Case report of an unusual extra-articular scapular malunion: Rare indication for surgery

INTRODUCTION

Scapular fractures are relatively rare injuries usually associated with high-energy trauma and multiple concomitant injuries. Most of scapular fractures do not require surgical intervention.

PATIENT AND CLINICAL HISTORY

A 42-year-old male sustained an extra-articular scapular body fracture along with multiple rib fractures with flail segments and right pneumothorax treated with intercostal drain. The scapula fracture was treated non-operatively initially, which resulted in very poor outcome. Operative intervention was planned following scans which showed a bony spike from the ventral surface impinging on the chest wall.

SURGICAL TECHNIQUE

Bony spur was approached from dorsal side using a three-dimensional anatomical model as a guide for accurate localization.

RESULTS

The patient's symptoms including shoulder stiffness and pain on deep inspiration settled down completely following removal of the spur.

DISCUSSION

This case presents a new indication for surgical intervention in scapular body fracture which has not been published before. All the relevant measurements related to the fracture namely gleno-polar angle, lateral border offset and angulation were within published limits of indications for conservative treatment. Despite this, it resulted in poor outcome necessitating surgical intervention.

Medium- and long-term results of high tibial osteotomy using Garches external fixator and gait analysis for dynamic correction in varus osteoarthritis of the knee

In arthritis of the varus knee, a high tibial osteotomy (HTO) redistributes load from the diseased medial compartment to the unaffected lateral compartment.

We report the outcome of 36 patients (33 men and three women) with 42 varus, arthritic knees who underwent HTO and dynamic correction using a Garches external fixator until they felt that normal alignment had been restored. The mean age of the patients was 54.11 years (34 to 68). Normal alignment was achieved at a mean 5.5 weeks (3 to 10) post-operatively. Radiographs, gait analysis and visual analogue scores for pain were measured pre- and post-operatively, at one year and at medium-term follow-up (mean six years; 2 to 10). Failure was defined as conversion to knee arthroplasty.

Pre-operative gait analysis divided the 42 knees into two equal groups with high (17 patients) or low (19 patients) adductor moments. After correction, a statistically significant (p < 0.001, t-test,) change in adductor moment was achieved and maintained in both groups, with a rate of failure of three knees (7.1%), and 89% (95% confidence interval (CI) 84.9 to 94.7) survivorship at medium-term follow-up.

At final follow-up, after a mean of 15.9 years (12 to 20), there was a survivorship of 59% (95% CI 59.6 to 68.9) irrespective of adductor moment group, with a mean time to conversion to knee arthroplasty of 9.5 years (3 to 18; 95% confidence interval ± 2.5).

HTO remains a useful option in the medium-term for the treatment of medial compartment osteoarthritis of the knee but does not last in the long-term.

Cite this article: Bone Joint J 2016;98-B:601–7.

Repair of defects and containment in revision total knee replacement

The treatment of bony defects of the tibia at the time of revision total knee replacement is controversial. The place of compacted morsellised bone graft is becoming established, particularly in contained defects. It has previously been shown that the initial stability of impaction-grafted trays in the contained defects is equivalent to that of an uncemented primary knee replacement. However, there is little biomechanical evidence on which to base a decision in the treatment of uncontained defects. We undertook a laboratory-based biomechanical study comparing three methods of graft containment in segmental medial tibial defects and compared them with the use of a modular metal augment to bypass the defect.

Using resin models of the proximal tibia with medial defects representing either 46% or 65% of the medial cortical rim, repair of the defect was accomplished using mesh, cement or a novel bag technique, after which impaction bone grafting was used to fill the contained defects and a tibial component was cemented in place. As a control, a cemented tibial component with modular metal augments was used in identical defects. All specimens were submitted to cyclical mechanical loading, during which cyclical and permanent tray displacement were determined.

The results showed satisfactory stability with all the techniques except the bone bag method. Using metal augments gave the highest initial stability, but obviously lacked any potential for bone restoration.

Fracture healing assessment comparing stiffness measurements using radiographs

Based on published reports, we presumed radiographs would be unreliable as a sole measure of fracture healing. To confirm this presumption we correlated radiographic fracture healing assessments with fracture stiffness measurements. We showed 100 plain radiographs of fractures with corresponding fracture stiffness measurements to 92 observers. The radiographs were shown twice to assess intraobserver variation. Observers were divided into three groups and asked to determine whether each fracture had healed (union corresponded to a fracture stiffness greater than 15 nm/degrees). Group 1 based fracture healing on the general appearance of healing. Groups 2 and 3 assessed fracture healing based on the number of cortices bridged by callus. In Group 2, the fracture was considered healed if two or more cortices were bridged on both radiographic views and in Group 3 if three or more cortices were bridged by callus. All groups performed poorly. There was no difference in terms of correct prediction of healing between methods, although there was a trend toward more reliability with cortical callus bridging assessment. We found substantial intraobserver variability, which improved using cortical bridging methods. Observers were less reliable at predicting healing when there was a metaphyseal extension to a diaphyseal fracture.

Mechanical testing of impaction bone grafting in the tibia

Clinical experience of impaction bone grafting for revision knee arthroplasty is limited, with initial stability of the tibial tray emerging as a major concern. The length of the stem and its diameter have been altered to improve stability. Our aim was to investigate the effect of the type of stem, support of the rim and graft impaction on early stability of the tray.

We developed a system for impaction grafting of trays which we used with morsellised bone in artificial tibiae. Trays with short, long thick or long thin stems were implanted, with or without support of the rim. They were cyclically loaded while measuring relative movement.

Long-stemmed trays migrated 4.5 times less than short-stemmed trays, regardless of diameter. Those with support migrated 2.8 times less than those without. The migration of short-stemmed trays correlated inversely with the density of the impacted groups. That of impaction-grafted tibial trays was in the range reported for uncemented primary trays. Movements of short-stemmed trays without cortical support were largest and sensitive to the degree of compaction of the graft. If support of the rim was sufficient or a long stem was used, impacted morsellised bone graft achieved adequate initial stability.

Neglected rupture of the Achilles tendon: Reconstruction with peroneus brevis tendon transfer

The management of acute and neglected subcutaneous tears of the Achilles tendon by peroneus tendon transfer is safe but technically demanding. It affords good recovery, even in patients with a long-term neglected rupture. Patients with a neglected rupture are at a slightly greater risk of post-operative complications and may never fully recover their ankle plantar flexion strength.

Irreversible and reversible pore formation by polymeric alkylpyridinium salts (poly-APS) from the sponge Reniera sarai

1. In this study, we investigated the electrophysiological actions of a high molecular weight fraction, predominantly containing two polymeric 1,3-alkylpyridinium salts (poly-APS) of 5.5 and approximately 19 kDa isolated from the marine sponge Reniera sarai. The biological properties of poly-APS are of particular interest because this preparation may be used to deliver macromolecules into the intracellular environment without producing long-term damage to cells. Poly-APS (50-0.05 micro g ml(-1)) was applied to cultured dorsal root ganglion neurones or HEK 293 cells and changes in cell membrane properties were measured using whole-cell patch-clamp recording and fura-2 Ca(2+) imaging. 2. Poly-APS (50 micro g ml(-1)) evoked irreversible depolarisations in membrane potential and reductions in input resistance. However, doses of 5 micro g ml(-1) and less produced reversible effects on these cell membrane characteristics and on Ca(2+) permeability. 3. At 0.05 micro g ml(-1), poly-APS could robust transient increases in Ca(2+) permeability without damaging the neurones or subsequently attenuating Ca(2+) entry through voltage-activated channels. 4. Bathing cells in NaCl-based extracellular medium containing 1.5 mM zinc attenuated the irreversible and reversible effects of poly-APS on membrane properties (membrane potential, input resistance and whole-cell currents). In both DRG neurones and HEK 293 cells, zinc attenuated Ca(2+) entry evoked by poly-APS. These effects of zinc were only observed if zinc was continually present during poly-APS application. However, zinc failed to attenuate the actions of poly-APS if it was applied after the sponge toxin preparation had evoked changes in membrane properties. 5. In conclusion, the pore-forming preparation poly-APS can have dose-dependent interactions with cell membranes and at low doses these can be reversible. Additionally, the interactions between poly-APS and cell membranes could be attenuated by zinc.

Percutaneous repair of ruptured Achilles tendon

Percutaneous repair of a ruptured Achilles tendon is a safe and reliable method of treating such injuries in patients with low sporting requirements. It has a lower incidence of wound complications compared with open techniques but a slightly higher incidence of re-rupture. Sural nerve injury is avoidable by careful placement of the incisions

Gabapentin-mediated inhibition of voltage-activated Ca2+ channel currents in cultured sensory neurones is dependent on culture conditions and channel subunit expression

We have used the whole cell patch clamp method and fura-2 fluorescence imaging to study the actions of gabapentin (1-(aminoethyl) cyclohexane acetic acid) on voltage-activated Ca(2+) entry into neonatal cultured dorsal root ganglion (DRG) neurones and differentiated F-11 (embryonic rat DRG x neuroblastoma hybrid) cells. Gabapentin (2.5 microM) in contrast to GABA (10 microM) did not influence resting membrane potential or input resistance. In current clamp mode gabapentin failed to influence the properties of evoked single action potentials but did reduce the duration of action potentials prolonged by Ba(2+). Gabapentin attenuated high voltage-activated Ca(2+) channel currents in a dose- and voltage- dependent manner in DRG neurones and reduced Ca(2+) influx evoked by K(+) depolarisation in differentiated F-11 cells loaded with fura-2. The sensitivity of DRG neurones to gabapentin was not changed by the GABA(B) receptor antagonist saclofen but pertussis toxin pre-treatment reduced the inhibitory effects of gabapentin. Experiments following pre-treatment of DRG neurones with a PKA-activator and a PKA-inhibitor implicated change in phosphorylation state as a mechanism, which influenced gabapentin action. Sp- and Rp-analogues of cAMP significantly increased or decreased gabapentin-mediated inhibition of voltage-activated Ca(2+) channel currents. Culture conditions used to maintain DRG neurones and passage number of differentiated F-11 cells also influenced the sensitivity of Ca(2+) channels to gabapentin. We analysed the Ca(2+) channel subunits expressed in populations of DRG neurones and F-11 cells that responded to gabapentin had low sensitivity to gabapentin or were insensitive to gabapentin, by Quantitative TaqMan PCR. The data obtained from this analysis suggested that the relative abundance of the Ca(2+) channel beta(2) and alpha(2)delta subunit expressed was a key determinant of gabapentin sensitivity of both cultured DRG neurones and differentiated F-11 cells. In conclusion, gabapentin inhibited part of the high voltage-activated Ca(2+) current in neonatal rat cultured DRG neurones via a mechanism that was independent of GABA receptor activation, but was sensitive to pertussis toxin. Gabapentin responses identified in this study implicated Ca(2+) channel beta(2) subunit type as critically important to drug sensitivity and interactions with alpha(1) and alpha(2)delta subunits may be implicated in antihyperalgesic therapeutic action for this compound.

Venom from Anemesia species of spider modulates high voltage-activated Ca(2+) currents from rat cultured sensory neurones and excitatory post synaptic currents from rat hippocampal slices

The actions of crude venom from Anemesia species of spider were investigated in cultured dorsal root ganglion neurones from neonatal rats and hippocampal slices. Using mass spectrometry (MALDI-TOF MS), 10-12 distinct peptides with masses between about 3 and 10kDa were identified in the crude spider venom. At a concentration of 5 microg/ml crude Anemesia venom transiently enhanced the mean peak whole cell voltage-activated Ca(2+) current in a voltage-dependent manner and potentiated transient increases in intracellular Ca(2+) triggered by 30mM KCI as measured using Fura-2 fluorescence imaging. Additionally, 5-8 microg/ml Anemesia venom increased the amplitude of glutamatergic excitatory postsynaptic currents evoked in hippocampal slices. Omega-Conotoxin GVIA (1 microM) prevented the increase in voltage-activated Ca(2+) currents produced by Anemesia venom. This attenuation occurred when the cone shell toxin was applied before or after the spider venom. Anemesia venom (5 microg/ml) created no significant change in evoked action potentials but produced modest but significant inhibition of voltage-activated K(+) currents. At a concentration of 50 microg/ml Anemesia venom only produced reversible inhibitory effects, decreasing voltage-activated Ca(2+) currents. However, no significant effects on Ca(2+) currents were observed with a concentration of 0.5 microg/ml. The toxin(s) in the venom that enhanced Ca(2+) influx into sensory neurones was heat-sensitive and was made inactive by boiling or repetitive freeze-thawing. Boiled venom (5 microg/ml) produced significant inhibition of voltage-activated Ca(2+) currents and freeze-thawed venom inhibited Ca(2+) transients measured using Fura-2 fluorescence. Our data suggest that crude Anemesia venom contains components, which increased neuronal excitability and neurotransmission, at least in part this was mediated by enhancing Ca(2+) influx through N-type voltage-activated Ca(2+) channels.

Multiple joint pain following steroid therapy

Images

Noiseless electro-optic processing of optical signals generated with squeezed light

We demonstrate an elegant way of handling optical signals which are generated using squeezed states of light without losing their improved signal to noise ratio. We do this by amplifing, without significant noise penalty, both signal and noise away from the quantum noise limit into the classical domain. This makes the information robust to losses. Our system achieves a signal transfer coefficient, T(s), close to unity. As a demonstration we amplify a small signal carried by 35% amplitude squeezed light and show that unlike the fragile squeezed input, the signal amplified output is robust to propagation losses. A signal transfer coefficient of T(s) = 0.75 is achieved even in the presence of large introduced (86%) downstream losses.

The effects of subliminal symbiotic stimulation on free-response and self-report mood

Research has shown that subliminal presentation of MOMMY AND I ARE ONE (MIO) can help improve adaptive functioning. Two experiments tried to determine whether changes in mood, especially free-response mood, could help explain these findings. In one experiment, 20 men were randomly assigned to receive either a subliminal MIO or control stimulus. Results showed predicted effects on a free-response and no effects on a self-report mood measure. In the other experiment, 54 male subjects randomly received one of three subliminal stimuli. They evidenced the same pattern of mood results. Sentential semantics were shown to be relevant to the obtained results. Ascending threshold and 150 forced-choice discrimination trials demonstrated that subjects could not report stimulus content. It was concluded that MIO effects were attributable to unconscious processing of the entire message and that free-response mood may partly mediate these effects. Suggestions for future research were offered.