Patterns of Nerve Injury and Recovery Rates of Infraclavicular Brachial Plexus Lesions Following Anterior Shoulder Dislocation.

PURPOSE: We reviewed our cases of infraclavicular brachial plexus injuries associated with anterior shoulder dislocation to determine patterns of injury, recovery rates, and factors associated with a poor motor outcome. METHODS: This was a retrospective review of patients who had sustained a concomitant nerve injury following dislocation of the glenohumeral joint treated with closed manipulation. The data collected included patient demographics, injury factors, and patterns of neurological deficits. The Medical Research Council (MRC) grade for motor power was the primary outcome measure, where a grade of 4 or 5 was regarded as achieving good motor recovery. Univariate and multivariable analyses were used to identify factors associated with persistent motor weakness (MRC grades 0-3) at the final follow-up. RESULTS: Between 2015 and 2019, 61 patients were assessed. There were 36 males and 25 females, with a median age of 64 years (interquartile range [IQR], 53-73 years). Four patterns of injury were identified: (1) isolated axillary nerve lesions; (2) single cord lesions; (3) combined lesions involving the medial and posterior cords; and (4) diffuse lesions affecting all 3 cords. Of 28 patients with isolated axillary nerve injuries, 22 recovered. All lateral cord injuries (11/11) and 20 of 24 posterior cord injuries recovered spontaneously. Recovery of hand intrinsic function from medial cord injuries had the worst outcome, with 14 of 27 patients not recovering beyond MRC grades 0 to 3. The median duration of dislocation before reduction was 6 hours (IQR, 3-12 hours). A multivariate analysis showed an association between the duration of shoulder dislocation and the likelihood of persistent motor weakness. CONCLUSIONS: Shoulder dislocations with motor deficits should be regarded as orthopedic emergencies and reduced expediently. Persistent motor weakness may be associated with a prolonged duration of dislocation prior to glenohumeral relocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The congenital undescended scapula syndrome: Sprengel and the cleithrum: a case series and hypothesis.

BACKGROUND: Sprengel deformity is a rare congenital shoulder girdle anomaly characterized by scapula malposition, periscapular muscle atrophy, and limited shoulder movement. Traditionally, it has been managed by omovertebral bar excision and muscle transplantation procedures guided by age and Cavendish grade. We present a unique observation in humans: a case series with Sprengel deformity possessing a cleithrum, an ancestral remnant of shoulder girdle development found in archaic bony fish. METHODS: Nine patients presented with so-called Sprengel deformity to a tertiary referral shoulder clinic. All were assessed clinically and radiologically with scapular radiographs and computed tomography or magnetic resonance imaging scans. The clinical and radiologic features were classified according to Cavendish and Rigault systems, respectively, and the scapular ratio was assessed. RESULTS: All patients were assigned grade 4 on the Cavendish scale. Six were grade 2 and 3 were grade 3 on the Rigault scale. The distinguishing pathoanatomic feature was partial endomuscular ossification of medial scapular suspension muscles, analogous to the cleithrum of bony fish. Five cases were treated operatively and 4 nonoperatively. Mean elevation and abduction significantly improved in surgical cases. DISCUSSION AND CONCLUSION: This finding not only challenges classic management of these rare patients but offers insight into scapular embryology and development. The association of scapular developmental and urogenital anomalies suggests that screening of the renal tract and genetic investigation in those with undescended scapula syndrome be considered. We suggest, to emphasize the nature of incomplete scapular descent and associated congenital anomalies and to clarify imprecise common use of the term Sprengel deformity, that this condition be called the congenital undescended scapula syndrome.

The role of biodegradable spacer implantation under local anesthesia for patients with massive rotator cuff tears and significant medical comorbidities.

Background: Massive rotator cuff tears are common, and the incidence increases with age. They are a challenging problem to deal with as many are irreparable. While there are a host of surgical options available, these can be prolonged procedures requiring general anesthesia and thus not suitable for elderly patients or those with significant medical comorbidities. In this study, we evaluate the role of a biodegradable balloon inserted under local anesthetic for a series of patients with massive cuff tears and significant medical comorbidities. Methods: A prospective pilot study was performed on a series of patients between June 2018 and April 2019. Demographic data, as well as preoperative and postoperative clinical data including Subjective Shoulder Value and Oxford Shoulder Scores, were obtained. Results: Four patients with magnetic resonance imaging-proven massive rotator cuff tears involving the supraspinatus were treated with an InSpace balloon under local anesthesia. All were of American Society of Anesthesiologists grade 4 and had exhausted nonoperative treatment. The mean Oxford Shoulder Score improved from a preoperative baseline of 17.25 (range 6-25) to a peak of 25.75 (range 15-34) at the 6-week postoperative mark before declining to 13.67 (range 6-23) at the final follow-up of 6 months. Subjective Shoulder Values also improved initially from a mean of 31.25 (range of 20-40) to a peak of 58.75 (range of 50-70) before reducing to 36.67 (range of 30-50) at the final follow-up of 6 months. Conclusion: We have described the safety and early benefit from the use of a biodegradable balloon spacer inserted under local anesthetic as a management option for patients with massive rotator cuff tears, who may be unfit for other extensive reconstruction options, particularly for short-term pain relief as significant long-term gains were not demonstrated.

Surgical management of late complications after colonic interposition for esophageal atresia.

Late complications after colonic interposition for neonatal esophageal atresia may lead to debilitating symptoms, poor quality of life, and malnutrition in young adults with otherwise normal life expectancies. We report our experience with 3 patients who underwent revision surgery more than 20 years after colonic interposition. Revision surgery may relieve symptoms and improve quality of life in selected patients. However, for patients with recurrent symptoms, further reconstructive options may be limited due to the lack of an available conduit, and long-term enteral feeding may be the only option for these patients.