaging had been done only in the supine position. CONCLUSION: The combination of these two fracture types is uncommon and has not been previously reported. Our report suggests that in cases of a proximal humerus fracture resulting from a high-energy mechanism, the surgeon should obtain an X-ray or perform fluoroscopy with the patient in the upright or semi-upright position before surgery to avoid missing an AC joint injury.

Proximity of the Coracoid Process to the Neurovascular Structures in Various Patient and Shoulder Positions: A Cadaveric Study.

PURPOSE: To examine and compare the distances from the anteromedial aspects of the coracoid base and the coracoid tip to the neurovascular structures in various patient positions. METHODS: The experiment was conducted in 15 fresh-frozen cadavers. We dissected 15 right and 15 left shoulders to measure the distances from the anteromedial aspects of the coracoid base and the coracoid tip to the lateral border of the neurovascular structures in the horizontal, vertical, and closest planes. The measurements were performed with the cadavers in the supine, lateral decubitus, and beach-chair positions. With cadavers in the beach-chair position, we evaluated 5 arm postures (arm at side, 45° of abduction, 90° of abduction, 45° of forward flexion, and 90° of forward flexion). RESULTS: The shortest distance from the coracoid base to the neurovascular structures was found in the beach-chair position with arm at side in the horizontal plane (27.4 ± 4.9 mm) and 90° of abduction in the vertical (21.8 ± 4.2 mm) and closest (19.5 ± 4.2 mm) planes. The distances in each plane were statistically significant compared with the supine and lateral decubitus positions (P < .005). Between the coracoid tip and the neurovascular structures, the shortest distance was found in the beach-chair position with 90° of abduction, with 29.3 ± 7.7 mm, 20.8 ± 4.9 mm, and 18.5 ± 5.1 mm in the horizontal, vertical, and closest planes, respectively. The distances were statistically significant in all planes compared with the supine and lateral decubitus positions (P < .005). CONCLUSIONS: Shoulder surgery in the area of the coracoid process is safe, especially with the patient in the supine position. The distance from the coracoid process to the neurovascular structures was closest in the beach-chair position with 90° of arm abduction. CLINICAL RELEVANCE: This study determined the distances between the coracoid process and the neurovascular structures during surgery around the coracoid process.

Perioperative administration of pregabalin in patients undergoing arthroscopic anterior cruciate ligament reconstruction: does it help to relieve postoperative pain?

OBJECTIVE: To evaluate the analgesic effect of perioperative administration of pregabalin in patients undergoing arthroscopic anterior cruciate ligament reconstruction. MATERIAL AND METHOD: Fifty-six patients were randomly assigned to receive either pregabalin 75 mg or a matching placebo, one hour prior to spinal anesthesia, with the second dose repeated 12 hours after the first dose in this comparative study. The means of postoperative pain intensity measured by a verbal rating scale (VRS) of 0 to 10, sedation score of 0 to 3, requirement for morphine using a patient-controlled analgesia (PCA) device, and the median respiratory rate, as well as adverse effect were recorded every four-hour up to 24 hours. RESULTS: Twenty-seven patients received pregabalin, and 29 cases got placebo. Characteristics were not significantly different between the two groups, except for the ages of 29.3 years in the pregabalin group, and 33.8 years in the placebo group. The means of postoperative pain severity, sedation score, consumption of PCA morphine, median respiratory rate, and adverse effects were not significantly different between the two groups. CONCLUSION: Perioperative administration of pregabalin was not superior to placebo in terms of reducing postoperative pain intensity and PCA morphine requirement in patients undergoing arthroscopic anterior cruciate ligament reconstruction.