Intermediate and Long-term Outcomes Following Surgical Decompression of Neurogenic Thoracic Outlet Syndrome in an Adolescent Patient Population.

Background: Although the diagnosis of thoracic outlet syndrome (TOS) is often missed, outcomes from surgical intervention significantly improve patient satisfaction. This article seeks to highlight patient characteristics, intraoperative findings, and both short and long-term outcomes of thoracic outlet decompression in the adolescent population. Methods: A retrospective chart review of patients between the ages of 13 and 21 years with a clinical diagnosis of neurogenic thoracic outlet syndrome (NTOS) who were treated surgically between 2000 and 2015 was performed. Data points including preoperative patient characteristics and intraoperative findings were collected. In addition, patient-reported outcome scores, including Visual Analog Scale (VAS), Single Assessment Numeric Evaluation (SANE), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire, Cervical Brachial Symptom Questionnaire (CBSQ), and NTOS index, were obtained for a cohort of patients with follow-up ranging from 2 to 15 years. Results: The study population consisted of 54 patients involving 61 extremities. The most common procedures included neurolysis of the supraclavicular brachial plexus (60, 98.4%), anterior scalenectomy (59, 96.7%), and middle scalenectomy (54, 88.5%). First rib resection (FRR) was performed in 28 patients (45.9%). Long-term outcomes were collected for 24 (44%) of 54 patients with an average follow-up of 69.5 months (range, 24-180 months). The average VAS improved from 7.5 preoperatively to 1.8 postoperatively. The average SANE increased from 28.9 preoperatively to 85.4 postoperatively. The average postoperative scores were 11.4 for the QuickDASH, 27.4 for the CBSQ, and 17.2 for the NTOS index. Subgroup analysis of patients having FRR (28, 45.9%) demonstrated no difference in clinical outcome measures compared with patients who did not have FRR. Conclusion: Surgical treatment of NTOS in adolescent patients has favorable intermediate and long-term outcomes.

Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19.

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.

Subscapularis sparing total shoulder arthroplasty through a superolateral approach: a radiographic study.

BACKGROUND: Most anatomic total shoulder arthroplasty (ATSA) techniques release and reattach the subscapularis tendon. The risk of failed healing is a widely recognized complication. The purpose of this study was to radiographically compare a traditional deltopectoral (DP) approach and a superolateral subscapularis sparing (SSS) technique through the rotator interval. METHODS: A single, independent, blinded, reviewer analyzed preoperative and postoperative radiographs of patients undergoing ATSA performed by a single surgeon. The reviewer assessed humeral head height, humeral head medial offset, humeral head diameter, head-neck angle, humeral head centering, and coracohumeral offset, and used the anatomic reconstruction index (ARI) to evaluate overall reconstruction quality. RESULTS: There were 70 SSS and 20 DP patients included. When comparing preoperative with postoperative differences, we found that there was no difference between groups in humeral head height (P = .19), humeral head medial offset (P = .38), and coracohumeral offset (P = .07). The DP group had a mean humeral head diameter oversizing of 1.4 mm, whereas the superolateral group had an undersizing of 2.8 mm (P < .001). The head-neck angle difference of the SSS approach was 2° greater than that found with the DP group (P < .001). The humeral head centering in the DP group was 7% displaced vs. 12% with the SSS group (P = .001) relative to the glenoid size. The ARI was 7.35 for the DP group and 6.93 for the SSS group (P = .50). DISCUSSION AND CONCLUSIONS: Radiographic comparison of these 2 ATSA techniques identified no statistical significant difference in 4 of 7 radiographic measurements and ARI. The SSS ATSA is a reasonable approach that yields similar radiographic measurements as a traditional DP total shoulder arthroplasty approach.

Brachial Plexus Injuries Associated With Open Subpectoral Biceps Tenodesis: A Report of Two Cases.

CASE: We report 2 cases of brachial plexus injury after open subpectoral biceps tenodesis. In 1 patient, the nerves likely sustained a stretch injury related to retractor use. In the other patient, multiple nerves were severed, and we hypothesize that they were caught in a drill bit. CONCLUSIONS: To decrease the risk of nerve injury due to traction or inadvertent wrapping of nerves in the drill bit or tenodesis screw, we recommend careful retractor use and tendon fixation techniques that use a protective sleeve during both drilling and fixation.

Radiographic restoration of native anatomy: a comparison between stemmed and stemless shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty is a reliable procedure for patients with degenerative glenohumeral disease, and reproduction of native shoulder anatomy leads to superior outcomes. The aim of this study was to compare the ability of stemmed and stemless implants to radiographically restore native glenohumeral anatomy. METHODS: Shoulder arthroplasties were performed in 79 patients, with 58 receiving a stemless implant and 21 receiving a stemmed implant. Preoperative and postoperative radiographs were assessed for humeral head height, humeral head centering, humeral head medial offset, humeral head diameter, humeral neck angle, and lateral humeral offset by 2 independent viewers. Measurements were scored and summed to identify the anatomic reconstruction index (ARI). Radiographic measurements were compared using the Student t test, and significance was set at P < .05 for all statistical analyses. Interobserver agreement of radiographic analyses was assessed using the intraclass correlation coefficient, finding excellent reliability (intraclass correlation coefficient, 0.92). RESULTS: Five of six radiographic measurements along with the calculated ARI demonstrated no differences between stemmed and stemless shoulder implants (humeral head diameter, P = .651; humeral head height, P = .813; humeral head medial offset, P = .592; lateral humeral offset, P = .311; humeral head centering, P = .414; and ARI, P = .862). Stemless implants showed improved restoration of the native humeral neck angle (0° for stemless vs. -3° for stemmed, P = .017). CONCLUSION: Radiographic restoration of anatomy is similar for stemmed and stemless shoulder arthroplasty implants.

Outcomes of Staged Treatment for Complex Distal Radius Fractures.

Introduction Distal radius fractures are common, but the results and complications of treatment with early external fixation and staged open reduction internal fixation have not been previously reported. Materials and methods Patients who received staged distal radius fracture treatment from 1/1/2008 to 12/31/2015 at the University of Alabama at Birmingham were identified. Patient, injury, and treatment characteristics, as well as complications, were collected from the medical record. Results There were 50 fractures in 47 patients, with mean follow-up of 9.3 months. Thirty-eight were open and 45 were intra-articular. For definitive treatment, 41 received a volar approach and nine a dorsal approach. Twenty wrists experienced one or more complications, including two non-unions. Five patients developed infections - one Kirschner wire site infection, one external fixator (ex-fix) pin site infection, and three deep infections. All deep infections occurred in tobacco users. The rate of deep infection with volar approach was 2.4%, compared to 22.2% with dorsal approach. Ex-fix pin sites overlapped radiographically with the plate in 20 fractures, with three deep infections in this group (15%) and no deep infections in the group without overlap. None of these differences reached statistical significance. Conclusions This protocol results in reliable healing of complex fractures, with a 96% union rate. However, 40% sustained complications. We conclude that this protocol is useful for temporizing complex fractures but caution that the complication rate is high. Since recent literature indicates that low-grade open distal radius fractures do not require emergent debridement and that immediate internal fixation is safe, complications might be avoided by restricting this protocol to complex or physiologically unstable patients.

Near-Infrared Vein Visualization in Index Finger Pollicization.

Near-infrared vein visualization devices allow for noninvasive identification of superficial veins. During index finger pollicization, preservation of the dorsal veins is important for protecting blood outflow from the digit. Near-infrared vein visualization devices can be used to identify the location of the dorsal veins prior to skin incision, allowing increased confidence during dissection. We describe the use of this device to identify veins during index finger pollicization.