Modern Treatment of Neurogenic Thoracic Outlet Syndrome: Pathoanatomy, Diagnosis, and Arthroscopic Surgical Technique.

Compressive pathology in the supraclavicular and infraclavicular fossae is broadly termed "thoracic outlet syndrome," with the large majority being neurogenic in nature. These are challenging conditions for patients and physicians and require robust knowledge of thoracic outlet anatomy and scapulothoracic kinematics to elucidate neurogenic versus vascular disorders. The combination of repetitive overhead activity and scapular dyskinesia leads to contracture of the scalene muscles, subclavius, and pectoralis minor, creating a chronically distalized and protracted scapular posture. This decreases the volume of the scalene triangle, costoclavicular space, and retropectoralis minor space, with resultant compression of the brachial plexus causing neurogenic thoracic outlet syndrome. This pathologic cascade leading to neurogenic thoracic outlet syndrome is termed pectoralis minor syndrome when primary symptoms localize to the infraclavicular area. Making the correct diagnosis is challenging and requires the combination of complete history, physical examination, advanced imaging, and ultrasound-guided injections. Most patients improve with nonsurgical treatment incorporating pectoralis minor stretching and periscapular and postural retraining. Surgical decompression of the thoracic outlet is reserved for compliant patients who fail nonsurgical management and respond favorably to targeted injections. In addition to prior exclusively open procedures with supraclavicular, infraclavicular, and/or transaxillary approaches, new minimally invasive and targeted endoscopic techniques have been developed over the past decade. They involve the endoscopic release of the pectoralis minor tendon, with additional suprascapular nerve release, brachial plexus neurolysis, and subclavius and interscalene release depending on the preoperative work-up.

Intramedullary Metacarpal Fracture Fixation: A Biomechanical Study of Screw Diameter and Comparison With Intramedullary Wire Stabilization.

PURPOSE: Interest in intramedullary metacarpal fracture fixation (IMFF) with screws is increasing. However, the optimal screw diameter for fracture fixation is not yet established. In theory, larger screws should be more stable, but there is concern about long-term sequelae of larger metacarpal head defects and extensor mechanism injury created during insertion as well as implant cost. Therefore, the purpose of this study was to compare different diameter screws for IMFF to a popular and more cost-effective alternative of intramedullary wiring. METHODS: Thirty-two cadaveric metacarpals were used in a transverse metacarpal shaft fracture model. Treatment groups consisted of IMFF with 3.0 × 60 mm, 3.5 x 60 mm, and 4.5 x 60 mm screws as well as 4 1.1-mm intramedullary wires. Cyclic cantilever bending was performed with the metacarpals mounted at 45° to simulate physiologic loading. Cyclical loading at 10, 20, and 30 N was performed to determine fracture displacement, stiffness, and ultimate force. RESULTS: At 10, 20, and 30 N of cyclical loading, all screw diameters tested provided similar stability as measured by fracture displacement and were superior to the wire group. However, ultimate force under load to failure testing was similar between the 3.5- and 4.5-mm screws and superior to 3.0-mm screws and wires. CONCLUSIONS: For IMFF, 3.0, 3.5, and 4.5-mm diameter screws provide adequate stability for early active motion and are superior to wires. When comparing the different screw diameters, 3.5- and 4.5-mm diameter screws offer similar construct stability and strength superior to the 3.0-mm diameter screw. Therefore, to minimize metacarpal head morbidity, smaller screw diameters may be preferable. CLINICAL RELEVANCE: This study suggests that IMFF with screws is biomechanically superior to wires in cantilever bending strength in the transverse fracture model. However, smaller screws may be sufficient to permit early active motion while minimizing metacarpal head morbidity.

Variation in scapulohumeral rhythm on dynamic radiography in pathologic shoulders: a novel diagnostic tool.

HYPOTHESIS: The purpose of this study was to analyze the SHR of patients diagnosed with small (SRCTs) and massive rotator cuff tears (MRCTs), adhesive capsulitis (AC), and glenohumeral osteoarthritis (GH-OA) and compare their measurements to those of patient controls with healthy shoulders using DDR. We hypothesize that various diagnoses will vary with regards to SHR. METHODS: The sequences of pulsed radiographs collated in DDR to create a moving image were prospectively analyzed during humeral abduction in normal controls and in 4 distinct shoulder pathology groups: SRCT, MRCT, AC, and GH-OA. GH and ST joint angles were measured at 0°-30°, 30°-60°, 60°-90°, and maximal coronal plane humeral abduction. SHR was defined as the ratio of the change in humeral abduction over the change in scapula upward rotation during humeral abduction and was calculated within the above angle intervals. RESULTS: A total of 121 shoulders were analyzed. Forty normal controls were compared to 13 SRCTs, 29 MRCTs, 16 AC, and 23 GH-OA. SHR during humeral abduction differed significantly in patients with MRCT (1.91 ± 0.72), AC (1.55 ± 0.37), and GH-OA (2.31 ± 1.01) compared to controls (3.39 ± 0.79). When analyzed across 30° intervals of abduction, there was a significantly lower SHR found at 0°-30°, 30°-60°, and 60°-90° in MRCT, AC, and GH-OA across each motion range compared to controls. Control patients had an arc of abduction of 103° ± 32°, which was significantly larger than all other pathologies (MRCT: 76° ± 23°, SRCT: 81° ± 21°, AC: 65° ± 27°, GH-OA: 71° ± 35°) and an average scapular abduction of 33° ± 14°, which was significantly less than patients with an MRCT (46° ± 10°) and AC (65° ± 27°). CONCLUSION: SHR remained significantly lower throughout shoulder abduction in MRCT (43.65%), AC (-54.29%), and GH-OA (32.01%) compared to controls. When isolating for humeral and scapular motion, all 4 pathologies had decreased GH abduction, whereas AC and MRCT had an increased scapular compensatory motion compared to controls. Quantifying kinematic patterns like SHR using DDR can be implemented as a novel, safe, and cost-effective method to diagnose shoulder pathology and to monitor response to treatment.

Pectoralis minor syndrome - review of pathoanatomy, diagnosis, and management of the primary cause of neurogenic thoracic outlet syndrome.

Thoracic outlet syndrome is an umbrella term for compressive pathologies in the supraclavicular and infraclavicular fossae, with the vast majority being neurogenic in nature. These compressive neuropathies, such as pectoralis minor syndrome, can be challenging problems for both patients and physicians. Robust understanding of thoracic outlet anatomy and scapulothoracic biomechanics are necessary to distinguish neurogenic vs. vascular disorders and properly diagnose affected patients. Repetitive overhead activity, particularly when combined with scapular dyskinesia, leads to pectoralis minor shortening, decreased volume of the retropectoralis minor space, and subsequent brachial plexus compression causing neurogenic thoracic outlet syndrome. Combining a thorough history, physical examination, and diagnostic modalities including ultrasound-guided injections are necessary to arrive at the correct diagnosis. Rigorous attention must be paid to rule out alternate etiologies such as peripheral neuropathies, vascular disorders, cervical radiculopathy, and space-occupying lesions. Initial nonoperative treatment with pectoralis minor stretching, as well as periscapular and postural retraining, is successful in the majority of patients. For patients that fail nonoperative management, surgical release of the pectoralis minor may be performed through a variety of approaches. Both open and arthroscopic pectoralis minor release may be performed safely with effective resolution of neurogenic symptoms. When further indicated by the preoperative workup, this can be combined with suprascapular nerve release and brachial plexus neurolysis for complete infraclavicular thoracic outlet decompression.

Machine Learning Can Predict Level of Improvement in Shoulder Arthroplasty.

The ability to accurately predict postoperative outcomes is of considerable interest in the field of orthopaedic surgery. Machine learning has been used as a form of predictive modeling in multiple health-care settings. The purpose of the current study was to determine whether machine learning algorithms using preoperative data can predict improvement in American Shoulder and Elbow Surgeons (ASES) scores for patients with glenohumeral osteoarthritis (OA) at a minimum of 2 years after shoulder arthroplasty. METHODS: This was a retrospective cohort study that included 472 patients (472 shoulders) diagnosed with primary glenohumeral OA (mean age, 68 years; 56% male) treated with shoulder arthroplasty (431 anatomic total shoulder arthroplasty and 41 reverse total shoulder arthroplasty). Preoperative computed tomography (CT) scans were used to classify patients on the basis of glenoid and rotator cuff morphology. Preoperative and final postoperative ASES scores were used to assess the level of improvement. Patients were separated into 3 improvement ranges of approximately equal size. Machine learning methods that related patterns of these variables to outcome ranges were employed. Three modeling approaches were compared: a model with the use of all baseline variables (Model 1), a model omitting morphological variables (Model 2), and a model omitting ASES variables (Model 3). RESULTS: Improvement ranges of ≤28 points (class A), 29 to 55 points (class B), and >55 points (class C) were established. Using all follow-up time intervals, Model 1 gave the most accurate predictions, with probability values of 0.94, 0.95, and 0.94 for classes A, B, and C, respectively. This was followed by Model 2 (0.93, 0.80, and 0.73) and Model 3 (0.77, 0.72, and 0.71). CONCLUSIONS: Machine learning can accurately predict the level of improvement after shoulder arthroplasty for glenohumeral OA. This may allow physicians to improve patient satisfaction by better managing expectations. These predictions were most accurate when latent variables were combined with morphological variables, suggesting that both patients' perceptions and structural pathology are critical to optimizing outcomes in shoulder arthroplasty. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Patient Perception of Pain Control (Not Opiate Amount) Affects Hospital Consumer Assessment of Healthcare Providers and Systems and Press Ganey Satisfaction Scores After Orthopaedic Trauma.

INTRODUCTION: Opiate abuse is a public health issue linked to prescribing. Prescribing increased partly in response to adopting pain as the fifth vital sign. Assessing pain control on patient satisfaction surveys, including government-mandated Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and optional private surveys (Press Ganey) administered on hospital discharge, may contribute. This study evaluates whether opiate amounts affect orthopaedic trauma patient perception of pain control and overall hospital rating on HCAHPS and Press Ganey surveys. METHODS: Consecutive adult patients >18 years surgically treated for isolated fractures (UE = upper extremity, LE = lower extremity, and PA = pelvis/acetabulum) at a level 1 trauma center between January 1, 2014, and December 31, 2016, were retrospectively analyzed. Hospital charts, HCAHPS, and Press Ganey data were reviewed; patients without survey responses were excluded. Data included comorbidities, psychiatric history, substance use, injury type, and surgery. Analysis included Spearman's rho for correlations, Wilcoxon rank-sum and Kruskal-Wallis for continuous variables, and adjusted ordinal regression to estimate association between opioid prescribing and patient ratings. RESULTS: One hundred fifty-two total patients (UE 29, LE 112, and PA 11) with mean age of 57 years and median length of stay 3 days were included. Adjusted models showed longer duration outpatient prescriptions were associated with lower rating on how often inpatient pain was controlled (P = 0.002), lower total MME inpatient was associated with higher ratings (HCAHPS P = 0.015; Press Ganey, P = 0.03), lower average daily MME inpatient was associated with lower ratings (HCAHPS P = 0.008; Press Ganey, P = 0.037), and shorter outpatient prescription duration was associated with lower ratings (P = 0.008). Patient perception of pain control was strongly associated with overall HCAHPS (P < 0.05) and Press Ganey (P < 0.001) ratings. DISCUSSION: Inpatient and outpatient opiate amounts and duration demonstrated some associations with overall scores. However, patients' pain control perception seems to have the strongest relationship with hospital rating. Counseling and multimodal pain control may lead to strong satisfaction scores without needing high opiates after orthopaedic trauma.

ORIF of Distal Humerus Fractures with Modern Pre-contoured Implants is Still Associated with a High Rate of Complications.

BACKGROUND: The purpose of this study was to identify complications after operative treatment of distal humerus fractures with anatomic, pre-contoured, locking distal humeral plates. We hypothesized that these fractures have high complication rates despite the use of these modern implants. MATERIALS AND METHODS: Between 2010 and 2018, 43 adult patients with a distal humerus fracture underwent open reduction and internal fixation (ORIF) at a Level I trauma center. Pre-operative variables, including medical comorbidities, mechanism of injury, open or closed fracture, AO/OTA fracture classification (Type A, B, or C), and nerve palsy, were recorded. Intra-operative variables including surgical approach, ulnar nerve transposition, and plate configuration were recorded. Anatomic, pre-contoured, locking distal humeral plates were used in all patients. Various plating systems were used based on surgeon preference and fracture pattern. Post-operative complications including infection, nonunion, malunion, painful implants, nerve palsy, heterotopic ossification, stiffness, and post-traumatic arthritis were recorded. RESULTS: Most fractures were Type C (53%). The posterior olecranon osteotomy approach (51%) and parallel plate configuration (42%) were used in most cases. At a mean follow-up of 15 months, the complication rate was 61% (26/43 patients). Among all patients, 49% (21/43 patients) required a reoperation. Elbow stiffness (19%) was the most common complication followed by nerve palsy (16%). There were four fracture nonunions (9%), deep infections (9%), painful implants (9%), post-traumatic arthritis (9%), and heterotopic ossification (9%). CONCLUSIONS: Distal humerus fractures treated with ORIF utilizing anatomic, pre-contoured, locking distal humeral plates have a high complication rate, with many requiring reoperation. LEVEL OF EVIDENCE: Therapeutic Level IV.

Ureteral Entrapment in an Associated Anterior Column and Posterior Hemitransverse Acetabular Fracture: A Case Report.

CASE: A 59-year-old man was struck by an automobile resulting in left anterior column posterior hemitransverse acetabular fracture with ureteral entrapment. Open reduction internal fixation was performed with removal of the ureter from the fracture. At follow-up 7 months post-op, the patient did not report significant hip or urinary symptoms, and implant position and fracture alignment remained intact. CONCLUSION: Surgeons should be mindful of possible ureteral injury associated with acetabular fractures. Awareness of this rare entrapment within medially displaced acetabular fractures may heighten clinical suspicion and improve management.

Ultrasound diagnosis and therapeutic intervention in the spine.

Spine pathology afflicts people across the globe and is responsible for a large portion of physician visits and healthcare costs. Imaging such as plain radiographs, CT, MRI, and ultrasound is vital to assess structure, function, and stability of the spine and also provide guidance in therapeutic interventions. Ultrasound utilization in spine conditions is less ubiquitous, but provides benefits in low costs, portability, and dynamic imaging. This study assesses ultrasound efficacy in diagnosis and therapeutic interventions for spine pathology. A systematic review conducted via PubMed, MEDLINE, and Google Scholar identified 3,630 papers with eventual inclusion of 73 papers with an additional 21 papers supplemental papers subsequently added. Findings highlighted ultrasound utilization for different structural elements of the spine such as muscle, bone, disc, ligament, canal, and joints are presented and compared with radiographs, CT, and MRI imaging where relevant. Spinal curvature and mobility are similarly presented. Ultrasound efficacy for guided therapeutics about the spine is presented and assessed against other modalities. Ultrasound is a widely used and efficacious modality to guide injections about the spine. Diagnostic utility is less well studied, but shows promise in assessing fractures, posterior ligamentous stability, and intra-operative hardware placement. The low cost, portability, and dynamic imaging ability make it an attractive modality particularly for developing health systems and resource limited environments such as combat settings and the International Space Station. Further study is recommended before broad adoption in diagnostics.

Effects of spaceflight on cartilage: implications on spinal physiology.

Spaceflight alters normal physiology of cells and tissues observed on Earth. The effects of spaceflight on the musculoskeletal system have been thoroughly studied, however, the effects on cartilage have not. This area is gaining more relevance as long duration missions, such as Mars, are planned. The impact on intervertebral discs and articular cartilage are of particular interest to astronauts and their physicians. This review surveys the literature and reports on the current body of knowledge regarding the effects of spaceflight on cartilage, and specifically changes to the spine and intervertebral disc integrity and physiology. A systematic literature review was conducted using PubMed, MEDLINE, and Google Scholar. Eighty-six unique papers were identified, 15 of which were included. The effect of spaceflight on cartilage is comprehensively presented due to limited research on the effect of microgravity on the spine/intervertebral discs. Cellular, animal, and human studies are discussed, focusing on human physiologic changes, cartilage histology, mineralization, biomechanics, chondrogenesis, and tissue engineering. Several common themes were found, such as decreased structural integrity of intervertebral disks and impaired osteogenesis/ossification. However, studies also presented conflicting results, rendering strong conclusions difficult. The paucity of human cartilage studies in spaceflight leaves extrapolation from other model systems the only current option for drawing conclusions despite known and unknown limitations in applicability to human physiology, especially spinal pathophysiology which is special interest. The aerospace and biomedical research communities would benefit from further human spaceflight articular cartilage and intervertebral disc studies. Further research may yield beneficial application for spaceflight, and crossover in understanding and treating terrestrial diseases like osteoarthritis and vertebral disc degeneration.