Demographics and Outcomes of Glenohumeral Dislocations in Individuals With Elevated Body Mass Index

INTRODUCTION

No specific study has investigated the characteristics and outcomes of anterior shoulder dislocations in morbidly obese individuals. The purpose of this study was to describe shoulder dislocations in patients with body mass index (BMI) greater than 40.

METHODS

A retrospective review was conducted to identify patients aged 18 years and older with a BMI ≥40 who presented with a shoulder dislocation in a single institution from 2000 to 2020. Dislocation patterns, associated injuries, treatment modalities, and associated complications were recorded.

RESULTS

A significant increase was noted in the number of patients with BMI greater than 40 presenting per year (r2 = -0.831, P < 0.01) over the past 20 years. A significant increase was noted in the average BMI per year in this population (r2 = 0.504, P = 0.028). Fifteen patients (19.5%) experienced at least one recurrent dislocation episode. Ten patients had a Bankart lesion that was associated with an elevated BMI (P = 0.04). Nine patients (11.7%) sustained an associated neurologic injury (no association with BMI).

CONCLUSIONS

Over time, there has been an increase in shoulder dislocations in morbidly obese individuals in the United States, alongside an overall increase in the average BMI of patients who present with shoulder dislocations.

Triceps tongue versus olecranon osteotomy for intra-articular distal humeral fractures: a matched-cohort study

BACKGROUND

There are various approaches to the distal humerus when managing a distal humeral fracture, and controversy exists regarding which approach is optimal. The purpose of this study was to report the outcomes of the triceps tongue (TT) approach when used for osteosynthesis of AO type 13-A, B, and C distal humeral fractures. Secondarily, we aimed to compare the outcomes of the TT approach vs. olecranon osteotomy (OO) when used for osteosynthesis of AO type 13-C distal humeral fractures.

METHODS

We performed a retrospective review of patients with distal humeral fractures treated with open reduction-internal fixation by either a TT or OO approach between 2007 and 2019 at 2 separate institutions. TT patients with AO type 13-C fractures were matched to OO patients at a 1:1 ratio based on age, sex, and fracture characteristics. Surgical time, intraoperative blood loss, elbow motion, fracture union, complications, and Disabilities of the Arm, Shoulder and Hand scores were compared.

RESULTS

A total of 28 patients treated with the TT approach were assessed, and the matched TT and OO cohorts each comprised 15 patients. The TT group showed less blood loss (119.3 mL vs. 268.5 mL, P = .03), had greater maximal flexion (126° vs. 116°, P = .03), and achieved a larger flexion-extension arc (108° vs. 93°, P = .05) than the OO group. In the OO cohort, 27% of patients had complications directly related to the OO, and OO patients had a higher rate of postoperative ulnar nerve neuritis (33% vs. 0%, P = .04). There was no difference in Disabilities of the Arm, Shoulder and Hand score (P = .08), procedure time (P = .2), total number of patients with ≥1 complication (P = .5), difficulty with union (P = .7), or number of patients requiring revision surgery (P = .7).

CONCLUSIONS

The TT approach is a safe and effective approach for the treatment of distal humeral fractures. When compared with the OO approach for AO type 13-C fractures, the TT approach did not differ regarding functional outcomes but showed increased range of motion, decreased intraoperative blood loss, and a lower rate of postoperative ulnar nerve neuritis. The TT approach should be considered as a safe and reliable first-line approach for intra-articular distal humeral fractures because it allows adequate visualization of the articular surface, eliminates complications related to osteotomy including delayed union or nonunion and hardware failure or irritation, and allows for easy conversion to total elbow arthroplasty.

Complications and functional outcomes after transolecranon distal humerus fracture

BACKGROUND

Transolecranon distal humerus fractures are uncommon injuries. This is the first multipatient case series to describe outcomes and complications following transolecranon distal humerus fractures in the adult population.

METHOD

Design: retrospective; setting: single level 1 trauma center; patients/participants: 16 patients; intervention: surgical management of transolecranon distal humerus fracture; main outcome measurement: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire after a minimum of 12 months.

RESULTS

A total of 16 patients with open (n = 12) or closed (n = 4) transolecranon distal humerus fractures were identified. Nine female and 7 male patients with a mean age of 47 years were included. Mechanisms of injury included motor vehicle collisions (n = 3), motorcycle crashes (n = 4), ground-level falls (n = 3), falls from height (n = 4), train collision (n = 1), and an industrial accident (n = 1). Seven patients (44%) presented with nerve injury. Patients underwent open reduction with internal fixation (n = 15), external fixation (n = 6), or both (n = 5). Additional surgeries were ultimately required in 11 patients (69%), with a mean of 3 surgeries to manage each patient's elbow injuries. All patients returned for at least 3 clinical follow-up visits; mean clinical follow-up was 15.8 months and mean radiographic follow-up was 12.3 months. Complications were observed in 15 patients (94%). Eleven patients (69%) had limited range of motion with a flexion arc of less than 100° at their last clinic visit. Seven patients (44%) developed deep wound infections requiring repeat débridement and intravenous antibiotics. Implant removal was performed in 10 patients (62.5%) because of infection (n = 5), symptomatic hardware (n = 4), or device failure (n = 1). Heterotopic ossification was seen in 8 patients (50%) and post-traumatic arthrosis in 4 (25%). Two patients (12.5%) required flap reconstruction for soft tissue defects. Nonunion occurred in 7 patients (44%). DASH scores were obtained for 10 patients (62.5%) at a mean of 3.8 years after injury. The mean DASH score was 40.2, ranging from 4.2 to 76.5. Among respondents, 7 (70%) were able to resume working, with an average DASH work module score of 25.

CONCLUSION

Management of transolecranon distal humerus fractures remain a challenge for orthopedic surgeons. Complication rates, including deep infection and nonunion, are high, with frequent long-term functional limitations posed to the patient, as evidenced by DASH scores.

Acute compartment syndrome of the deltoid: a case report and systematic review of the literature

Background

Deltoid compartment syndrome is a rare entity. The purpose of this study was to report a recent case and perform a systematic literature review.

Methods

Patient data were gathered from chart review and clinical encounters. For the review, the MEDLINE, Embase, and Ovid databases were queried for deltoid compartment syndrome cases. Seventeen articles reporting on 18 patients with deltoid compartment syndrome were included.

Results

Including our patient, 9 of 19 patients (47.4%) presented with compartment syndrome limited to the deltoid. Most patients presented with additional affected compartments, most commonly in the ipsilateral arm (7 of 19, 37%). Isolated deltoid involvement often resulted from iatrogenic injury; of 10 iatrogenic reports, 8 involved only the deltoid. Of 19 cases, 5 (26%) occurred in powerlifters, climbers, or anabolic steroid or testosterone injectors. In 13 of 19 cases (68%), the patients were men aged 18-36 years, and only 1 female case (5%) was reported. Prolonged recumbence owing to substance abuse was documented in 6 of 19 cases (32%).

Conclusion

Deltoid compartment syndrome is rare, with only 19 reported cases, including our patient. Men are more commonly affected, and isolated deltoid compartment syndrome occurs in about 50% of reported cases. More than half of cases are iatrogenic, secondary to prolonged lateral decubitus positioning, injections, and surgical interventions about the shoulder. Prolonged recumbence from intoxication is also a common etiology. Providers should be aware of and recognize deltoid compartment syndrome to facilitate urgent surgical management.

Emergency Department Utilization After Outpatient Hand Surgery

BACKGROUND

The purpose of this study was to identify the utilization rate and most common reasons for presentation to the emergency department (ED) after elective outpatient hand surgery and to determine preoperative risk factors for these ED visits.

METHODS

Patients who underwent elective hand surgery at an ambulatory surgery center between 2014 and 2015 were retrospectively evaluated using the New York and Florida State Databases. The primary outcome was all-cause 7- and 30-day ED utilization rates. Reasons for presentation to the ED were recorded and manually stratified. Bivariate and multivariate analyses were performed to identify independent predictors of ED utilization.

RESULTS

From 2014 to 2015, 212,506 procedures were identified; the 7- and 30-day ED visit rates were 1.8% and 4.4%, respectively. Postoperative pain was the most common cause of an ED visit after outpatient hand surgery at 7 days (25.4%) and 30 days (16.1%) postoperatively. Overall, 98% of patients presenting to the ED for postoperative pain were subsequently discharged home. After controlling for confounding, comorbid congestive heart failure, chronic lung disease, diabetes, renal failure, schizophrenia, and depression were independent risk factors for an ED visit at up to 30 days postoperatively. Those with Medicare insurance were 94% more likely to present to the ED within 30 days than those with private health insurance, whereas those with Medicaid were more than three times as likely to present to the ED as those with private insurance.

DISCUSSION

ED utilization after outpatient hand surgery is low, with postoperative pain being the most common cause of an ED visit at all time points. Nearly 98% of patients presenting to the ED for postoperative pain are subsequently discharged home.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort.

A cadaveric study of radial and ulnar bowing in the sagittal and coronal planes

BACKGROUND

This study provides a comprehensive, full-length assessment of radial and ulnar bowing in anteroposterior (AP) and sagittal planes.

METHODS

Radial and ulnar AP and lateral bowing were assessed using orthogonal digital photographs of 211 randomly selected cadaveric bilateral forearms (422 radius, 422 ulna bones) from a well-preserved osteologic collection.

RESULTS

In the radial AP plane, an apex-radial bow was present at a mean of 58% of bone length (slightly distal to midpoint), with a mean depth of 1.3 cm. In the radial lateral plane, an apex-dorsal bow occurred at a mean of 45% of bone length, with a mean depth of 0.8 cm. In the ulnar AP plane, apex-radial bow occurred at a mean of 32% of bone length with a mean depth of 1.0 cm. In the ulnar lateral plane, the majority of specimens (81%) had an apex-dorsal bow, whereas 19% had a reverse (apex-volar) bow. Lateral ulnar bow was located at a mean of 33% of bone length with a mean depth of 2.0 cm, with 36% of specimens possessing a lateral bow located at 35% or more distal along the ulna. Side-to-side differences for bow location and depth were less than 2% of bone length.

CONCLUSIONS

Ulnar lateral bow was found to be more distal than in previously published works, which analyzed only the proximal ulna, and this study describes a reverse ulnar bow in 19% of specimens. This demonstrates lateral ulnar morphology to be more variable than previously defined with minimal side-to-side variability, which are important considerations for fracture fixation and elbow arthroplasty.

Prevalence of Bennett lesions based on sex, ancestry, and age in an osteologic collection of 5,662 scapulae

BACKGROUND

Bennett lesions represent an extra-articular ossification on the posteroinferior aspect of the glenoid fossa and a potential source of posterior shoulder pain and limitation. The prevalence of Bennett lesions in the general population is unknown.

MATERIALS AND METHODS

A total of 5,662 scapulae from 2,831 individual cadaveric specimens greater than 18 years of age at the time of death were examined. Matching scapulae were evaluated for Bennett lesions by two independent authors. Lesion prevalence was calculated and statistical analysis performed to evaluate differences in prevalence based on specimen sex (males vs. females), ancestry (African-American vs. Caucasian) and with increasing age at the time of death.

RESULTS

Bennett lesions were observed in 3.5% (n = 98 of 2,831) of specimens and 1.8% (n = 104 of 5,662) of scapulae. Interobserver reliability was 0.83, indicating excellent agreement among authors. Males possessed significant higher odds of possessing a Bennett lesion when compared to females (p = .009) and African-American specimens when compared to Caucasian specimens (p < .001). Each additional year of age was associated with a 1.4% increase in odds of a specimen having a Bennett lesion, while no significant increase in Bennett lesion prevalence was appreciated with increasing specimen age at the time of death when comparing male to female specimens (p = .07) or African-American to Caucasian specimens (p = .73).

CONCLUSIONS

Bennett lesions were identified in 3.5% of osseous specimens and 1.8% of scapulae, with significantly higher prevalence in male and African-American specimens.

Distal Radius Fractures: AAOS Appropriate Use Criteria Versus Actual Management at a Level I Trauma Center

BACKGROUND

The aim of this study is to determine whether the American Academy of Orthopaedic Surgeons' (AAOS) Appropriate Use Criteria (AUC) for distal radius fractures correlates with actual treatment by orthopedic hand surgeons at a level I trauma center.

METHODS

ICD-9 codes were used to retrospectively identify patients who presented with wrist fractures over 1 year. Patients with isolated distal radius fractures were evaluated using the AAOS AUC application for distal radius fractures. Actual treatment was then compared with treatment recommended by the AUC.

RESULTS

Of the 112 patients, 64 (57%) received treatment that matched the AAOS AUC recommendation as an "appropriate treatment." Actual management matched the AUC recommendation 100%, 7%, and 50% of the time, for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type A, B, and C fractures, respectively. Surgery was performed for type A, B, and C fractures 30%, 7%, and 50% of the time, respectively. For type B fractures, only the 2 cases that were managed operatively were in agreement with the AUC. For type C fractures, increased patient age (57 years and older) was significantly associated with nonoperative treatment decisions. Surgeon decisions for nonoperative treatment were in agreement with the AUC recommendations 40% of the time, whereas surgeon decisions for surgery matched the AUC recommendations 97% of the time.

CONCLUSIONS

We found low agreement between actual treatment decisions and the AUC-recommended "appropriate" treatments, especially for the type B and C fractures that were managed nonoperatively. The AUC favors surgery for all intra-articular fractures, while we emphasized age and fracture displacement in our decision-making process.

Transfer of a Radial Nerve Branch to the Brachialis Nerve for Restoration of Elbow Flexion

Nerve transfers for brachial plexus reconstruction and the treatment of peripheral nerve injury have demonstrated excellent clinical outcomes and may be superior to nerve grafting. Previously described nerve transfers for restoration of elbow flexion include the Oberlin (ulnar to musculocutaneous) and double fasicular (median to biceps and ulnar to brachialis) transfers. However, these transfers cannot be performed in patients with loss of elbow flexion and concomitant high median and ulnar nerve injury. Other transfers utilizing the thoracodorsal or intercostal nerves have been described; however, this requires sacrifice of the latissimus dorsi muscle or potential nerve donors for a free, functioning gracilis muscle transfer. The triceps lower medial head and anconeus motor branch is a frequently used nerve donor with minimal morbidity. As an alternative for this specific patient population, we report the transfer of the triceps lower medial head and anconeus motor branch to the brachialis nerve as an option to restore elbow flexion.

Modified brachioradialis wrap for stabilizing the distal radioulnar joint: case report

Distal radioulnar joint (DRUJ) stability requires competent static and dynamic soft tissues. Multiple DRUJ techniques have been described in the literature. Our method is a novel modification of the Gupta method of DRUJ stabilization used in a revision reconstruction on a patient with a total wrist arthroplasty. A brachioradialis graft is harvested and tunneled through Parona's space volar to the pronator quadratus and through the muscle body. The tendon is then brought dorsal between the radius and ulna to the dorsal side of the distal ulna and sutured to the floor of the 5th extensor compartment, as well as to the surrounding extensor reticulum ulnar to the 6th compartment with nonabsorbable sutures. Our modification of the method described by Gupta prevents ulnar subluxaton of the extensor carpal ulnaris (ECU), allows the tendon graft construct to more adequately resist volar translation of the radius, and thus acts like a leash to pull the radius dorsally to the stationary ulna. This modification gives the graft a better force vector to resist the volar translation of the distal radius. We are able to present successful 30-month follow-up of this procedure.

An unusual knee mass in a soccer player

Introduction:

Non-traumatic knee joint effusion and fullness is a relatively common presenting complaint among athletes and non-athletes. Due to its broad differential diagnosis, a comprehensive evaluation beginning with history and physical examination are recommended. Imaging including plain radiography, magnetic resonance imaging (MRI), and in some cases ultrasound are preferred modalities. If inflammatory arthritis is suspected, joint aspiration and analysis may help diagnosis.

Case Presentation:

A 37-year-old male soccer player presented with a complaint of left anterior knee pain and fullness for a few months. Physical examination revealed a healthy appearing male with obvious fullness of his left suprapatellar pouch and posterolateral knee. Plain radiographs were unremarkable. MRI demonstrated an effusion infiltrated by multiple, low intensity projections from a fatty mass in the suprapatellar pouch consistent with lipoma arborescens.

Conclusions:

Lipoma arborescens is a rare synovial disorder characterized by replacement of subsynovial tissue with mature fat cells, most commonly in the knee joint. MRI is the best diagnostic modality to evaluate and confirm the diagnosis as well as rule out other pathologies. More recent single case-reports and clinical series endorse arthroscopic synovectomy as the treatment of choice.

Evaluation of utility in shoulder pathology: Correlating the American Shoulder and Elbow Surgeons and Constant scores to the EuroQoL

AIM: To study whether health utility scores can be derived from shoulder-specific scores.

METHODS: Authors investigated two questions: (1) do the American Shoulder and Elbow Surgeons (ASES) score and the Constant score correlate with the EuroQoL (EQ-5D), a measure of health utility? (2) can the ASES and Constant scores be obtained from a complete study sample without bias? Thirty subjects with various shoulder diagnoses completed ASES, Constant, and EQ-5D instruments. Pearson correlations were calculated to assess the associations between EQ-5D score and ASES and Constant scores.

RESULTS: The correlation between EQ-5D score and ASES score was 0.60 (P < 0.001); it was 0.54 for EQ-5D and Constant scores (P < 0.003). A multiple regression model containing ASES score, Constant score, age, and gender failed to adequately predict EQ-5D. Moreover, 25% of patients meeting the inclusion criteria did not complete the ASES questionnaire because they did not feel that specific questions, such as “do usual sport - list” and “throw ball overhand,” applied to them.

CONCLUSION: Authors’ results do not support the use of the ASES and Constant scores in predicting EuroQol health utility values. However, the Constant score was more suitable for this patient population because all patients were able to complete it.

Sperm plasma membrane breakdown during Drosophila fertilization requires Sneaky, an acrosomal membrane protein

Fertilization typically involves membrane fusion between sperm and eggs. In Drosophila, however, sperm enter eggs with membranes intact. Consequently, sperm plasma membrane breakdown (PMBD) and subsequent events of sperm activation occur in the egg cytoplasm. We previously proposed that mutations in the sneaky (snky) gene result in male sterility due to failure in PMBD. Here we support this proposal by demonstrating persistence of a plasma membrane protein around the head of snkysperm after entry into the egg. We further show that snky is expressed in testes and encodes a predicted integral membrane protein with multiple transmembrane domains, a DC-STAMP-like domain, and a variant RING finger. Using a transgene that expresses an active Snky-Green fluorescent protein fusion (Snky-GFP), we show that the protein is localized to the acrosome, a membrane-bound vesicle located at the apical tip of sperm. Snky-GFP also allowed us to follow the fate of the protein and the acrosome during fertilization. In many animals, the acrosome is a secretory vesicle with exocytosis essential for sperm penetration through the egg coats. Surprisingly, we find that the Drosophila acrosome is a paternally inherited structure. We provide evidence that the acrosome induces changes in sperm plasma membrane, exclusive of exocytosis and through the action of the acrosomal membrane protein Snky. Existence of testis-expressed Snky-like genes in many animals, including humans, suggests conserved protein function. We relate the characteristics of Drosophila Snky, acrosome function and sperm PMBD to membrane fusion events that occur in other systems.