Successful reverse total shoulder replacement in a patient with Apert syndrome.

Apert syndrome, first described in the literature by a French pediatrician Eugene Apert, is a rare congenital form of acrocephalodactyly with autosomal dominant inheritance. Classically, this syndrome is characterized by craniosynostosis, midface hypoplasia, and symmetrical syndactyly of hands and feet resulting from embryonic anomalies during the third week of gestation. It is also associated with a variety of abnormalities of the viscera, involving the neurological, genitourinary, and cardiorespiratory systems. Glenohumeral manifestations of Apert syndrome include glenoid dysplasia, an oblong humeral head with a prominence of the greater tuberosity, acromial prominence, and inferior subluxation of the glenohumeral joint. This pathological anatomy results in progressive degenerative changes, synchondrosis, and restriction in shoulder joint mobility, particularly in flexion and abduction. While surgical options for the accompanying deformities of the feet and spine are described, interventions for shoulder pathology are not well-defined. Joint replacement surgery could offer such patients pain relief and improved function. Reverse total shoulder arthroplasty is yet to be described in Apert syndrome and this case report presents the outcome in a 48-year-old male. Level of evidence: IV case report.

Open versus Single- or Dual-Portal Endoscopic Carpal Tunnel Release: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Compared to the traditional open carpal tunnel release (OCTR), the additional safety and efficacy benefits of endoscopic carpal tunnel release (ECTR) remains unclear. The aim of this study is to evaluate the outcomes of ECTR versus conventional OCTR as well as determine if a difference exists between the 2 most common endoscopic techniques: the single-portal and the dual-portal endoscopic technique. METHODS: We conducted a systematic literature search of Medline, Embase, PubMed, and the CENTRAL. Additional articles were identified by handsearching reference lists. We included all randomized controlled trials that compared outcomes of ECTR with OCTR technique. Outcomes assessed included length of surgery, patient reported symptom and functional measures, time to return to work, and complications. A sub-group analysis was performed to indirectly compare single- versus dual-portal endoscopic approaches. Statistical analysis was performed via a random-effects model using Review Manager 5 Software. RESULTS: A meta-analysis of 23 studies revealed a significantly higher incidence of transient postoperative nerve injury with ECTR, regardless of the number of portals, as compared with OCTR, although overall complication and re-operation rates were equivalent. Scar tenderness was significantly diminished with dual-portal endoscopic release when compared to single-portal and open methods. The rates of pillar pain, symptom relief, and patient reported satisfaction did not differ significantly between treatment groups. CONCLUSIONS: Although endoscopic surgery may be appealing in terms of reduced postoperative morbidity and a faster return to work for patients, surgeons should be mindful of the associated learning curve and higher incidence of transient nerve injury. Further study is required to identify if an advantage exists between different endoscopic techniques.

Validity and reliability of smartphone inclinometer applications for measurement of elbow range of motion in paediatric patients.

PURPOSE: Precise measurement of elbow range of motion (ROM) post-injury or surgery forms an important part of determining prognosis and the need for further intervention. Clinicians are increasingly incorporating smartphone use in our medical practice; we sought to determine if a smartphone goniometer application is a valid and reliable tool for assessment of elbow ROM in the paediatric patient, compared to visual and goniometer assessment. METHODS: In total, 20 paediatric patients (40 elbows) between six and 15 years of age with an elbow or forearm injury were included in this prospective series. Elbow flexion, extension, pronation and supination were measured independently by two orthopaedic clinicians. Measurements were taken from injured as well as unaffected side using a standardized technique, first with visual estimation and then using a universal goniometer (UG) and smartphone goniometer application Angle Meter via Google Play store (Smart Tool Factory, Istanbul, Turkey). RESULTS: There was excellent interobserver reliability for all three modalities, with average intraclass correlation coefficient (ICC) values greater than 0.90. Visual estimation had the lowest average ICC of 0.92, compared to 0.97 for UG and smartphone. Overall, there was excellent intraobserver reliability between the smartphone application and the gold standard UG for all elbow movements with ICCs ranging between 0.98 to 0.99 and mean absolute difference ranging from 1.1 ± 1.0° to 2.6 ± 1.9°. The smartphone application showed superior agreement over visual estimation when compared to the gold standard UG with lower mean differences and 95% limits of agreement (LOA) falling within 10°. CONCLUSIONS: Our study demonstrates that a smartphone application is a valid and reliable assessment tool for measurement of elbow ROM in paediatric patients, and better than visualization alone. LEVEL OF EVIDENCE: III.

Management of lower limb fractures in patients with spinal cord injuries.

BACKGROUND: Low-energy fractures of the lower limb in patients post spinal cord injury (SCI) present significant management challenges. This is the first Australian study to review the experience from a tertiary referral SCI centre and aims to identify trends and suggest therapeutic options. METHODS: Retrospective review over a 5-year period in patients with SCI treated for a lower limb fragility fracture. Patient demographics, spinal injury severity scores, fracture characteristics and treatment were assessed. Time to union, length of stay and treatment-related complications were also examined. RESULTS: A total of 38 SCI patients with 42 lower extremity fractures met inclusion criteria. Mean age was 55.7 years and mean duration post-SCI at fracture was 22.5 ± 12.7 years. The femur (73.8%) was more commonly fractured than the lower leg (26.2%), with extra-articular distal femoral fractures most prevalent (35.7%). A total of 25 (60%) fractures were managed operatively, and 17 (40%) non-operatively. The majority of femoral fractures were managed with intramedullary nailing. Tibial fractures were more commonly managed non-operatively. Eight cases (19.1%) experienced complications, with a significant difference between frequency of complications in non-operative (35.3%) and operative (8.0%) groups; P = 0.045. All fractures united except one; time to union was shorter in patients treated surgically (13.6 ± 6.4 weeks) compared to those managed non-operatively (19.1 ± 8.1 weeks). CONCLUSIONS: Lower limb fragility fractures in patients with SCI can be managed successfully via either operative or non-operative measures. In this series, fewer complications and shorter time to union were found in patients managed operatively.