Ultrasound-guided interscalene block anesthesia performed by an orthopedic surgeon: a study of 1322 cases of shoulder surgery.

BACKGROUND: Interscalene blocks are becoming increasingly common for shoulder surgeries. This study primarily aimed to demonstrate the efficacy and complications and the secondarily to investigate the anesthesia-related time and patient satisfaction of an ultrasound-guided interscalene block performed by an orthopedic surgeon. METHODS: We retrospectively reviewed the medical records of 1322 consecutive patients (arthroscopic, 1225 cases; open, 97 cases) with a mean age of 64.2 years, who underwent shoulder surgery (arthroscopic or opensurgery) under an ultrasound-guided interscalene block performed by an orthopedic surgeon at a single institution between December 2012 and December 2019. We investigated patient satisfaction, block success rates, and complications and also compared the anesthesia-related time of an interscalene block with that of general anesthesia (428 cases, arthroscopic, 257 cases; open, 171 cases) for shoulder surgery with patients in the beach chair position during the same period. Difference between total anesthesia time and surgical time was defined as anesthesia-related time. RESULTS: Approximately 98.3% of patients were satisfied with an interscalene block, and the block success rate on the first attempt was 99.9%. Total complication incidence was 2.3%, with no recorded life-threatening complications. Anesthesia-related times were significantly shorter in the interscalene block group than those in the general anesthesia group (45 ± 14 min vs. 100 ± 26 min, P < .001). CONCLUSION: An ultrasound-guided interscalene block performed by an orthopedic surgeon for shoulder surgery is effective and safe, requires less time, and has a high patient acceptance rate, making it a feasible and alternative to the block performed by anesthesiologists.

Acromial and humeral head osteolysis following superior capsular reconstruction using autologous tensor fascia lata graft.

BACKGROUND: Graft tear is a critical complication following superior capsular reconstruction (SCR) as it directly links with clinical outcomes. No previous reports have described acromial and humeral head osteolysis following SCR. Acromial and humeral head osteolysis may incidentally occur after SCR using autologous tensor fascia lata graft. This study aimed to demonstrate the incidence of osteolysis following SCR using autologous tensor fascia lata graft and investigate the factors that affect osteolysis. METHODS: This retrospective cohort study included patients who underwent SCR for irreparable rotator cuff tears between June 2014 and June 2019. The patients were divided into 2 groups-those with no osteolysis and those with osteolysis-and were compared. For subanalysis, patients in the osteolysis group were further divided into 3 groups according to the location of the osteolysis-acromial osteolysis, humeral head osteolysis, and acromial and humeral head osteolysis-to clarify the factors determining the location of osteolyses. The shoulder range of motion was evaluated preoperatively and 24 months postoperatively. Additionally, the following items were evaluated: condition of the subscapularis tendon, Hamada classification (grade 2 or 3), critical shoulder angle, acromiohumeral distance measured preoperatively and 24 months postoperatively, graft size, and graft thickness. In addition, the graft condition was evaluated using magnetic resonance imaging 12 months postoperatively. RESULTS: In total, 57 patients were enrolled and followed up for a minimum of 2 years (follow-up rate, 92% [57 of 62 cases]). Overall, the incidence of osteolysis following SCR was 35.1% (20 of 57 cases; acromial osteolysis in 7, humeral head osteolysis in 3, and acromial and humeral head osteolysis in 10). Compared with the group with no osteolysis, the osteolysis group had no inferior clinical outcomes or higher graft tear rates. The proportions of Hamada grade 3 (P = .041) and involvement of the subscapularis tendon (P = .020) were significantly higher in the osteolysis group. The relative risks of subscapularis involvement and Hamada grade 3 for osteolysis were 2.9 and 5.1, respectively. In the subanalysis, the factors determining the location of the osteolysis could not be clarified. CONCLUSIONS: This study suggested that the progression of the Hamada classification and condition of the subscapularis tendon affect the occurrence of osteolyses. However, these osteolyses were not associated with clinical outcomes, including graft tear rate and shoulder range of motion.

The clinical outcomes and tuberosity healing after reverse total shoulder arthroplasty for acute proximal humeral fracture using the turned stem tension band technique.

BACKGROUND: Recent studies have reported the clinical effectiveness of tuberosity healing after reverse total shoulder arthroplasty in patients with proximal humeral fractures with respect to joint stability, long-term survival, and postoperative range of motion. However, it is challenging to achieve robust fixation of the fragile bone fragments in elderly patients. This study aimed to report on the radiographic and clinical outcomes of patients who underwent reverse total shoulder arthroplasty for acute proximal humeral fractures using a Turned stem Tension Band technique-a simple suture configuration that can apply a compressive force on both tuberosities at the same time. METHODS: Eighteen patients who underwent reverse total shoulder arthroplasty for complex proximal humeral fractures (age 80.4 ± 4.7 years, range 70-87 years), using our Turned stem Tension Band technique, were included in this study and evaluated postoperatively for range of motion, American Shoulder and Elbow Surgeons score, Numerical Rating Scale, and tuberosity healing, with minimum 2-years follow-up (mean 34.5 months, range 24-60 months). RESULTS: At the final follow-up, mean range of motion results were active flexion, 119 ± 34°; active abduction, 116 ± 35°; active external rotation, 27 ± 12°; and active internal rotation, L3. Six of 11 (55%) patients with 4-part dislocated fractures had neurological disorders from the time of injury; of these, three patients obtained shoulder elevation under 90° at the final follow-up. The mean American Shoulder and Elbow Surgeons score was 77.3 ± 10.7, and the mean Numerical Rating Scale was 1.2 ± 0.9. Fifteen of 18 (83%) patients were satisfied with the results. The tuberosity healing rate was 100% (18 of 18). CONCLUSIONS: The Turned stem Tension Band technique in reverse total shoulder arthroplasty for proximal humeral fractures provides a robust fixation, regardless of the fracture pattern, which results in a high tuberosity healing rate.

Association between sagittal spinal alignment and postoperative shoulder range of motion following reverse total shoulder arthroplasty.

BACKGROUND: The range of internal rotation sometimes deteriorates after reverse total shoulder arthroplasty; however, the underlying mechanisms remain unclear. This study aimed to investigate the association between sagittal spinal alignment and internal rotation deterioration after reverse total shoulder arthroplasty. METHODS: We retrospectively reviewed 52 patients who underwent reverse total shoulder arthroplasty by a single surgeon between October 2014 and December 2018. The sagittal spine was radiographed, and the sagittal spinal alignment was evaluated based on 10 parameters (e.g. C7-HA: the distance between the plumb line from the center of the seventh cervical vertebral body and the center of the hip axis). We divided the patients into two groups, group A (internal rotation deterioration; 23 patients) and B (without internal rotation deterioration; 29 patients). Logistic regression analysis was performed to analyze the association between sagittal spinal alignment and internal rotation deterioration after reverse total shoulder arthroplasty, and a receiver operating characteristic curve was used to analyse the cutoff value of independent variables that was correlated with IR deterioration. RESULTS: Logistic regression analysis demonstrated the correlation between C7-HA and internal rotation deterioration (odds ratio, 1.95; 95% confidence interval, 1.33-2.84; P < 0.001). The receiver operating characteristic curve suggested that when C7-HA was at least 2.44 cm, it was strongly correlated with deterioration of internal rotation (sensitivity, 91.3%; specificity, 93.1%; P < 0.001; area under the curve, 0.938). Group A was significantly inferior to group B in not only internal rotation but also flexion and abduction. CONCLUSIONS: This study suggested that a remarkably positive value in C7-HA was a factor that was correlated with deterioration of internal rotation. In addition, the deformation of sagittal spinal alignment would impact on the range of motion after reverse total shoulder arthroplasty.

Severe hand contracture treated by external fixation after proximal row carpectomy and awake tenolysis after general anesthesia: A case report.

Wide-awake local anesthesia has many advantages. We describe a new method to use wide-awake local anesthesia with more flexibility. A 32-year-old man with a severe right-hand contracture after an iatrogenic tourniquet accident during an anterolateral thigh flap for a partial hand amputation underwent contracture release using external fixation after proximal row carpectomy and subsequent tenolysis. We performed most of the tenolysis procedure under general anesthesia and the final stage with an intraoperative assessment of active finger movement and dissection under local anesthesia. He regained his grip strength 2.5 years post-injury. General anesthesia is useful to treat a surgical site with extensive hard scars, whereas local anesthesia is useful for adjusting tension in an awake patient. The indication for wide-awake surgery is yet to be established; our method of combining general and local anesthesia in the tenolysis procedure illustrates the possibilities in expanding this method.

A Three-Step Method for the Treatment of Radioulnar Synostosis with Posterior Radial Head Dislocation.

Congenital radioulnar synostosis with posterior dislocation of the radial head remains challenging to treat. We describe a three-step treatment method that combines radial shaft osteotomy with a custom-made device, ulnar shaft osteotomy, and local adipofascial flap elevation procedures. For posterior radial head dislocation treatment, osteotomy near the proximal radius cannot recover physiological rotation of the radial head. Thus, we chose a precise radial shaft osteotomy with a custom-made device according to preoperative planning based on three-dimensional evaluation of the bone deformation. Performing radial shaft osteotomy alone, however, may not be enough to achieve sufficient supination range of motion. We, therefore, also performed ulnar shaft osteotomy. Finally, we elevated the local adipofascial flap to prevent re-adhesion. In three patients, the range of motion of the elbow improved postoperatively. In conclusion, our three-step method does not require a microsurgical technique and is easy to perform.

Do Not Cut Wood with an Angle Grinder, or You Might Lose a Finger: A Retrospective Study.

Background: Angle grinders are a handheld power tool used for grinding and polishing stone, metal, and concrete. Some people, however, use them with a circular saw blade attachment for cutting wood and consequently, suffer injuries. We aimed to investigate the underlying cause and mechanisms of injuries caused by cutting wood with an angle grinder. Methods: We conducted a retrospective study using medical records from our trauma center and identified 15 patients treated for angle grinder injury between 2017 and 2018. Moreover, we contacted the National Consumer Affairs Center of Japan for further information about angle grinder injuries. Results: Nine of the 15 patients used angle grinders improperly, of which only three patients were aware of the risk of injury. The details of the nine patients were as follows: the types of injuries: complete finger amputation (n = 2), partial finger amputation (n = 1), tendon injury with phalangeal fracture (n = 5), and tendon injury alone, (n = 1); the causes of accidents: kickback (n = 7) and glove entanglement (n = 2); and the accident situations: on-the-job (n = 5) and do-it-yourself (n = 4). Conclusions: The primary cause of angle grinder injury caused by cutting wood was a lack of user knowledge that an angle grinder cannot be used as a cutting tool. Appropriate feedback from hand surgeons are necessary to urge manufacturers to take safety measures.

Modified load sharing rip-stop technique in patients with traumatic transtendinous rotator cuff tear: Surgical technique and clinical outcomes.

BACKGROUND: Transtendinous rotator cuff tear is likely to occur due to trauma in sports activities, with a frequency of <2% of total rotator cuff tears. These tears are difficult to treat because of limited tendon tissue in the proximal stump, and standard repair techniques are sometimes ineffective. Few studies have reported on the repair technique and clinical outcomes for transtendinous rotator cuff tear, and an appropriate repair technique has, therefore, not been established. The purpose of this study was to use our modified load sharing rip-stop technique to repair transtendinous rotator cuff tear and to clarify the clinical effectiveness of this technique. METHODS: This was a retrospective case series review of eight patients who underwent the modified load sharing rip-stop technique for repairing traumatic transtendinous rotator cuff tear between January 2013 and June 2017. The eight patients were followed up for at least 2 years (range: 24-41 months). Cuff integrity was evaluated using magnetic resonance imaging at 12 months after surgery using the Sugaya classification. We evaluated the pre- and postoperative ranges of motion, American Shoulder and Elbow Surgeons score, Constant Shoulder Score, and muscle strength at 90° abduction. Data were analyzed using the Mann-Whitney U test and Fisher's exact tests. P < .05 was considered to indicate statistical significance. RESULTS: Six patients were classified as Sugaya I and two as Sugaya II. ASES score (38.5-90.2, P = .0008), Constant shoulder score (36.5-79, P = .002), flexion (85°-158.1°, P = .002), abduction (85°-157.5°, P = .001), external rotation (38.8°-55°, P = .024), and muscle strength at 90° abduction (2.95-5.39 kg, P = .028) improved significantly. Six patients were able to return to their previous sports activity. CONCLUSION: Using our modified load sharing rip-stop technique for repair of transtendinous rotator cuff tear, patients obtained good clinical outcomes and could return to sports activities.

How Long Should We Immobilize the Wrist after Vascularized Bone Grafting for the Treatment of Scaphoid Nonunion?

Background: Although vascularized bone grafting can effectively treat scaphoid nonunion, the optimal duration of the immobilization period after bone grafting is unclear. Therefore, we aimed to examine the difference in the union rate and range of motion between short and long immobilization periods and infer the optimal post-immobilization period after pedicled vascularized bone grafting for scaphoid nonunion treatment. Methods: A total of 23 wrists (21 men and 1 woman) with scaphoid nonunion treated using an intercompartmental supraretinacular artery pedicled vascularized bone graft were analyzed. We examined the difference in the union rate and range of motion between patients immobilized for less than 49 days (short immobilization group) and those immobilized for more than 49 days (long immobilization group). The range of motion of the wrist joint was measured before and after surgery. Patient outcomes were also assessed. Results: The overall union rate was 95.6%. A significant difference was found in postoperative extension and flexion between the two groups, but not in terms of the functional outcome. If the intraoperative fixation is solid, intraoperative proximal pole bleeding is confirmed, and the follow-up radiograph shows a normal healing process, we propose immobilization of the wrist for ≤ 7 weeks. Conclusions: The immobilization duration should depend on the solidity of intraoperative fixation and a satisfactory appearance on follow-up radiography: absence of a gap at the graft interface, surrounding lucency, or movement of the implant and displacement of the graft. If there are no signs of graft failure and fixation is solid, immobilization of the wrist for 7 weeks or less is recommended.

Examination of the Dorsal Finger Vein Anatomy Using a Vein Visualization Device.

Background: The vein anatomy of the dorsal finger is often difficult to identify suitable veins for anastomosis when treating digital amputations, but it has not been well studied to date. The aim of our study was to determine the vein anatomy of the dorsal finger using a vein visualization device. Methods: The study sample consisted of 20 volunteers (11 men and 9 women; 148 fingers and 37 thumbs). The number and location of veins, the distance from the finger midline to the most central vein, and the distance from the central vein to the adjacent vein were examined using a vein visualization device, Stat Vein®, at the eponychial level, distal interphalangeal (DIP) joints, and proximal interphalangeal joints. Results: In the finger, the distance from the nail lunula edge to the vein at the eponychial level was about 5 mm and that from the central vein to the adjacent vein at the DIP joints was about 8 mm. In the thumb, the distance from the nail lunula margin to the vein at the eponychial level was about 5 mm and that from the central vein to the adjacent vein at the interphalangeal joints was about 6 mm. Conclusions: Treatment of DIP joint-level finger amputation requires identification of the central vein at first and then the site about 8 mm away from the central vein. In the treatment of eponychial-level finger amputation, the vein is found about 5 mm away from the nail lunula edge.

Reconstructing the Epicondyle and Collateral Ligament in Missing Condylar Region Associated with Severe Elbow Trauma: A Report of 2 Cases.

CASES: We report 2 cases of missing condylar region associated with severe elbow trauma treated with our new surgical technique and present the outcomes at the 9- and 10-year follow-ups. Our method focused on anatomical isometric point reconstruction, which consisted of the reconstruction of the missing condylar region with the iliac bone and the collateral ligament with the palmaris longus tendon. CONCLUSIONS: This injury is rare, and treatment is challenging because of the difficulty in identifying the isometric point. Both patients achieved good elbow function. The bone defect region was almost remodeled with minimal bone tunnel enlargement. Overall, our technique can provide positive results.

Association Between the Postoperative Condition of the Subscapularis Tendon and Clinical Outcomes After Superior Capsular Reconstruction Using Autologous Tensor Fascia Lata in Patients With Pseudoparalytic Shoulder.

BACKGROUND: Superior capsular reconstruction (SCR) has been performed for irreparable rotator cuff tear and pseudoparalytic shoulder (PPS); however, poor clinical outcomes have occasionally been reported. Previous studies have shown that the cause of poor clinical results was mainly graft rupture; however, poor clinical outcomes have also been observed in some cases even though the graft was not ruptured. HYPOTHESIS/PURPOSE: We hypothesized that the subscapularis (SSC) tendon would be an important factor affecting clinical outcomes after SCR. The purpose was to clarify the correlation between the condition of the SSC tendon and clinical outcomes after SCR in patients with PPS. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This retrospective cohort study included 27 patients who had undergone SCR for PPS performed by 1 surgeon between June 2014 and July 2017. The 27 patients were divided into 3 groups for evaluation: group A (n = 12), irreparable supraspinatus (SSP) and infraspinatus (ISP) tears but intact SSC tendon; group B (n = 11), irreparable SSP and ISP tears and repairable SSC tear; and group C (n = 4), irreparable SSP, ISP, and SSC tears. We evaluated the preoperative and postoperative ranges of motion (ROMs; active flexion, abduction, external rotation, and internal rotation), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form score, and graft condition on magnetic resonance imaging at 12 months postoperatively. All data were analyzed using the Mann-Whitney U, Wilcoxon signed-rank test, and Fisher exact tests, and P < .05 was considered significant. RESULTS: Postoperative flexion, abduction, and internal rotation ROMs were significantly lower in group C than in groups A and B (flexion: 70.0° ± 17.8° vs 153.3° ± 14.3° and 154.5° ± 14.3°, P = .003 and P = .003, respectively; abduction: 67.5° ± 15° vs 148.3° ± 22.5° and 140° ± 29.3°, P = .003 and P = .004, respectively; internal rotation: L4 vs Th10 and Th11, P = .005 and P = .008, respectively). All 23 patients in groups A and B were able to recover from PPS; however, no patient recovered from PPS in group C. CONCLUSION: The present study suggests that the SSC tendon is the important factor for achieving good clinical outcomes after SCR in patients with PPS. When the SSC tendon was irreparable, SCR was not an effective treatment for patients with PPS.

Thorough Debridement Facilitated by Timely Planning of One-Bone Forearm Surgery: A Report of 2 Cases.

CASES: Two patients with complex open forearm fractures underwent initial treatment with radioulnar fusion (arthrodesis of the radius to the ulna)-one patient sustained elbow and forearm injuries in a car accident and the other had an elbow injury caused by conveyor belt entanglement. CONCLUSIONS: Differentiating viable tissue from nonviable tissue is important in the management of potentially contaminated wounds. Arthrodesis of the radius to the ulna is generally considered a salvage option for complicated forearm instability. The decision to perform arthrodesis of the radius and ulna in the initial treatment facilitated the management of soft-tissue injuries and helped prioritize hand function.

Correction of Humpback Deformities in Patients With Scaphoid Nonunion Using 1,2-Intercompartmental Supraretinacular Artery Pedicled Vascularized Bone Grafting With a Dorsoradial Approach.

PURPOSE: Although 1,2-intercompartmental supraretinacular artery (1,2-ICSRA)-based vascularized bone grafting (VBG) has gained popularity in the treatment of scaphoid nonunion, correcting humpback deformities with this technique remains challenging. The purpose of this retrospective study was to determine the possibility of correcting humpback deformities using a 1,2-ICSRA VBG with a dorsoradial approach. METHODS: We treated 25 patients with scaphoid nonunion using a 1,2-ICSRA VBG between January 2007 and December 2017. For those with a humpback deformity, we performed vascularized wedge grafting from the dorsoradial side, instead of inlay bone grafting from the dorsal or volar side of the scaphoid. After excluding patients with scaphoid nonunion without a humpback deformity and those followed up for less than 6 months, we reviewed the imaging results and union rate in the remaining 19 patients (18 men and 1 woman). The nonunion sites and patient distribution were as follows: proximal one-third, 2; waist, 16; and distal one-third, 1. RESULTS: The union rate at the last follow-up performed a minimum of 6 months after the intervention was 94.7%. The correction was adequate in 17 patients and inadequate in 2 patients. The lateral intrascaphoid, radiolunate, and scapholunate angles were improved. CONCLUSIONS: Humpback and dorsal intercalated segmental instability deformities can be corrected adequately using a 1,2-ICSRA VBG with a dorsoradial approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.