Arthroscopic transosseous rotator cuff repair: how to avoid damaging the axillary nerve-a cadaveric study.

INTRODUCTION: Arthroscopic transosseous rotator cuff repair can be performed with an external guide, although the proximity to the axillary nerve raises safety concerns. The aim of this study is to determine the safety of different drilling angles regarding the axillary nerve. MATERIALS AND METHODS: We performed a bone tunnel in the greater tuberosity in 17 fresh frozen shoulders, using an external guide at four different angles: 40°, 50°, 60°, and 70°. At each angle, we measured the distance between the drill and the axillary nerve, the distance from the acromion to the skin incision point, and the perimeter of the arm at the axilla. RESULTS: The distance to the axillary nerve was safe with the guide at an angle of 40°, 50° and 60°, but not at 70° (p = 0.001). We found significant differences between all four angles (p < 0.05). Regression analysis demonstrated the influence of the guide angle in all measurements assessed (p < 0.001). There was no association between the measurements taken and the axillary perimeter (p > 0.5). CONCLUSIONS: Arthroscopic transosseous rotator cuff repair with an external guide does not pose a risk for the axillary nerve using angles of 60° or less.

Normal Shoulder MRI and MR Arthrography: Anatomy and Technique.

The use of MR for the diagnosis of shoulder lesions is well established, as well as MR arthrography for the diagnosis for shoulder instability and microinstability. For an accurate evaluation is essential to know the normal anatomy and variants to avoid the misdiagnosis of a pitfall as pathological condition. In addition we will discuss which variants might be clinically relevant. We will review the classical frequent variants such as intraarticular structures, especially glenohumeral ligaments and labrum but also bone, cartilage and rotator cuff variants and pitfalls. Both static and dynamic structures play an important role providing stability at different positions and with different range of motion.

The anterolateral corner of the radial metaphysis as a source of bone graft for the treatment of scaphoid nonunion.

As a source of corticocancellous grafts for treating scaphoid nonunions, the anterolateral corner of the distal radial metaphysis has several advantages over other alternatives: it provides good-quality corticocancellous bone, it allows one to harvest the graft and treat the scaphoid through the same incision, it does not require general anesthesia, and it has less morbidity than occurs when obtaining the graft from the iliac crest.

Role of Fibular Allograft in Proximal Humerus Fractures: A Systematic Review.

OBJECTIVES: To analyze the outcomes and complication rates of fibular allografts (FA) as an augmentation technique for proximal humeral fractures and determine their appropriate indications. DATA SOURCES: English- and Spanish-language articles in PubMed, MEDLINE, Embase, Web of Science (Core Collection), and Google Scholar databases were systematically reviewed with the Preferred Reporting Items for Systematic Reviews guidelines on April 10, 2020. STUDY SELECTION: Studies of patients with proximal humeral fractures treated primarily with FA and locking compression plates and with a minimum follow-up of 6 months were included, and presenting results with standardized clinical scales, radiological values, and operative complications. DATA EXTRACTION: Two authors independently extracted data from the selected studies with a standardized data collection form. Subsequently, each extracted data set was consolidated on the agreement of authors. DATA SYNTHESIS: From the initial screening of 361 articles, 5 case series and 6 retrospective cohort studies were included. A meta-analysis was not performed. CONCLUSIONS: FA improved the clinical and radiological results, thereby reducing complications. The optimal indication for this procedure may be a 4-part fracture with medial column disruption in younger adults. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Postoperative Imaging of the Wrist and Hand.

In this article we will do an overview of the general and specific complications that occur after the most common wrist and hand surgeries. Knowledge of the different surgical techniques is essential for postoperative imaging evaluation. General complications include infection, complex regional pain syndrome, problems related with the surgical approach (open or arthroscopic) and bone healing problems. The most frequent fractures of the wrist with specific complications are distal radius fractures and scaphoid fractures as associated with tendon ruptures secondary to friction, nonunion or secondary malignment. We will briefly review the different approaches for triangular fibrocartilage injuries, including acute and degenerative lesions. Scapholunate instability is the most common instability and an important indication for surgery with pin fixation in the acute setting and arthroplasty or arthrodesis in the chronic irreparable injuries. One of the most common surgeries of the wrist is carpal tunnel release, although complications are uncommon, radiologists should be familiar with the normal appearance and pathological changes after surgery. Trapeziometacarpal joint osteoarthritis is frequent especially in postmenopausal women and has several treatment options depending on the stage.

Can collagenase effectiveness in Dupuytren's contracture be improved by using ultrasound-guided Injection? A comparative study.

The objective of this study was to compare the effectiveness of ultrasound-guided injection of collagenase Clostridium histolyticum (CCH) in patients with Dupuytren's contracture (DC), with the standard injection. We hypothesised that the ultrasound-guided Injection of CCH is more effective than the standard injection. A prospective cohorts study in patients with DC was done. We treated consecutively 47 fingers with the standard injection and 43 with the ultrasound-guided. Patients in both groups had the same inclusion criteria. The degrees of contracture of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints were measured before treatment and after three months. We compared the effectiveness of each type of injection in respect to obtaining a complete finger extension and to the percentage of improvement in each finger and in each joint. With ultrasound-guided injection, complete finger extension was obtained in 54% of cases and an 81% mean percentage of correction of the finger contracture; with standard injection 49% and 77%, respectively. In the MCP joint, the mean percentage of correction was 92.5 % in the ultrasound-guided Injection group and 84% in the standard injection group. In the PIP joint, it was 75.1% in the ultrasound-guided injection group and 65.3% in the standard injection group. These results showed no statistical significance. Hand surgeons must balance the possible benefits of the ultrasound-guided injection with the complexity and resources needed to perform the technique.

Conservative treatment of 3-part and 4-part proximal humeral fractures: a systematic review.

BACKGROUND: Although there are numerous publications about surgical treatment of proximal humeral fractures (PHFs), few assess conservative treatment, which is the most common approach. The aim of this systematic literature review was to assess criteria for indications, treatment protocols, and outcomes obtained with the conservative treatment of 3-part and 4-part PHF. METHODS: We searched the PubMed and Cochrane databases for clinical studies published between 2000 and 2019 on conservative treatment for 3-part and 4-part PHF that included patients older than 18 years, a minimum follow-up of 1 year, fracture classification, and description of outcomes with assessment scales. RESULTS: The search yielded 26,660 records. We reviewed 44 of them in full, and finally 6 studies were included. We obtained a population of 133 patients (79% women), with a mean age of 74.3 years (range 25 to 98) and mean follow-up of 32 months (range 12 to 68.8). According to the Neer classification system, there were 41% (55) three-part fractures and 59% (78) four-part fractures; 5.81% of the patients were lost to follow-up. The mean Constant score was 64.5 for three-part fractures and 54.9 patients with four-part fractures. Consolidation was achieved in 95% of the three-part fractures and 91% of the four-part fractures. Loss of mobility varied according to the type of fracture. Regarding complications, the most frequent was malunion (21%), followed by avascular necrosis (9%). CONCLUSIONS: Our data show that most three-part PHFs treated conservatively achieve fracture consolidation even noting a negligible rate of malunion got fair-good functional results with few complications, while the orthopedic four-part PHF treatment presents high rate of consolidation with less rate of malunion than the three-part PHF but achieve poor functional results with few complications. LEVEL OF EVIDENCE: Level IV, Systematic Review.

Expanded Distribution of Pain as a Sign of Central Sensitization in Individuals With Symptomatic Knee Osteoarthritis.

BACKGROUND: Expanded distribution of pain is considered a sign of central sensitization (CS). The relationship between recording of symptoms and CS in people with knee osteoarthritis (OA) has been poorly investigated. OBJECTIVE: The aim of this study was to examine whether the area of pain assessed using pain drawings relates to CS and clinical symptoms in people with knee OA. DESIGN: This was a cross-sectional study. METHODS: Fifty-three people with knee OA scheduled to undergo primary total knee arthroplasty were studied. All participants completed pain drawings using a novel digital device, completed self-administration questionnaires, and were assessed by quantitative sensory testing. Pain frequency maps were generated separately for women and men. Spearman correlation coefficients were computed to reveal possible correlations between the area of pain and quantitative sensory testing and clinical symptoms. RESULTS: Pain frequency maps revealed enlarged areas of pain, especially in women. Enlarged areas of pain were associated with higher knee pain severity (rs=.325, P<.05) and stiffness (rs=.341, P<.05), lower pressure pain thresholds at the knee (rs=-.306, P<.05) and epicondyle (rs=-.308, P<.05), and higher scores with the Central Sensitization Inventory (rs=.456, P<.01). No significant associations were observed between the area of pain and the remaining clinical symptoms and measures of CS. LIMITATIONS: Firm conclusions about the predictive role of pain drawings cannot be drawn. Further evaluation of the reliability and validity of pain area extracted from pain drawings in people with knee OA is needed. CONCLUSION: Expanded distribution of pain was correlated with some measures of CS in individuals with knee OA. Pain drawings may constitute an easy way for the early identification of CS in people with knee OA, but further research is needed.

Angiolymphoid hyperplasia with eosinophilia involving the cubital nerve.

A tumor involving cubital nerve was resected and studied; it was classified as an angiolymphoid hyperplasia with eosinophilia (ALHE). Immunohistochemical and molecular study was done both to confirm the reactive nature of the process and rule out the presence of clonal T or B cell rearrangement. This lesion has been designated as epitheloid hemangioma [Coindre (1994) Ann Pathol 14:426]. Typically, ALHE occurs in the skin and the subcutaneous tissue, and extracutaneous involvement is rare. No cases of ALHE affecting a nerve have been described, but a case of Kimura's disease, the lesions of which have repeatedly been confused with ALHE, has been reported involving median nerve.