Comparing Access to Engaging Hill-Sachs Lesions Between the Modified Posterior Deltoid Split Approach and Standard Deltopectoral Approach for Bone Grafting.

Background: Hill-Sachs lesions are common after shoulder instability, and treatment options vary but include remplissage or implantation of structural bone graft. Large Hill-Sachs lesions not addressed by remplissage are challenging to manage and may frequently require an open surgical approach for bone filling treatment options. The optimal approach to maximize visualization of the humeral head during these procedures remains unclear. Purpose/Hypothesis: The purpose of this study was to compare the area of the humeral head accessed using a modified posterior deltoid split approach versus a standard deltopectoral approach without surgical dislocation, with particular attention to access of engaging Hill-Sachs lesions for the purpose of bone grafting in the setting of anterior shoulder instability. It was hypothesized that both approaches would provide equal access to a simulated Hill-Sachs lesion. Study Design: Controlled laboratory study. Methods: Four human cadaveric shoulders were mounted in the beach-chair position. The modified posterior deltoid split approach and nonextensile deltopectoral approaches were performed. A typical Hill-Sachs lesion was simulated on the humeri. The percentage of the total surface area of the humeral head that was accessed, including access to the simulated Hill-Sachs lesion, was mapped using 3-dimensional digitizing software. Results: The deltopectoral approach provided 45% ± 15.2% access (range, 24% to 58%) to the humeral head versus 22.2% ± 6.1% (range, 17% to 30%) for the modified posterior deltoid split approach (P = .057). The modified posterior deltoid split approach enabled 100% access of the simulated Hill-Sachs lesion compared with 0% for the nonextensile deltopectoral approach. The angle of access to the articular surface was direct and perpendicular with the modified posterior deltoid split approach. Conclusion: The overall surface area of the humeral head accessed via the modified posterior deltoid split approach was less compared with the deltopectoral approach; however, the entire area of a typical Hill-Sachs lesion was able to be accessed from the modified posterior deltoid split approach, whereas this area was not well visualized from the standard deltopectoral approach. Clinical Relevance: The modified posterior deltoid split approach provided sufficient access to the humeral head for the purposes of grafting an engaging Hill-Sachs lesion in the setting of anterior shoulder instability.

Preoperative planning with three-dimensional CT vs. three-dimensional magnetic resonance imaging does not change surgical management for shoulder instability.

Background: This study aims to determine the effect of time and imaging modality (three-dimensional (3D) CT vs. 3D magnetic resonance imaging (MRI)) on the surgical procedure indicated for shoulder instability. The hypothesis is there will be no clinical difference in procedure selection between time and imaging modality. Methods: Eleven shoulder surgeons were surveyed with the same ten shoulder instability clinical scenarios at three time points. All time points included history of present illness, musculoskeletal exam, radiographs, and standard two-dimensional MRI. To assess the effect of imaging modality, survey 1 included 3D MRI while survey 2 included a two-dimensional and 3D CT scan. To assess the effect of time, a retest was performed with survey 3 which was identical to survey 2. The outcome measured was whether surgeons made a "major" or "minor" surgical change between surveys. Results: The average major change rate was 14.1% (standard deviation: 7.6%). The average minor change rate was 12.6% (standard deviation: 7.5%). Between survey 1 to the survey 2, the major change rate was 15.2%, compared to 13.1% when going from the second to the third survey (P = .68). The minior change rate between the first and second surveys was 12.1% and between the second to third interview was 13.1% (P = .8). Discussion: The findings suggest that the major factor related to procedural changes was time between reviewing patient information. Furthermore, this study demonstrates that there remains significant intrasurgeon variability in selecting surgical procedures for shoulder instability. Lastly, the findings in this study suggest that 3D MRI is clinically equivalent to 3D CT in guiding shoulder instability surgical management. Conclusion: This study demonstrates that there is significant variability in surgical procedure selection driven by time alone in shoulder instability. Surgical decision making with 3D MRI was similar to 3D CT scans and may be used by surgeons for preoperative planning.

An Unexpected Finding in a Concussed Circus Acrobat.

Persistent post-concussive syndrome (PPCS) outlines a complex array of neurocognitive and psychological symptoms that persist in patients after a concussion. A 58-year-old female presented reporting recurrent loss of consciousness, and retrograde and anterograde amnesia following multiple concussions. She also endorsed persistent nausea, balance insufficiencies, hearing loss, and cognitive impairment. In addition, this patient had high-risk sexual behavior without prior testing for sexually transmitted infections. Given her clinical history, the differential included PPCS, complex post-traumatic stress disorder, Korsakoff syndrome, hypothyroidism, and sexually transmitted infection (STI)-related neurocognitive disorder. On exam, this patient had a positive Romberg sign, prominent resting tremoring of upper extremities, and pinpoint pupils unresponsive to light, with bilateral nystagmus. Syphilis testing was positive. The patient was treated with intramuscular benzathine penicillin with significant improvement in gait, balance, headaches, vision, and cognition three months after treatment. Although rare, neurocognitive disorders, including late-stage syphilis, should be considered in the differential diagnosis for PPCS.

Evaluation of the Hand and Wrist via Telephone and Video Visit.

BACKGROUND:  The COVID-19 pandemic has highlighted the utility of telemedicine, with rapid incorporation throughout 2020. Telemedicine is a timely, safe, and effective means of evaluating, triaging, and treating patient conditions, including those of the musculoskeletal system. Hand and wrist complaints are frequently encountered in the primary care setting, and some can have serious consequences if not promptly diagnosed. Prior to the pandemic, over a quarter of the nation's allopathic degree-granting medical schools had initiated telemedicine training as part of the preclinical phase of their curriculum, and about half had implemented it into clerkships prior to the pandemic. Despite rapid acceptance, increased ease of access, and prior attempts to incorporate telemedicine into the educational curriculum, telemedicine evaluation continues to pose challenges to both the patient and provider. This is likely due to a lack of established protocols outlining clinical data collection through a virtual interface. Although telemedicine requires the patient to perform a physical examination, it allows the physician to collect clinically important information while observing the patient in their home environment. AIMS:  The aim of this paper is to provide a step-by-step method to evaluate and triage hand and wrist complaints. METHODS:  Our group has created a step-by-step evaluation pathway to help physicians direct their patients through typical hand and wrist examination elements, including inspection, palpation, range of motion (ROM), strength, special, and functional testing. RESULTS:  We have developed a table of evaluation questions and instructions and a glossary of images of each maneuver to facilitate hand and wrist examination via telemedicine. CONCLUSION:  This paper provides a guide for extracting clinically relevant information while performing telemedicine examinations of the hand.

Evolutionary optimization of an anatomical suction cup: Lip collagen content and its correlation with flow and substrate in Neotropical suckermouth catfishes (Loricarioidei).

In riverine ecosystems, downstream drag caused by fast-flowing water poses a significant challenge to rheophilic organisms. In neotropical rivers, many members of a diverse radiation of suckermouth catfishes (Loricarioidei) resist drag in part by using modified lips that form an oral suction cup composed of thick flesh. Histological composition and morphology of this cup are interspecifically highly variable. Through an examination of 23 loricarioid species, we determined that the tissue most responsible for lip fleshiness is collagen. We hypothesized that lip collagen content is interspecifically correlated with substrate and flow so that fishes living on rocky substrates in high-flow environments have the largest, most collagenous lips. By mapping the amount and distribution of lip collagen onto a phylogeny and conducting ANOVA tests, we found support for this hypothesis. Moreover, these traits evolved multiple times in correlation with substrate and flow, suggesting they are an effective means for improving suction-based attachment. We hypothesize that collagen functions to reinforce oral suction cups, reducing the likelihood of slipping, buckling, and failure under high-flow, high-drag conditions. Macroevolutionary patterns among loricarioid catfishes suggest that for maximum performance, biomimetic suction cups should vary in material density according to drag and substrate requirements.