Risk factors of poor mid-term shoulder functional outcomes of osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures: a retrospective study with a minimum 5-year follow-up.

BACKGROUND: Osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures yields satisfactory bone union rates; however, it may adversely affect postoperative shoulder function. To date, factors affecting mid- or long-term shoulder functional outcomes following intramedullary nail fixation have not been clarified. In this study, we aimed to identify the risk factors for poor mid-term functional outcomes over 5 years postoperatively following antegrade intramedullary nail osteosynthesis for humeral shaft fractures. METHODS: We retrospectively identified 33 patients who underwent surgery using an antegrade intramedullary nail for acute traumatic humeral shaft fractures and were followed up for at least 5 years postoperatively. We divided the patients into clinical failure and no clinical failure groups using an age- and sex-adjusted Constant score of 55 at the final follow-up as the cutoff value. We compared preoperative, perioperative, and postoperative factors between the two groups. RESULTS: Five of the 33 patients had poor shoulder functional outcomes (adjusted Constant score < 55) at a mean follow-up of 7.5 years postoperatively. Proximal protrusion of the nail at the time of bone union (P = 0.004) and older age (P = 0.009) were significantly associated with clinical failure in the univariate analyses. Multivariate analysis showed that proximal protrusion of the nail (P = 0.031) was a risk factor for poor outcomes. CONCLUSIONS: The findings of this study provide new information on predictive factors affecting mid-term outcomes following osteosynthesis using antegrade nails. Our results demonstrated that proximal protrusion of the nail was significantly associated with poor mid-term functional shoulder outcomes. Therefore, particularly in older adults, it is essential to place the proximal end of the intramedullary nail below the level of the articular cartilage.

Osteosynthesis using a plate lacking the anterior component and canulated cancellous screws to treat an avulsion fracture of the calcaneal tuberosity: A case report.

INTRODUCTION: Avulsion fractures of the calcaneal tuberosity with significant displacement can cause soft tissue complications in the heel. However, a treatment strategy for calcaneal tuberosity fractures with poor heel-skin condition is yet to be established. Here, we report a case involving avulsion fracture of the calcaneal tuberosity presenting with superficial skin necrosis that was treated with a plate lacking the anterior component and screws inserted percutaneously. PRESENTATION OF CASE: A 74-year-old woman presented with progressive right heel pain following an injury to her heel sustained approximately six weeks previously. She had experienced difficulty walking due to heel pain and superficial necrosis was observed on the posterior surface of the heel. Radiography and computed tomography revealed an avulsion fracture of the calcaneal tuberosity with superior displacement. Open reduction was performed using a lateral L-shaped incision. After inserting two cancellous screws percutaneously into the calcaneal tuberosity, we fixed a plate lacking the anterior component to the lateral surface of the calcaneus. The superficial necrosis healed gradually post-operatively. Bone union was confirmed using radiography six months post-operatively. DISCUSSION: We developed a novel surgical procedure to treat avulsion fractures of the calcaneal tuberosity with poor skin condition. The combination of a plate lacking the anterior component and the percutaneous insertion of canulated cancellous screws can reduce the risk of post-operative soft tissue complications while maintaining fixation of the fractured fragment. CONCLUSION: Our findings provide a novel surgical method for the treatment of avulsion fractures of the calcaneal tuberosity with soft tissue complications.

Recent advances in unlinked total elbow arthroplasty in Japan.

Background: Total elbow arthroplasty (TEA) is a valuable therapeutic approach for improving function and relieving pain in severely deformed elbow joints. However, TEA is associated with a high incidence of complications. In Japan, the use of unlinked TEA has a long history, with the development of the Kudo prosthesis marking a significant milestone. Subsequently, various unlinked implant designs have been developed. Although favorable long-term clinical results have been reported, complications remain a concern. To further improve the outcome of unlinked TEA, attempts have been made in recent years to develop various surgical approaches and intraoperative support devices. This review focuses on the clinical outcomes and recent advances in unlinked TEA in Japan. Methods: A comprehensive review of clinical results and advancements in unlinked TEA in Japan was conducted. The analysis included trends in the number of TEA, medium-term and long-term results for unlinked TEA, surgical approaches, or preoperative planning techniques. Results: Several implant designs have been developed in Japan. Clinical studies have reported satisfactory long-term outcomes with these implants, but complications, such as infection, fractures, and dislocation, have been observed. In order to enhance the outcomes of unlinked TEA, various triceps-on approaches have been developed as alternatives to the triceps-detaching approach, which compromises the continuity between the triceps tendon and ulna, leading to inevitable complications related to the triceps tendon. Preservation or repair of the surrounding soft tissues is considered critical for preventing postoperative instability due to the absence of a radial head in the current unlinked TEA design. Computed tomography-based 3-dimensional preoperative planning has been pioneered in Japan, demonstrating its effectiveness in predicting implant size and achieving appropriate implant placement. Additionally, augmented reality-assisted surgery is being explored to accurately translate preoperative planning into the surgical procedure. Conclusion: Unlinked TEA for inflammatory arthritis has exhibited promising long-term results in Japan, with ongoing efforts to improve surgical techniques and preoperative planning. Further advancements are anticipated to prevent complications such as dislocation and peri-implant fractures.

Symptomatic Nonunion of the Coracoid Process Following Osteosynthesis Using a Suture Button for Coracoid Process and Distal Clavicle Fracture: A Case Report.

BACKGROUND Coracoid process fractures are uncommon and are often complicated by many types of shoulder girdle injuries. Previous reports have shown that osteosynthesis for isolated coracoid process fractures results in favorable outcomes and high bone union rates. However, owing to the rarity of coracoid process fractures combined with distal clavicle fractures, there are limited data to guide treatment strategies. We report a case of symptomatic nonunion despite performing osteosynthesis for fractures of the coracoid process and distal clavicle. CASE REPORT A 60-year-old man presented with left shoulder pain after falling from the back of a truck. Radiography and computed tomography (CT) findings revealed fractures of the left distal clavicle and coracoid process. We performed plate and costoclavicular fixation using a suture button for the distal clavicle fracture and cannulated cancellous screw fixation for the coracoid process fracture. However, the patient experienced severe pain around the coracoid and had limited shoulder range of motion 1 year postoperatively. CT revealed nonunion of the coracoid process, prompting a recommendation for surgery. However, despite severe persistent functional impairment, the patient refused surgery 1.5 years postoperatively. CONCLUSIONS This case suggests the potential for symptomatic nonunion of the coracoid process when using a suture-button device for a distal clavicle fracture. To prevent postoperative nonunion of the coracoid process, postoperative CT evaluation is necessary. If a symptomatic delayed bone union of coracoid process is observed, considering early removal of the suture button is recommended.

Surgical Repair for Rhomboid Major Tear: A Case Report.

Rhomboid tears are a rare type of tendon injury. Although rhomboid tears can present with periscapular pain and scapular dyskinesis, their clinical presentations and diagnostic procedures remain largely unknown. In addition, few reports are available on the surgical treatment of rhomboid tears. We report a rhomboid repair case for a complete rhomboid major tear diagnosed based on physical findings and magnetic resonance imaging (MRI). A 28-year-old man presented with right medial scapular pain that appeared after carrying a heavy box. He had right medial scapular tenderness, with worsening pain during shoulder joint elevation. The inferior pole of the right scapula was lateral compared with the left scapula, and a dent was observed on the medial scapula. Magnetic resonance imaging revealed a tear in the right rhomboid major at its insertion, with muscle retraction. Two months of conservative treatment failed to improve his symptoms; therefore, we performed a surgical repair. We created the bone holes on the medial border of the scapula and repaired the torn rhomboid major muscle to its insertion using the Krackow stitch technique. He had a satisfactory functional outcome without postoperative retearing. This case report provides new information on the clinical presentation and surgical procedure of rhomboid major tears and the first MRI finding that depicts a rhomboid tear clearly. In cases of rhomboid tears, persistent medial scapular pain and winging scapula can be clinically problematic, requiring surgery. In addition to physical findings, a periscapular MRI is useful in diagnosing rhomboid tears. The results of this case study suggest that surgical repair using locking sutures is an option for treating complete rhomboid tears with muscle retraction.

Influence of Proximal Humeral Cortical Bone Thickness on the Radiographic Outcome After Osteosynthesis of Proximal Humeral Fractures: Propensity Matching Score Analysis.

Introduction: Osteoporosis can affect the surgical outcomes of proximal humeral fractures in older people. Recently, the cortical bone thickness of the proximal humerus on plain radiograph has been proposed to reflect local osteoporosis of the proximal humerus; however, its effect on the surgical outcome of proximal humeral fractures remains unclear. The purpose of this study is to investigate the influence of cortical bone thickness on postoperative radiographic outcomes after osteosynthesis for proximal humeral fractures. Materials and Methods: We retrospectively identified 190 patients (≥50 years) who underwent osteosynthesis with an intramedullary nail or plate for proximal humeral fractures. The patients were categorized into 2 groups according to the cut-off value of an average proximal humerus cortical bone thickness of 6 mm on plain radiographs: patients with and without local osteoporosis. After propensity score matching, we compared the incidence of postoperative radiographic complications between the 2 groups. We also performed subgroup analyses of outcomes in a subgroup of patients who underwent intramedullary nailing and those who underwent plate fixation. Results: Propensity score matching yielded 60 patients in each group. No significant difference in complication rates was observed between the 2 groups. However, in the intramedullary nailing subgroup, the incidence of reduction loss was significantly higher in patients with local osteoporosis than in those without local osteoporosis (51.7% vs 14.3%, P = .002). Discussion: The proximal humeral cortical bone thickness had no significant effect on the overall radiographic outcome; however, reduction loss after intramedullary nailing was susceptible to local osteoporosis of the proximal humerus. Conclusion: Our study suggests that plate fixation is advantageous in preventing postoperative reduction loss in patients with lower cortical bone thickness.

Curettage and external fixation for displaced pathological fracture through non-ossifying fibroma in the radius: A case report.

Non-ossifying fibromas are extremely rare in the upper extremity, such as those in the radius and humerus. The treatment of completely displaced fractures following non-ossifying fibromas in the radius has not been reported. We present the case of a pathological fracture caused by a non-ossifying fibroma in the radius treated using external fixation. The patient was a 10-year-old girl who presented to our hospital with right forearm pain after an accidental fall. She had no remarkable medical history. Radiographs and computed tomography showed a pathological fracture through osteolytic lesions with sclerotic rims in the diaphysis of the radius, suggesting a pathological fracture through a non-ossifying fibroma in the radius. We performed tumor curettage and external fixation due to marked fracture displacement. Histological findings were compatible with those of non-ossifying fibroma. Six months post-surgery, there were no limitations in the range of motion of supination and pronation of the forearm, and radiographs confirmed a bone union. Although non-ossifying fibromas in the radius are rare, cases with large lesions can cause pathological fractures after minor trauma. This case suggests that curettage and external fixation are beneficial, especially if early surgery is required due to unacceptable displacement and when there is no time for a biopsy to rule out malignancy.

Plate fixation using parallelogram prism iliac bone grafts for clavicle oblique nonunion with shortening deformity: a case report.

BACKGROUND: Plate fixation using a tricortical iliac bone graft can provide a high ratio of bone union and restore clavicle length in cases of atrophic nonunion. However, the surgical treatment of clavicle oblique nonunions with marked shortening deformity remains challenging and unresolved. Here, we describe a case of clavicle oblique nonunion with shortening that was treated using plate fixation with parallelogram prism iliac bone grafts. CASE PRESENTATION: A 46-year-old man presented to our hospital with severe medial scapular pain. He had been diagnosed with a right clavicle mid-shaft fracture in a motorcycle accident 9 months earlier. He underwent conservative treatment, but radiographs and computed tomography showed clavicle oblique nonunion with marked shortening. Physical examination revealed no pain at the nonunion site; however, tenderness was noted on the medial side of the right scapula and protrusion of the inferior scapular angle was prominent. His symptoms interfered with daily life and required surgery. After release of the nonunion, we harvested the parallelogram prism bone grafts from the iliac crest. We inserted these bone grafts into the fracture ends and fixed them with lag screws, after which we performed plate fixation. Immediately after surgery, right medial scapular pain and scapula winging subsided. Bone union was achieved, and the length of the clavicle was restored at 9 months postoperatively. CONCLUSIONS: This case report provides new information on the surgical treatment of clavicle oblique nonunion with shortening deformity. The presence of medial scapular pain and winging scapula can be clinically problematic in cases of clavicle nonunion with marked shortening. Our case revealed that reliable bone union and clavicle length recovery can be achieved with plate fixation and iliac bone grafts.

Inferior subluxation of humeral head after osteosynthesis for greater tuberosity fracture.

BACKGROUND: Inferior subluxation of the humeral head is frequently observed immediately after surgery for proximal humerus fractures; however, the incidence and risk factors of inferior subluxation after osteosynthesis for isolated greater tuberosity fractures remain unsolved. Additionally, the postoperative course of inferior subluxation has not been elucidated. The purpose of the present study is to identify the predictors for the occurrence of postoperative inferior subluxation by multivariate analysis and investigate the postoperative shift of inferior subluxation and its effect on surgical outcomes. METHODS: We retrospectively identified 68 patients who underwent surgery for isolated greater tuberosity fractures. The dependent variable was the inferior subluxation at 1 week postoperatively. The explanatory variables were age, sex, affected side of the shoulder, body mass index, history of smoking, local osteoporosis, time period to surgery, axillary nerve injury, inferior subluxation before surgery, fracture dislocation, surgical approach, surgical method, operative time, amount of blood loss, and postoperative drainage. Baseline variables that were statistically significant in the univariate analyses were included in the logistic regression analysis. The patients were further categorized into two groups according to the presence of inferior shoulder subluxation exhibited 1 week postoperatively: patients with inferior subluxation (+ IS group) and patients without inferior subluxation (- IS group). We compared the incidence of postoperative complications between the two groups. RESULTS: Of 68 patients, 17 (25.0%) had inferior shoulder subluxation observed 1 week postoperatively. Multivariate analysis showed that long operative time was a risk factor for postoperative subluxation (odds ratio = 1.03; P = 0.030). In all cases, inferior subluxation disappeared within 3 months of surgery. No significant difference in complication rate was observed between the + IS and - IS groups. CONCLUSIONS: The present study provides novel information regarding postoperative inferior subluxation of fractures of the greater tuberosity. Inferior subluxation occurred in 25% of patients immediately after surgery. Long operative time contributes to the onset of postoperative inferior subluxation; however, this was temporary in all cases and had no significant effect on the surgical outcomes. LEVEL OF EVIDENCE: Level III.

Total elbow arthroplasty using an augmented reality-assisted surgical technique.

BACKGROUND: Precision placement of implants in total elbow arthroplasty (TEA) using conventional surgical techniques can be difficult and riddled with errors. Modern technologies such as augmented reality (AR) and 3-dimensional (3D) printing have already found useful applications in many fields of medicine. We proposed a cutting-edge surgical technique, augmented reality total elbow arthroplasty (ARTEA), that uses AR and 3D printing to provide 3D information for intuitive preoperative planning. The purpose of this study was to evaluate the accuracy of humeral and ulnar component placement using ARTEA. METHODS: Twelve upper extremities from human frozen cadavers were used for experiments performed in this study. We scanned the extremities via computed tomography prior to performing TEA to plan placement sites using computer simulations. The ARTEA technique was used to perform TEA surgery on 6 of the extremities, whereas conventional (non-ARTEA) techniques were used on the other 6 extremities. Computed tomography scanning was repeated after TEA completion, and the error between the planned and actual placements of humeral and ulnar components was calculated and compared. RESULTS: For humeral component placement, the mean positional error ± standard deviation of ARTEA vs. non-ARTEA was 1.4° ± 0.6° vs. 4.4° ± 0.9° in total rotation (P = .002) and 1.5 ± 0.6 mm vs. 8.6 ± 1.3 mm in total translation (P = .002). For ulnar component placement, the mean positional error ± standard deviation of ARTEA vs. non-ARTEA was 5.5° ± 3.1° vs. 19.5° ± 9.8° in total rotation (P = .004) and 1.5 ± 0.4 mm vs. 6.9 ± 1.6 mm in total translation (P = .002). Both rotational accuracy and translational accuracy were greater for joint components replaced using the ARTEA technique compared with the non-ARTEA technique (P < .05). CONCLUSION: Compared with conventional surgical techniques, ARTEA had greater accuracy in prosthetic implant placement when used to perform TEA.

Pneumorachis from the cervical to the sacral spinal canal with spinal epidural abscess by gas gangrene.

We present a 70-year-old woman with severe diabetes mellitus, who experienced low back pain and left lower leg paralysis. Computed tomography showed air in the spinal canal from C4 to S5, and magnetic resonance imaging revealed an epidural abscess from Th11 to L1. Laboratory findings showed increases in inflammatory indicators and blood culture indicated the presence of Escherichia coli. The patient was treated conservatively with antibiotics. Neurological deficits and inflammatory data improved during the course. Follow-up imaging studies showed the disappearance of gas and epidural abscess. The existence of air in the spinal canal is a rare condition known as pneumorachis. To the best of our knowledge, such a long pneumorachis ranging from the cervical to the sacral spinal canal with epidural abscess caused by gas gangrene has not yet been described. We should therefore realize the possibility of epidural abscess produced by gas gangrene and treat it appropriately.

Association between time to surgery and 90-day mortality after hip fracture: A retrospective cohort study of 1734 cases.

BACKGROUND: It remains unclear whether early surgical intervention can reduce mortality after surgery in hip fracture patients. The aim of this study was to investigate the association between time from injury to surgery and mortality rate within 90 days after hip fracture surgery. METHODS: We retrospectively identified 1827 patients who underwent hip fracture surgery in a tertiary care center in Japan between April 2007 and March 2017. After applying exclusion criteria (patients with spontaneous fracture, multiple fractures, revision surgery, total hip arthroplasty, or a refusal to participate), 1734 patients were included. We extracted data concerning patients' age, race, sex, operative procedure, American Society of Anesthesiologists (ASA) score, days from injury to surgery (injury-surgery days), and days from admission to surgery (admission-surgery days), which could affect 90-day mortality after surgery. Variables associated with 90-day mortality were determined using multivariate logistic regression analysis. RESULTS: The 90-day postoperative mortality rate was 3.5% (60 of 1734). Multivariable analysis showed that injury-surgery days were not associated with 90-day mortality (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.80 to 1.05; P = 0.19), and that older age (OR, 1.06; 95% CI, 1.02 to 1.10; P = 0.005), male sex (OR, 3.62; 95% CI, 1.86 to 7.03; P < 0.001) and high ASA score (OR, 2.10; 95% CI, 1.06 to 4.18; P = 0.034) significantly increased 90-day mortality. In addition, admission-surgery days were not associated with 90-day mortality (OR, 0.95; 95% CI, 0.83 to 1.09; P = 0.45). CONCLUSION: Our results demonstrated that time from injury to surgery was not associated with mortality within 90 days after surgery after adjusting for age, sex, operative procedure, and ASA score.

Pacemaker Lead Dislodgement Due to Left Shoulder Dislocation: A Case Report.

CASE: A 63-year-old man with a cardiac pacemaker presented with a left shoulder dislocation. His heart rate was 46 beats per minute, and pacemaker testing demonstrated an elevated pacing threshold, a decreased sensing threshold, and stable pacemaker lead impedance. Lead dislodgement due to the shoulder dislocation was suspected, and the patient underwent repositioning of the lead. CONCLUSION: When a patient with a pacemaker dislocates a shoulder, it should be confirmed that the heart rate is above the programmed lower rate of the pacemaker; electrocardiography should be performed, and the pacing parameters should be checked to ensure that pacing failure is not overlooked.