A cadaveric study of the posterior band of the inferior glenohumeral ligament of the shoulder and its dynamic behaviour in different arm positions.

Purpose: The inferior glenohumeral ligament (IGHL) is composed of three parts: the anterior branch or band (AB), the axillary pouch and the posterior band (PB). The latter has rarely been studied. We aim to describe the PB of the IGHL and its dynamic behaviour in different arm positions. Methods: Twelve fresh cadaveric shoulders were used and the two bands (AB and PB) of the IGHL were dissected and isolated, taking away all muscle, ligaments and capsule. Characteristics of the bands were studied in five positions: maximum external rotation (ER1), abduction (ABD), internal rotation (IR), ABD external rotation (ER2) and anterior elevation-adduction-IR (Hawkins-Kennedy test position). Progressive and randomized sectioning of the bands and capsule with a scalpel was performed to study its impact on mobility and translation of the glenohumeral joint. Results: The bands that tensioned first were in ER1, the AB at 97 ± 9° (80-110); in ER2, the AB at 81 ± 19° (30-100); in IR, the PB at 64 ± 9° (50-80); and in ABD, the PB at 87 ± 10° (70-105). Isolated sectioning of the AB had no effect on ABD, whilst isolated sectioning of the PB allowed greater ABD. In ER2, the AB limited anterior translation. After sectioning the AB, anterior translation remained limited by the PB, which wrapped around the humeral head and locked the joint by pressing the two joint surfaces tightly together. In Hawkins-Kennedy position anterior elevation-adduction-IR, the AB is the first constraint and the posterior translation was limited by the PB alone only in four cases. Conclusions: When the IGHL is isolated, ligament limitation of glenohumeral ABD seems to be uniquely dependent on the PB. In the Hawkins and Kennedy position, the AB is the first constraint. In the case of an isolated lesion to the AB, the PB participates in anterior stabilization of the shoulder by wrapping around the humeral head that cannot dislocate. These findings confirm the role of the PB in glenohumeral joint stability. Level of Evidence: Level IV.

Surgical anatomy of the nail.

Knowledge of nail anatomy is a prerequisite for both diagnostic and therapeutic purposes. The nail apparatus is a highly specialized structure, but is in close relationship to the distal phalanx which supports it and to the pulp which carries the sensory receptors and is involved in pinching. It can be divided by the nail plate into the perionychium underneath, and the paronychium above. The perionychium includes, from proximal to distal: the nail matrix, the sole structure responsible for the growth of the nail plate; the nail bed, mostly responsible for adhesion of the plate; and the hyponychium, which is the most distal part, where the nail plate loses its adhesion. The paronychium comprises three nail folds, one proximal and two lateral, that embed the nail plate. The nail apparatus is richly vascularized, with three main sources, and richly innervated, which explains why trauma and surgery are so painful.

A biomechanical study of the medial row tightening on stability of single stitch suture-bridge construct.

PURPOSE: To define the more stable knot tightening of a suture bridge when a single limb is preserved. METHODS: Five different sutures were tested: No. 2 Ethibond (Ethicon), Hi-Fi (ConMed Linvatec), Sutblue (SBM), SingleFlat (SBM), Hi-Fi Ribbon (ConMed Linvatec). A Surgeon's Knot was tied around a 30-mm circumference device, 6 times for each experiment. A single limb was kept to analyze failure modes of the knot. First step was to analyze which of pulling or sliding suture of the construct must be kept preventing failure of the knot. The cutting distance from the knot was evaluated at 1 mm and 4 mm with the suture loops pre-tensioned to 10 N and fixed to a second row after a 50 N tension load. The more stable construct was found: a single-pull load to 100 N and cyclic load (to 50 N for 30 cycles) experiments were conducted to evaluate the impact of cycling on knot loosening. RESULTS: The more stable construct was obtained when the non-post limb was tensioned, and the post limb was cut at 4 mm (p < 0.01). Loop circumference increased after each experiment for all tested sutures, independently of the preserved limb and the cutting distance. Elongation was significant for all tested sutures in all groups. Knot failure mostly occurred by slippage, only with tapes. CONCLUSIONS: A suture-bridge construct with the non-post limb preserved and the post limb cut at a 4 mm distance from the knot provides with the best security. Sutures are safer than tapes in suture bridge.

Glenoidplasty With Posterior Labral Reattachment for Posterosuperior Glenoid Impingement.

BACKGROUND: Posterosuperior glenoid impingement (PSGI), also known as shoulder internal impingement, is a cause of shoulder pain in athletes involved in overhead-throwing sports. PSGI is a condition mostly treated by rehabilitation. Surgery is indicated after unsatisfactory nonoperative management. However, with most of the surgical techniques proposed, the shoulder remains persistently painful during sport activity. HYPOTHESIS: We aimed to evaluate the efficiency of adding posterior labral reattachment to glenoidplasty as a surgical treatment for PSGI. Our hypothesis was that posterior labral reattachment would have a positive effect on shoulder pain. To our knowledge, this combined procedure has not been previously described. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively reviewed 11 male patients with PSGI treated with glenoidplasty and posterior labral reattachment at a single institution during a 7-year period and with a minimum 30-month follow-up after surgery. Most patients were recreational athletes, with 5 of them practicing at the national level and 1 being a professional athlete. Patients completed an online questionnaire consisting of the Simple Shoulder Test (SST), the Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow questionnaire, and a specific PSGI survey. Pre- and postoperative shoulder pain were analyzed using the paired t test, with significance set at P < .05. RESULTS: All 11 patients investigated sought surgery because of persistent shoulder pain while practicing their sport. The patients underwent glenoidplasty and posterior labral fixation, and data for 9 patients were available for analysis (mean age, 29 years; range, 24-42 years). At a minimum 30-month follow-up, most patients (77.8%) showed decreased pain, and 8 patients were able to return to their previous sports activities, with 7 returning at the same or higher level. There was 1 patient who had to change sports because of a lack of force, while a second patient temporarily changed sport and then returned to his sport but at an inferior level. Pre- and postoperative pain differed significantly (P < .05). Surgery did not impair daily life in all patients. CONCLUSION: Glenoidplasty associated with posterior labral reattachment significantly diminished shoulder pain in athletes involved in throwing sports. Most patients were able to return to their previous sport at the same or higher level. Posterior labral fixation may improve the benefit of glenoidplasty by decreasing pain.

Frequency and risk factors of complications after surgical treatment of ankle fractures : a retrospective study of 433 patients.

Ankle fractures are frequently treated using surgical interventions, and are associated with a high rate of postoperative complications. We wonder if complications can be anticipated and correlated to patient demographics, lifestyle, fracture or surgery related factors. We retrospectively reviewed all medical reports of patients who underwent ankle fracture surgery between 2013 and 2017. We focused our risks factors analysis on 5 common complications : poor wound healing, surgical site infection, malunion, nonunion and chronic pain. Multivariate logistic regression was performed to analyze significant risk factors for these complications. We identified 433 patients. Complications were present in 26% of the cases. The most frequent complication was poor wound healing (10%) associated with deep surgical site infection in 6%. Malunion was found in 7% and nonunion in 3%. Seven percent of patients suffered from chronic pain. More severe fractures happened to be a risk factor for poor wound healing (p = 0,032) and malunion (p < 0,001). Open fractures had respectively 6 to 9 times more mal- (p = 0,012) and nonunion (p = 0,018). Overweight patients with alcohol abuse were doubling their chances of cutaneous (p = 0,030) and infectious (p = 0,040) complications, and tripling their risks of ankle fracture nonunion (p = 0,003). Female and patients operated at night (p = 0,045) seemed to be more at risk to develop chronic pain (p = 0,028). Complications of ankle fracture treatment are frequent and their risks increases with more complex and open fractures. This study brings new evidence concerning the combined effect of overweight and alcohol abuse on poor wound healing, surgical site infection and non-union.