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Stern E, Karzon AL, Hussain ZB, Khawaja SR, Cooke HL, Pirkle S, Bowers RL, Gottschalk MB, Wagner ER. Arthroscopic Pectoralis Minor Release After Reverse Shoulder Arthroplasty: A Novel Consideration for Postarthroplasty Pain. JBJS Case Connect 2023; 13:01709767-202306000-00024. [PMID: 37146169 DOI: 10.2106/jbjs.cc.22.00804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
CASE A 74-year-old male patient presenting with chronic radiating shoulder pain, paresthesias, and weakness had previously undergone reverse shoulder arthroplasty and anterior cervical discectomy and fusion for an irreparable cuff tear and cervical radiculopathy, respectively. After being diagnosed with neurogenic thoracic outlet syndrome and undergoing physiotherapy, the patient's recalcitrant condition was surgically managed with arthroscopic pectoralis minor tenotomy, suprascapular nerve release, and brachial plexus neurolysis. CONCLUSION This ultimately led to complete pain relief and improved function. By sharing this case, we aim to shed light on this overlooked pathology and help prevent unnecessary procedures for others suffering from similar conditions.
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Affiliation(s)
- Elinor Stern
- Department of Orthopaedic Surgery Emory University, Atlanta, Georgia
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Nuñez de Arenas-Arroyo S, Martínez-Vizcaíno V, Cavero-Redondo I, Álvarez-Bueno C, Reina-Gutierrez S, Torres-Costoso A. The Effect of Neurodynamic Techniques on the Dispersion of Intraneural Edema: A Systematic Review with Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14472. [PMID: 36361353 PMCID: PMC9655711 DOI: 10.3390/ijerph192114472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND There is evidence for the positive effects of neurodynamic techniques in some peripheral entrapment neuropathies, but the rationale for these effects has not been validated. We aimed to estimate the direct effect of neurodynamic techniques on the dispersion of artificially induced intraneural edema measured by dye spread in cadavers. METHODS We systematically searched the MEDLINE, WOS, Scopus, and the Cochrane databases from inception to February 2020 for experimental studies addressing the efficacy of neurodynamic techniques on the dispersion of artificially induced intraneural edema. The DerSimonian and Laird method was used to compute pooled estimates of the mean differences (MDs) and its respective 95% confidence intervals (CIs). Subgroup analyses were conducted according to the type of neurodynamic technique. In addition, a 95% prediction interval was calculated to reflect the variation in true treatment effects in different settings, including the effect to be expected in future patients. RESULTS Pooled results showed a significant increase in fluid dispersion (MD = 2.57 mm; 95%CI: 1.13 to 4.01). Subgroup analysis showed increased dye spread in the tensioning techniques group (MD = 2.22 mm; 95%CI: 0.86 to 3.57). CONCLUSION Neurodynamic techniques improved the intraneural edema dispersion and should be considered for the management of peripheral compression neuropathies. Furthermore, tensioning techniques appear to be effective in helping to disperse intraneural edema.
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Affiliation(s)
| | - Vicente Martínez-Vizcaíno
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca 340000, Chile
| | - Iván Cavero-Redondo
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca 340000, Chile
| | - Celia Álvarez-Bueno
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
- Universidad Artística y Politécnica del Paraguay, Asunción 2024, Paraguay
| | - Sara Reina-Gutierrez
- Health and Social Research Center, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Ana Torres-Costoso
- Facultad de Fisioterapia y Enfermería, Universidad de Castilla-La Mancha, 45071 Toledo, Spain
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Stouthandel MEJ, Pullens P, Bogaert S, Schoepen M, Vangestel C, Achten E, Veldeman L, Van Hoof T. Application of frozen Thiel-embalmed specimens for radiotherapy delineation guideline development: a method to create accurate MRI-enhanced CT datasets. Strahlenther Onkol 2022; 198:582-592. [DOI: 10.1007/s00066-022-01928-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 03/10/2022] [Indexed: 11/30/2022]
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Serrano Mateo L, Maranillo Alcaide E, Arvinius C, Sañudo Tejero JR, Marco F. Elongation of the brachial plexus after reverse shoulder arthroplasty: an anatomical study. Surg Radiol Anat 2022; 44:861-868. [PMID: 35381847 DOI: 10.1007/s00276-022-02929-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The use of reverse shoulder arthroplasty (RSA) is becoming more extended and its clinical results are good or excellent according to the literature. The main biomechanical characteristic of RSA is that it lowers and medializes the centre of rotation of the shoulder causing an arm lengthening. Although the number of neurological complications is low (5%), there are more neurophysiological changes in the brachial plexus with RSA than with the anatomic shoulder arthroplasty. The main goal of this study was to quantify the lengthening of the terminal branches of the brachial plexus suffered after RSA implantation. MATERIALS AND METHODS 20 Embalmed cadavers were analysed. Four distances using bone references were employed to measure the lengthening of the arm and subacromial space. The brachial plexus and its terminal branches (radial, axillary, ulnar, musculocutaneous and median nerves) and the axillary artery, were identified and marked. Measurements were made to determine the change of position of the neurovascular structures, the arm lengthening and the lengthening of each nerve before and after the implantation of RSA. Two models of RSA were used: SMR®(Lima) and Delta Xtend®(DePuy-Synthes). RESULTS The mean arm elongation was 10.5 mm. The subacromial space suffers an elongation of 20.5-29.8%. All the neurovascular structures suffered elongation: median nerve 23.1%, musculocutaneous nerve 22.1%, ulnar nerve 19%, radial nerve 17%, axillary nerve 12-14.5%, axillary artery 24.8%. There were no differences in the results between the types of prosthesis. CONCLUSIONS Due to its design, the RSA causes an arm lengthening which is reflected by the elongation of the neurovascular structures of the arm.
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Affiliation(s)
- Laura Serrano Mateo
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain.
| | - Eva Maranillo Alcaide
- Anatomy and Embryology Department, Medicine Faculty, Complutense University, Madrid, Spain
| | - Camilla Arvinius
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain
| | | | - Fernando Marco
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain
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Burnett Z, Werner BC. Risk Factors, Management, and Prognosis of Brachial Plexopathy Following Reverse Total Shoulder Arthroplasty. Orthop Clin North Am 2022; 53:215-221. [PMID: 35365266 DOI: 10.1016/j.ocl.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Brachial plexus injuries can have a significant impact on patient outcomes following RTSA by slowing the overall recovery and return of function. Risk factors for brachial plexopathy include traction injury related to arm positioning and exposure during the procedure, direct nerve injury from surgical dissection, and compression injury from retractor placement. Risk of nerve injury can be minimized by limiting the time spent with the arm extended and externally rotated and avoiding excessive traction on the arm during humeral preparation and implant insertion. Prompt identification of postoperative brachial plexopathy is important to optimize the recovery of function.
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Affiliation(s)
- Zachary Burnett
- Department of Orthopaedic Surgery, University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22903, USA
| | - Brian C Werner
- University of Virginia, 400 Ray C. Hunt Drive, Suite 330, Charlottesville, VA 22903, USA.
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Razmjou H, van Osnabrugge V, Anunciacion M, Nunn A, Drosdowech D, Roszkowski A, Szafirowicz A, Boljanovic D, Wainwright A, Nam D. Maximizing Muscle Function in Cuff-Deficient Shoulders: A Rehabilitation Proposal for Reverse Arthroplasty. J Shoulder Elb Arthroplast 2022; 5:24715492211023302. [PMID: 34993379 PMCID: PMC8492033 DOI: 10.1177/24715492211023302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/17/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose The purpose of this review is to describe the role of altered joint biomechanics in reverse shoulder arthroplasty and to propose a rehabilitation protocol for a cuff-deficient glenohumeral joint based on the current evidence.Methods and Materials: The proposed rehabilitation incorporates the principles of pertinent muscle loading while considering risk factors and surgical complications. Results In light of altered function of shoulder muscles in reverse arthroplasty, scapular plane abduction should be more often utilized as it better activates deltoid, teres minor, upper trapezius, and serratus anterior. Given the absence of supraspinatus and infraspinatus and reduction of external rotation moment arm of the deltoid in reverse arthroplasty, significant recovery of external rotation may not occur, although an intact teres minor may assist external rotation in the elevated position. Conclusion Improving the efficiency of deltoid function before and after reverse shoulder arthroplasty is a key factor in the rehabilitation of the cuff deficient shoulders. Performing exercises in scapular plane and higher abduction angles activates deltoid and other important muscles more efficiently and optimizes surgical outcomes.
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Affiliation(s)
- Helen Razmjou
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Varda van Osnabrugge
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mark Anunciacion
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Nunn
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Darren Drosdowech
- Roth
- McFarlane Hand & Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, Western University, London, Ontario, Canada
| | - Ania Roszkowski
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Analia Szafirowicz
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dragana Boljanovic
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amy Wainwright
- Holland Bone and Joint Program, Holland Orthoapaedic & Arthritic Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Diane Nam
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Orthopedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Kim SC, Kim IS, Jang MC, Yoo JC. Complications of reverse shoulder arthroplasty: a concise review. Clin Shoulder Elb 2021; 24:42-52. [PMID: 33652512 PMCID: PMC7943379 DOI: 10.5397/cise.2021.00066] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/14/2021] [Indexed: 11/25/2022] Open
Abstract
Reverse shoulder arthroplasty is an ideal treatment for glenohumeral dysfunction due to cuff tear arthropathy. As the number of patients treated with reverse shoulder arthroplasty is increasing, the incidence of complications after this procedure also is increasing. The rate of complications in reverse shoulder arthroplasty was reported to be 15%-24%. Recently, the following complications have been reported in order of frequency: periprosthetic infection, dislocation, periprosthetic fracture, neurologic injury, scapular notching, acromion or scapular spine fracture, and aseptic loosening of prosthesis. However, the overall complication rate has varied across studies because of different prosthesis used, improvement of implant and surgical skills, and different definitions of complications. Some authors included complications that affect the clinical outcomes of the surgery, while others reported minor complications that do not affect the clinical outcomes such as minor reversible neurologic deficit or minimal scapular notching. This review article summarizes the processes related to diagnosis and treatment of complications after reverse shoulder arthroplasty with the aim of helping clinicians reduce complications and perform appropriate procedures if/when complications occur.
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Affiliation(s)
- Su Cheol Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Il Su Kim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Chang Jang
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Chul Yoo
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Hachadorian ME, Mitchell BC, Siow MY, Wang W, Bastrom T, Sullivan TB, Huang BK, Edmonds EW, Kent WT. Identifying the axillary nerve during shoulder surgery: an anatomic study using advanced imaging. JSES Int 2020; 4:987-991. [PMID: 33345245 PMCID: PMC7738427 DOI: 10.1016/j.jseint.2020.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background The axillary nerve (AXN) is one of the more commonly injured nerves during shoulder surgery. Prior anatomic studies of the AXN in adults were performed using cadaveric specimens with small sample sizes. Our research observes a larger cohort of magnetic resonance imaging (MRI) studies in order to gain a more representative sample of the course of the AXN and aid surgeons intraoperatively. Methods High-resolution 3T MRI studies performed at our institution from January 2010 to June 2019 were reviewed. Four blinded reviewers with musculoskeletal radiology or orthopedic surgery training measured the distance of the AXN to the surgical neck of the humerus (SNH), the lateral tip of the acromion (LTA), and the inferior glenoid rim (IGR). Intraclass correlation coefficient was calculated to assess reliability between reviewers. The nerve location was assessed relative to rotator cuff tear status. Results A total of 257 shoulder MRIs were included. Intraclass correlation coefficient was excellent at 0.80 for the SNH, 0.90 for the LTA, and 0.94 for the IGR. All intraobserver reliabilities were above 0.80. The mean distance from the AXN to SNH was 1.7 cm (range, 0.7-3.1 cm; interquartile range, 1.38-2.00) and that from the AXN to IGR was 1.6 cm (range, 0.6-2.6 cm; interquartile range, 1.33-1.88). The mean AXN to LTA distance was 7.1 cm, with a range of 5.2-9.0 cm across patient heights; there was a large effect size related to the LTA to AXN distance and patient height with a correlation of r = 0.603 (P < .001). Rotator cuff pathology appears to affect nerve location by increasing the distance between the AXN and SNH (P = .027). Discussion/Conclusion The AXN is vulnerable to injury during both open and arthroscopic shoulder procedures. This injury can be either a result of direct trauma to the nerve or secondary to traction placed on the nerve with reconstructive procedures that distalize the humerus. Our study demonstrates that the AXN can be found as little as 5.6 mm from the IGR and 6.9 mm from the SNH. In addition, we illustrate the relationship between patient height and the LTA to AXN distance and complete rotator cuff tears and the SNH to AXN distance. Our study is the first to demonstrate the nerve's proximity to important surgical landmarks of the shoulder using a large sample size of high-resolution images in living human shoulders.
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Affiliation(s)
- Michael E Hachadorian
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Brendon C Mitchell
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Matthew Y Siow
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Wilbur Wang
- Department of Musculoskeletal Radiology, University of California San Diego, San Diego, CA, USA
| | - Tracey Bastrom
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - T Barrett Sullivan
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
| | - Brady K Huang
- Department of Musculoskeletal Radiology, University of California San Diego, San Diego, CA, USA
| | - Eric W Edmonds
- Department of Orthopaedic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - William T Kent
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, CA, USA
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Kim HJ, Kwon TY, Jeon YS, Kang SG, Rhee YG, Rhee SM. Neurologic deficit after reverse total shoulder arthroplasty: correlation with distalization. J Shoulder Elbow Surg 2020; 29:1096-1103. [PMID: 32081632 DOI: 10.1016/j.jse.2019.11.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 11/15/2019] [Accepted: 11/23/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neurologic problems after reverse total shoulder arthroplasty (RTSA) have been reported, but there are a lack of studies regarding which nerve(s) are damaged and the outcomes for the patients who had neurologic complications after RTSA. The purpose of this study was to assess the prevalence and outcomes of neurologic deficit after RTSA and to evaluate the correlation between nonanatomic rearrangement of the shoulder joint and neurologic complications after RTSA. We hypothesized that the neurologic deficit was associated with excessive distalization or lateralization of the humerus after RTSA. METHODS RTSA was performed on 182 consecutive shoulders with cuff tear arthropathy. Comparative analysis was performed on 34 shoulders with (group 1) and 148 shoulders without (group 2) neurologic deficit. RESULTS The mean follow-up period in the study was 58.5 months (range: 24-124). The mean age was 71.5 ± 7.7 years in group 1 and 73.1 ± 7.2 years in group 2. Neurologic deficit after RTSA was found in 34 shoulders (19%). The mean postoperative acromiohumeral distance was 34.1 ± 11.0 mm in group 1 and 29.4 ± 7.6 mm in group 2 (P = .015). Significant differences in terms of postoperative distalization of the humerus were seen between group 1 (24.5 ± 9.4 mm) and group 2 (20.5 ± 8.3 mm) (P = .009). The most common forms of neurologic deficit after RTSA were axillary nerve (41.2%) and radial nerve (15%) injuries. Thirty shoulders (88%) had neuropraxia, and 4 shoulders (12%) had axonotmesis. By conservative treatment, all patients with neurologic complications achieved complete recovery without any additional surgery; the mean recovery period was 7.4 months (range: 2-38 months). CONCLUSION Neurologic deficit occurred in 19% of patients who underwent RTSA, and it was significantly correlated with humeral distalization after surgery. Axillary nerve was mostly involved, and all patients with neurologic deficit achieved complete recovery without any additional surgery.
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Affiliation(s)
- Hwan Jin Kim
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Tae Yoon Kwon
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yoon Sang Jeon
- Department of Orthopaedic Surgery, College of Medicine, Inha University, Incheon, Republic of Korea
| | - Se Gu Kang
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Yong Girl Rhee
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Sung-Min Rhee
- Shoulder & Elbow Clinic. Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University, Seoul, Republic of Korea.
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10
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Collotte P, Erickson J, Vieira TD, Domos P, Walch G. Midterm clinical and radiologic results of reverse shoulder arthroplasty with an eccentric glenosphere. J Shoulder Elbow Surg 2020; 29:976-981. [PMID: 31911214 DOI: 10.1016/j.jse.2019.09.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 09/25/2019] [Accepted: 09/30/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND An eccentric glenosphere (EG) has been proposed as a way of preventing scapular notching after reverse shoulder arthroplasty (RSA). Our aim was to report the midterm clinical and radiographic results of EG after RSA. A number of the patients described here were included in a previous study with short-term follow-up. The current retrospective study gave us the opportunity to follow many of these patients for a longer period of time. METHODS A retrospective analysis of prospectively collected data was conducted. Statistical significance was set at P < .001. Forty-nine RSAs with an EG and at least 60 months of follow-up were included. Range of motion (ROM), Constant scores (CSs), and Subjective Shoulder Value (SSV) were assessed. Scapular notching was graded according to the Sirveaux classification. RESULTS At the last follow-up, the mean improvement in active elevation (ROM) was 46° and the mean CS increased by nearly 31 points (both groups P < .001). The final SSV was 70%. Twenty-one patients (43%) had scapular notching, but in two-thirds of patients it was low-grade. CONCLUSION The use of an EG provided excellent clinical outcomes that persisted with midterm follow-up. The rate of notching was lower than in other studies with EGs, but further studies are required to confirm this. An EG was safe and there were no issues with baseplate loosening or failure.
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Affiliation(s)
- Philippe Collotte
- Ramsay Générale de Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France.
| | | | - Thais Dutra Vieira
- Ramsay Générale de Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
| | - Peter Domos
- The Royal Free London NHS Foundation Trust, London, UK
| | - Gilles Walch
- Ramsay Générale de Santé, Hôpital privé Jean Mermoz, Centre Orthopédique Santy, Lyon, France
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11
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Stouthandel MEJ, Vanhove C, Devriendt W, De Bock S, Debbaut C, Vangestel C, Van Hoof T. Biomechanical comparison of Thiel embalmed and fresh frozen nerve tissue. Anat Sci Int 2020; 95:399-407. [PMID: 32144646 DOI: 10.1007/s12565-020-00535-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 02/24/2020] [Indexed: 12/13/2022]
Abstract
The aim of this study was to determine the effect of Thiel embalming on the biomechanical properties of nerve tissue, to validate the use of Thiel embalmed bodies as a reliable model system for obtaining biomechanical data to supplement neurodynamic models, for anesthesiological and neurosurgical training and for future preclinical test set-ups involving nerve tissue. Upon the arrival of a body at the anatomy department, a fresh median nerve was harvested, the harvest site was sutured and following the Thiel embalming procedure the Thiel embalmed median nerve of the opposing wrist was harvested. Micro CT was performed to establish the cross-sectional area and biomechanical tensile testing was performed to compare the Young's modulus/elasticity of fresh frozen and Thiel embalmed nerves. Thiel embalming did not cause a significant difference in elasticity when comparing Thiel embalmed and fresh frozen specimens. A correlation was found between the cross-sectional area of Thiel embalmed nerve specimens and their Young's modulus. Thiel embalming does not significantly alter the elasticity of nerve tissue compared to fresh frozen nerve tissue. Similar shapes were observed when comparing the stress/strain curves of both specimen types. This indicates that Thiel embalmed nerve tissue is a viable alternative for using fresh frozen specimens when investigating biomechanical principles/mechanisms. Some specimens showed a reversed trend in Young's modulus that could be related to slight differences in embalming outcome, so caution is advised when Thiel embalmed specimens are used to obtain raw numerical data for direct application in the clinic.
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Affiliation(s)
- Michael E J Stouthandel
- Department of Human Structure and Repair, Ghent University, Radiotherapy Park, Entrance 98, C. Heymanslaan 10, 9000, Ghent, Belgium.
| | - Christian Vanhove
- Infinity Lab, Ghent University, Building P8, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Wouter Devriendt
- Agfa Healthcare, 150 Royall Street (Second Floor), Canton, Massachusetts, 02021, USA
| | - Sander De Bock
- IBiTech-bioMMeda, Ghent University, Block B, Entrance 36, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Charlotte Debbaut
- Infinity Lab, Ghent University, Building P8, C. Heymanslaan 10, 9000, Ghent, Belgium
| | - Carl Vangestel
- Directorate Taxonomy and Phylogeny, Royal Belgian Institute of Natural Sciences, 1000, Brussels, Belgium.,Terrestrial Ecology Unit, Biology Department, Ghent University, 9000, Ghent, Belgium
| | - Tom Van Hoof
- Department of Human Structure and Repair, Ghent University, Radiotherapy Park, Entrance 98, C. Heymanslaan 10, 9000, Ghent, Belgium
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Audenaert EA, Khanduja V, Bauwens C, Van Hoof T, Pattyn C, Steenackers G. A discrete element model to predict anatomy of the psoas muscle and path of the tendon: Design implications for total hip arthroplasty. Clin Biomech (Bristol, Avon) 2019; 70:186-191. [PMID: 31526958 DOI: 10.1016/j.clinbiomech.2019.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/05/2019] [Accepted: 09/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The accurate estimation of a muscle's line of action is a fundamental requirement in computational modelling. We present a novel anatomical muscle wrapping technique and demonstrate its clinical use on the evaluation of the Psoas muscle mechanics in hip arthroplasty. METHODS A volume preserving, spring model to parameterize muscle anatomy changes during motion is presented. Validation was performed by a CT scan of a cadaver model in multiple positions. The predicted psoas musculotendinous path was compared with the actual imaging findings. In a second stage, psoas kinetics were compared between a conventional versus a resurfacing hip arthroplasty during gait. FINDINGS Anatomy prediction error was found to be 2.12 mm on average (SD 1.34 mm). When applied to psoas mechanics during walking, the muscle was found to wrap predominantly around the femoral head providing a biomechanically efficient and nearly constant moment arm for flexion during the entire gait cycle. However, this advantage was found to be lost in small diameter hip arthroplasty designs resulting in an important mechanical disadvantage. The moment arm for flexion, was on average 36% (SD 0.03%) lower in the small diameter conventional hip arthroplasty as compared to the large diameter head of the hip resurfacing and this difference was highly significant. (p < 0.001). INTERPRETATION Despite the shortcomings of an "in silico" and cadaveric study, our findings are in accordance with previous clinical and gait studies. Furthermore, the findings are strongly in favour of large diameter implant designs, warranting their further development and optimisation.
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Affiliation(s)
- E A Audenaert
- Department of Orthopedic Surgery and Traumatology, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Trauma and Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK; Department of Electromechanics, Op3Mech research group, University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium; Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - V Khanduja
- Department of Trauma and Orthopedics, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - C Bauwens
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - T Van Hoof
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - C Pattyn
- Department of Human Structure and Repair, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium
| | - G Steenackers
- Department of Electromechanics, Op3Mech research group, University of Antwerp, Groenenborgerlaan 171, 2020 Antwerp, Belgium
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Strong BM, Voloshin I. Posterior Interosseous Nerve Proximity to Cortical Button Implant for Distal Biceps Repair With Single and 2-Incision Approaches. J Hand Surg Am 2019; 44:613.e1-613.e6. [PMID: 30301643 DOI: 10.1016/j.jhsa.2018.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 07/23/2018] [Accepted: 09/04/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE Fixation with a cortical button is the biomechanically strongest surgical approach for distal biceps repair, and utilization of the 2-incision approach may provide a more anatomical repair and improved terminal supination strength. The risk of injury to the posterior interosseous nerve (PIN) associated with this approach requires further investigation. METHODS A distal biceps repair with a cortical button was performed on 10 cadavers, 5 utilizing the single-incision approach and 5 utilizing the 2-incision approach. Contrast was injected into the radial nerve and computed tomography scans were obtained. The distance between the drilled cortical perforation and the PIN was measured. RESULTS The mean distance from the cortical perforation to the PIN was not significantly different between approaches (9.4 mm and 8.8 mm). A PIN entrapment was seen in 0 out of 5 for the single-incision approach and 1 out of 5 for the 2-incision approach. CONCLUSIONS Distal biceps repair with cortical button fixation places the PIN at risk of injury regardless of the approach used. Methods of fixation that require bicortical drilling should be especially avoided when using the 2-incision approach. CLINICAL RELEVANCE Distal biceps repair utilizing bicortical drilling for fixation through a 2-incision approach poses high risk of injury to the PIN and should be avoided.
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Affiliation(s)
- Benjamin M Strong
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
| | - Ilya Voloshin
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY.
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14
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Rojas J, Familiari F, Borade AU, Joseph J, Deune EG, Ingari JV, McFarland EG. Exposure of the brachial plexus in complex revisions to reverse total shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2019; 43:2789-2797. [DOI: 10.1007/s00264-019-04349-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 05/14/2019] [Indexed: 02/07/2023]
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15
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Stouthandel MEJ, Veldeman L, Van Hoof T. Call for a Multidisciplinary Effort to Map the Lymphatic System with Advanced Medical Imaging Techniques: A Review of the Literature and Suggestions for Future Anatomical Research. Anat Rec (Hoboken) 2019; 302:1681-1695. [PMID: 31087787 DOI: 10.1002/ar.24143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 01/21/2019] [Accepted: 03/09/2019] [Indexed: 12/13/2022]
Abstract
This review intends to rekindle efforts to map the lymphatic system by using a more modern approach, based on medical imaging. The structure, function, and pathologies associated with the lymphatic system are first discussed to highlight the need for more accurately mapping the lymphatic system. Next, the need for an interdisciplinary approach, with a central role for the anatomist, to come up with better maps of the lymphatic system is emphasized. The current approaches on lymphatic system research involving medical imaging will be discussed and suggestions will be made for an all-encompassing effort to thoroughly map the entire lymphatic system. A first-hand account of our integration as anatomists in the radiotherapy department is given as an example of interdisciplinary collaboration. From this account, it will become clear that the interdisciplinary collaboration of anatomists in the clinical disciplines involved in lymphatic system research/treatment still holds great promise in terms of improving clinical regimens that are currently being employed. As such, we hope that our fellow anatomists will join us in an interdisciplinary effort to map the lymphatic system, because this could, in a relatively short timeframe, provide improved treatment options for patients with cancer or lymphatic pathologies all over the world. Anat Rec, 302:1681-1695, 2019. © 2019 American Association for Anatomy.
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Affiliation(s)
| | - Liv Veldeman
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium.,Department of Radiation Oncology, Ghent University Hospital, Ghent, Belgium
| | - Tom Van Hoof
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
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16
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LiBrizzi CL, Rojas J, Joseph J, Bitzer A, McFarland EG. Incidence of clinically evident isolated axillary nerve injury in 869 primary anatomic and reverse total shoulder arthroplasties without routine identification of the axillary nerve. JSES OPEN ACCESS 2019; 3:48-53. [PMID: 30984892 PMCID: PMC6444175 DOI: 10.1016/j.jses.2018.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background It has been suggested that, during primary shoulder arthroplasty, surgeons should identify the axillary nerve through direct visualization, palpation, or the “tug test” to prevent iatrogenic nerve injury. Our goal was to document the rate of isolated axillary nerve injury (IANI) in patients who had undergone primary anatomic total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) without routine identification of the axillary nerve. Methods Data on 869 cases of primary shoulder arthroplasty (338 TSAs and 531 RTSAs) performed by 1 surgeon between 2003 and 2017 were reviewed. Neither the tug test nor identification of the axillary nerve through palpation or visualization was used in any case. The primary outcome was new IANI documented within 3 months after arthroplasty. The frequency of IANI was summarized using point estimates and 95% confidence intervals (CIs). Results Six cases met the criteria for IANI. The overall incidence of IANI was 0.7% (95% CI, 0.3%-1.4%). The incidence of IANI was 0.3% (95% CI, 0%-1.6%) after TSA and 0.9% (95% CI, 0.3%-2.1%) after RTSA. All IANIs were cases of neurapraxia, and all patients had experienced complete neurologic recovery at last follow-up. Conclusion Complete, permanent IANI resulting from direct surgical trauma during primary shoulder arthroplasty can be avoided without using the tug test or routine identification of the nerve. A low incidence of partial temporary IANI can be expected, which may be related to indirect traction injuries.
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Affiliation(s)
- Christa L LiBrizzi
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Jorge Rojas
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Jacob Joseph
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Alexander Bitzer
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Edward G McFarland
- Division of Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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17
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Rhee SM, Lee JD, Park YB, Yoo JC, Oh JH. Prognostic Radiological Factors Affecting Clinical Outcomes of Reverse Shoulder Arthroplasty in the Korean Population. Clin Orthop Surg 2019; 11:112-119. [PMID: 30838115 PMCID: PMC6389533 DOI: 10.4055/cios.2019.11.1.112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 10/14/2018] [Indexed: 01/20/2023] Open
Abstract
Background Despite the growing use of reverse shoulder arthroplasty (RSA), it is associated with relatively frequent complications and uncertain clinical outcomes. We investigated radiological factors affecting clinical outcomes of RSA in the Korean population. Methods We evaluated physical findings, radiographic findings, visual analog scale scores for pain and satisfaction, and several functional scores in 179 consecutive patients who underwent RSA at two centers between 2008 and 2014. Results In 146 included RSAs, pain and forward flexion improved with deltoid lengthening (average, 23.5 ± 9.1 mm; p = 0.039). External rotation decreased with medialization (average, 16.8 ± 6.0 mm, p = 0.025), whereas internal rotation showed no correlation with humeral retroversion. Scapular notching (n = 44, 30%) significantly decreased with greater inferior glenosphere overhang (average, 2.94 ± 3.0 mm; p = 0.001), greater prosthesis scapular neck angle (average, 104° ± 10.3°; p = 0.001), greater glenoid neck length (average, 9.8 ± 2.54 mm; p = 0.012), lower inferior baseplate tilt angle (average, 105.5° ± 9.2°; p = 0.009), and varus humeral neck-shaft angle (p = 0.046), and it did not affect ranges of motion and pain, satisfaction, and functional scores. At the final follow-up, medialization was related to improvement in pain and satisfaction, and inferior glenosphere overhang to functional scores. Conclusions Proper amount of deltoid lengthening (mean, 2.3 cm) and inferior glenosphere overhang (mean, 2.9 mm) should be chosen for the better outcomes, while the center of rotation should be individualized according to patient characteristics in the Korean population.
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Affiliation(s)
- Sung-Min Rhee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jeong Dong Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Yong Bok Park
- Department of Orthopedic Surgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Jae Chul Yoo
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Han Oh
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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18
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Razmjou H, Woodhouse LJ, Holtby R. Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants. Physiother Can 2018; 70:212-220. [PMID: 30275646 DOI: 10.3138/ptc.2016-99] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Purpose: The objectives of this survey study were to provide an estimate of the prevalence of neuropathic pain (NP) and to explore the cross-sectional and longitudinal group differences postoperatively. Method: A cohort of consecutive patients who had undergone total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or humeral head replacement (HHR) were surveyed within an average of 3.8 years after surgery. Questionnaires completed at the time of the survey were the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale, the visual analogue scale (VAS) for pain, the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, the Patient Health Questionnaire-9 (PHQ-9), and a satisfaction questionnaire. Results: Of the 141 candidates who were invited to participate in the study, 115 patients participated (85 TSA, 21 HHR, and 9 RSA), for an 82% response rate. Five patients (4%) met the criteria for NP, of whom one had a loosening of the prosthesis and required further surgery. Having NP was associated with greater pain (VAS; p=0.001), greater depression (PHQ-9; p=0.001), more disability (WOOS; p=0.030), and less satisfaction with the surgery (p=0.014). There was no relationship between the presence of NP and patients' age, sex, preoperative pain, range of motion results, or WOOS scores (p>0.05). Conclusions: Persistent pain of neuropathic origin is not common after shoulder arthroplasty, but it is a significant contributor to poor mental and physical well-being and thus warrants further research.
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Affiliation(s)
- Helen Razmjou
- Department of Rehabilitation, Holland Orthopaedic & Arthritic Centre.,Department of Physical Therapy.,Sunnybrook Research Institute
| | - Linda J Woodhouse
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton.,McCaig Institute for Bone and Joint Health, Calgary
| | - Richard Holtby
- Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre.,Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto
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19
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Lowe JT, Lawler SM, Testa EJ, Jawa A. Lateralization of the glenosphere in reverse shoulder arthroplasty decreases arm lengthening and demonstrates comparable risk of nerve injury compared with anatomic arthroplasty: a prospective cohort study. J Shoulder Elbow Surg 2018; 27:1845-1851. [PMID: 30111503 DOI: 10.1016/j.jse.2018.06.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/04/2018] [Accepted: 06/13/2018] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS Grammont-style reverse shoulder arthroplasty (RSA) has an increased risk of nerve injury compared with anatomic total shoulder arthroplasty (TSA) due to arm lengthening. We hypothesized that an RSA with a lateralized glenosphere and 135° neck-shaft angle would reduce humeral lengthening and decrease the risk of nerve injury to the level of a TSA. METHODS The study prospectively enrolled 50 consecutive patients undergoing RSA (n = 30) or TSA (n = 20) as determined by a power analysis based on previous research for our institution. Intraoperative neuromonitoring was used to detect nerve alerts during 4 distinct stages of the procedure. Preoperative and postoperative arm lengths were measured on scaled radiographs. Patients were examined immediately postoperatively and at follow-up visits for neurologic complications. RESULTS Mean motor and sensory nerve alerts per case were similar for TSA and RSA (motor: TSA, 1.5 ± 2; RSA, 1.5 ± 2; P = .96; sensory: TSA, 0.6 ± 0.9; RSA, 0.2 ± 0.6; P = .06). The mean change in arm length was 3 ± 7 mm in the TSA cohort vs. 14 ± 7 mm in the RSA cohort (P = .0001). Temporary neurologic changes postoperatively were noted in 1 TSA and 1 RSA patient, amounting to a 4% incidence of nerve injury. CONCLUSIONS An RSA design with a lateralized glenosphere and a lower neck-shaft angle decreases arm lengthening compared with the Grammont design. The reduction in lengthening appears to eliminate the historically increased risk of neurologic injury associated with RSA relative to TSA.
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Affiliation(s)
- Jeremiah T Lowe
- New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Sarah M Lawler
- New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA
| | - Edward J Testa
- New England Baptist Hospital, Boston, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Andrew Jawa
- New England Baptist Hospital, Boston, MA, USA; Boston Sports and Shoulder Center, Waltham, MA, USA.
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20
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Risk Factors for Neurological Injury After Reverse Total Shoulder Arthroplasty. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2018. [DOI: 10.1097/bte.0000000000000103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Van Der Bracht H, Tampere T, Beekman P, Schepens A, Devriendt W, Cromheecke M, Verdonk P, Victor J. Peak stresses shift from femoral tunnel aperture to tibial tunnel aperture in lateral tibial tunnel ACL reconstructions: a 3D graft-bending angle measurement and finite-element analysis. Knee Surg Sports Traumatol Arthrosc 2018; 26:508-517. [PMID: 29124289 DOI: 10.1007/s00167-017-4739-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 10/02/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate the effect of tibial tunnel orientation on graft-bending angle and stress distribution in the ACL graft. METHODS Eight cadaveric knees were scanned in extension, 45°, 90°, and full flexion. 3D reconstructions with anatomically placed anterior cruciate ligament (ACL) grafts were constructed with Mimics 14.12®. 3D graft-bending angles were measured for classic medial tibial tunnels (MTT) and lateral tibial tunnels (LTT) with different drill-guide angles (DGA) (45°, 55°, 65°, and 75°). A pivot shift was performed on 1 knee in a finite-element analysis. The peak stresses in the graft were calculated for eight different tibial tunnel orientations. RESULTS In a classic anatomical ACL repair, the largest graft-bending angle and peak stresses are seen at the femoral tunnel aperture. The use of a different DGA at the tibial side does not change the graft-bending angle at the femoral side or magnitude of peak stresses significantly. When using LTT, the largest graft-bending angles and peak stresses are seen at the tibial tunnel aperture. CONCLUSION In a classic anatomical ACL repair, peak stresses in the ACL graft are found at the femoral tunnel aperture. When an LTT is used, peak stresses are similar compared to classic ACL repairs, but the location of the peak stress will shift from the femoral tunnel aperture towards the tibial tunnel aperture. CLINICAL RELEVANCE the risk of graft rupture is similar for both MTTs and LTTs, but the location of graft rupture changes from the femoral tunnel aperture towards the tibial tunnel aperture, respectively. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Hans Van Der Bracht
- Department of Orthopaedic Surgery and Traumatology, AZ Sint-Lucas Gent, Groenebriel 1, 9000, Ghent, Belgium
| | - Thomas Tampere
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
| | - Pieter Beekman
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium.
| | - Alexander Schepens
- Department of Orthopaedic Surgery and Traumatology, AZ Sint-Lucas Gent, Groenebriel 1, 9000, Ghent, Belgium
| | - Wouter Devriendt
- Department of Biofluid, Tissue and Solid Mechanics for Medical Applications, bioMMeda, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - Michiel Cromheecke
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
| | - Peter Verdonk
- Department of Orthopaedics and Traumatology, AZ Monica, Harmoniestraat 68, 2018, Antwerp, Belgium
| | - Jan Victor
- Department of Orthopaedics and Traumatology, University Hospital Ghent, De pintelaan 185, 9000, Ghent, Belgium
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Effect of neurodynamic mobilization on fluid dispersion in median nerve at the level of the carpal tunnel: A cadaveric study. Musculoskelet Sci Pract 2017; 31:45-51. [PMID: 28734168 DOI: 10.1016/j.msksp.2017.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 07/11/2017] [Accepted: 07/15/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To evaluate the effect of neurodynamics mobilization (NDM) on an artificially induced edema in the median nerve at the level of the carpal tunnel in unembalmed cadavers and to assess whether NDM tensioning techniques (TT) and NDM sliding techniques (SLT) induce similar effects on intraneural fluid dispersion. DESIGN Fourteen upper extremities of seven unembalmed cadavers were used in this study. A biomimetic solution was injected directly under the epineurium of the median nerve at the level of the proximal transverse carpal ligament. The initial dye spread was allowed to stabilize and measured with a digital caliper. Tensioning and sliding techniques were applied following a randomized crossover design to each upper extremity and were performed for a total of 5 min each. Post-intervention dye spread measurements were taken after each technique. RESULTS After the first mobilization, the mean longitudinal dye spread (7.5 ± 6.6 mm) was significantly greater (p = 0.024) compared to the stabilized dye spread. There was a significant longitudinal diffusion effect with both, TT (p = 0.018) and SLT (p = 0.016), with no statistically significant difference between techniques (p = 0.976). The order in which techniques were administered did not influence the diffusion. CONCLUSION Five minute of passive NDM in the form of tensioning or sliding technique induced significant fluid dispersion in the median nerve at the carpal tunnel of unembalmed human cadavers. This study provides support for clinical mechanism of NDM in reducing intraneural edema.
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Lenoir H, Dagneaux L, Canovas F, Waitzenegger T, Pham TT, Chammas M. Nerve stress during reverse total shoulder arthroplasty: a cadaveric study. J Shoulder Elbow Surg 2017; 26:323-330. [PMID: 27697454 DOI: 10.1016/j.jse.2016.07.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 06/18/2016] [Accepted: 07/01/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neurologic lesions are relatively common after total shoulder arthroplasty. These injuries are mostly due to traction. We aimed to identify the arm manipulations and steps during reverse total shoulder arthroplasty (RTSA) that affect nerve stress. METHODS Stress was measured in 10 shoulders of 5 cadavers by use of a tensiometer on each nerve from the brachial plexus, with shoulders in different arm positions and during different surgical steps of RTSA. RESULTS When we studied shoulder position without prostheses, relative to the neutral position, internal rotation increased stress on the radial and axillary nerves and external rotation increased stress on the musculocutaneous, median, and ulnar nerves. Extension was correlated with increase in stress on all nerves. Abduction was correlated with increase in stress for the radial nerve. We identified 2 high-risk steps during RTSA: humeral exposition, particularly when the shoulder was in a position of more extension, and glenoid exposition. The thickness of polyethylene humeral cups used was associated with increased nerve stress in all but the ulnar nerve. CONCLUSION During humeral preparation, the surgeon must be careful to limit shoulder extension. Care must be taken during exposure of the glenoid. Extreme rotation and oversized implants should be avoided to minimize stretch-induced neuropathies.
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Affiliation(s)
- Hubert Lenoir
- Centre Ostéo-Articulaire des Cèdres, Echirolles, France.
| | - Louis Dagneaux
- Hip, Knee and Foot Surgery Unit, Centre Hospitalier Régional Universitaire Montpellier University Hospital, Montpellier, France
| | - François Canovas
- Hip, Knee and Foot Surgery Unit, Centre Hospitalier Régional Universitaire Montpellier University Hospital, Montpellier, France; Laboratory of Anatomy, Montpellier 1 University, Montpellier, France
| | | | - Thuy Trang Pham
- Toulouse-Purpan University Hospital Center, Toulouse, France
| | - Michel Chammas
- Hand and Upper Extremity Surgery Unit, Centre Hospitalier Régional Universitaire Montpellier University Hospital, Montpellier, France
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Tampere T, Van Hoof T, Cromheecke M, Van der Bracht H, Chahla J, Verdonk P, Victor J. The anterior cruciate ligament: a study on its bony and soft tissue anatomy using novel 3D CT technology. Knee Surg Sports Traumatol Arthrosc 2017; 25:236-244. [PMID: 27624179 DOI: 10.1007/s00167-016-4310-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 08/31/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The purpose of this study is twofold: first, to visualize both the tibial and femoral bony insertion surfaces and second, to describe the anterior cruciate ligament (ACL) geometrically, using novel 3D CT imaging. In addition, new concepts of best-fit cylinder and central axis are introduced and evaluated. METHODS Eight unpaired knees of embalmed cadavers were used in this study. Following the dissection process, the ACL was injected with a contrast medium for CT imaging. The obtained CT images in extension, 45°, 90° and full flexion were segmented and rendered in 3D allowing morphological and morphometric analysis of the ACL. Anatomical footprint centres, femoral and tibial footprint surface area, best-fit ACL-cylinder intersection area, best-fit ACL-cylinder/footprint coverage ratio, best-fit ACL-cylinder central axis projections at the tibial and femoral footprint in the four positions were used to describe the anatomy of the ACL, based on the Bernard, Hertel and Amis grid. RESULTS Based on these parameters, with the best-fit cylinder representing the bulk of the ACL, a changing fibre-recruitment pattern was seen with a moving position of the central axis from posterior to anterior on the femoral and tibial footprint, going from extension to flexion. Furthermore, the numerical data show an increase in tibial footprint coverage by the best-fit cylinder through the ACL when the knee is progressively flexed, whereas an inverse relationship was seen on the femoral side. CONCLUSION This study is the first to describe the detailed anatomy of the human ACL with respect to its course and footprints using a 3D approach. It confirms the large difference and inter-patient variability between the tibial and femoral footprint area with the former being significantly smaller. The best-fit cylinder concept illustrates the recruitment pattern of the native ACL where in extension the postero-lateral fibres are recruited and in flexion rather the antero-medial bundle, which can be valuable information in reconstructive purposes. The best-fit cylinder and central axis concept offers additional insights into the optimal tunnel placement at the tibial and femoral footprint in order to cover the largest portion of the native ACL soft tissue, aiming for optimal ACL reconstruction.
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Affiliation(s)
- Thomas Tampere
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Tom Van Hoof
- Department of Anatomy, Ghent University, Ghent, Belgium
| | - Michiel Cromheecke
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - Hans Van der Bracht
- Department of Orthopaedic Surgery and Traumatology, Sint Lucas Ghent, Groenebriel 1, 9000, Ghent, Belgium
| | - Jorge Chahla
- Steadman Philippon Research Institute, 181W Meadow Dr, Vail, CO, 81657, USA
| | - Peter Verdonk
- Department of Orthopaedic Surgery, Monica Hospitals, Harmoniestraat 68, 2018, Antwerp, Belgium
- Faculty of Medicine, Ghent University, Ghent, Belgium
- Department of Orthopaedic Surgery, Antwerp University, Ghent, Belgium
| | - Jan Victor
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
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Parisien RL, Yi PH, Hou L, Li X, Jawa A. The risk of nerve injury during anatomical and reverse total shoulder arthroplasty: an intraoperative neuromonitoring study. J Shoulder Elbow Surg 2016; 25:1122-7. [PMID: 27283371 DOI: 10.1016/j.jse.2016.02.016] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 01/22/2016] [Accepted: 02/12/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study compared the incidence and pattern of potential nerve injuries between reverse shoulder (RSA) and total shoulder arthroplasty (TSA) using intraoperative neuromonitoring. Our hypothesis was that RSA has a greater risk of nerve injury than TSA due to arm lengthening. METHODS We reviewed 36 consecutive patients who underwent RSA (n = 12) or TSA (n = 24) with intraoperative neuromonitoring. The number of nerve alerts was recorded for each stage of surgery. Neurologic function was assessed preoperatively and postoperatively at routine follow-up visits. Predictive factors for increased intraoperative nerve alerts and clinically detectable neurologic deficits were determined. RESULTS There were nearly 5 times as many postreduction nerve alerts per patient in the RSA cohort compared with the TSA cohort (2.17 vs. 0.46). There were 17 unresolved nerve alerts postoperatively, with only 2 clinically detectable nerve injuries, which fully resolved by 6 months postoperatively. A preoperative decrease in active forward flexion and the diagnosis of rotator cuff arthropathy were independent predictors of intraoperative nerve alerts. CONCLUSION RSA has a higher incidence of intraoperative nerve alerts than TSA during the postreduction stage due to arm lengthening. Decreased preoperative active forward flexion and the diagnosis of rotator cuff arthropathy are predictors of more nerve alerts. The clinical utility of routine intraoperative nerve monitoring remains in question given the high level of nerve alerts and lack of persistent postoperative neurologic deficits.
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Affiliation(s)
- Robert L Parisien
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, USA
| | - Paul H Yi
- Department of Orthopaedics, University of California, San Francisco, San Francisco, CA, USA
| | - Laura Hou
- Department of Orthopaedics, New England Baptist Hospital, Boston, MA, USA
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University Medical Center, Boston, MA, USA
| | - Andrew Jawa
- Department of Orthopaedics, New England Baptist Hospital, Boston, MA, USA.
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Kim SG, Choi CH. Isolated Musculocutaneous Nerve Palsy after the Reverse Total Shoulder Arthroplasty. Clin Shoulder Elb 2016. [DOI: 10.5397/cise.2016.19.2.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Gilbert KK, Smith MP, Sobczak S, James CR, Sizer PS, Brismée JM. Effects of lower limb neurodynamic mobilization on intraneural fluid dispersion of the fourth lumbar nerve root: an unembalmed cadaveric investigation. J Man Manip Ther 2016; 23:239-45. [PMID: 26955255 DOI: 10.1179/2042618615y.0000000009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES Manual and physical therapists incorporate neurodynamic mobilisation (NDM) to improve function and decrease pain. Little is known about the mechanisms by which these interventions affect neural tissue. The objective of this research was to assess the effects of repetitive straight leg raise (SLR) NDM on the fluid dynamics within the fourth lumbar nerve root in unembalmed cadavers. METHODS A biomimetic solution (Toluidine Blue Stock 1% and Plasma) was injected intraneurally, deep to the epineurium, into the L4 nerve roots of seven unembalmed cadavers. The initial dye spread was allowed to stabilise and measured with a digital calliper. Once the initial longitudinal dye spread stabilised, an intervention strategy (repetitive SLR) was applied incorporating NDMs (stretch/relax cycles) at a rate of 30 repetitions per minute for 5 minutes. Post-intervention calliper measurements of the longitudinal dye spread were measured. RESULTS The mean experimental posttest longitudinal dye spread measurement (1.1 ± 0.9 mm) was significantly greater (P = 0.02) than the initial stabilised pretest longitudinal dye spread measurement. Increases ranged from 0.0 to 2.6 mm and represented an average of 7.9% and up to an 18.1% increase in longitudinal dye spread. DISCUSSION Passive NDM in the form of repetitive SLR induced a significant increase in longitudinal fluid dispersion in the L4 nerve root of human cadaveric specimen. Lower limb NDM may be beneficial in promoting nerve function by limiting or altering intraneural fluid accumulation within the nerve root, thus preventing the adverse effects of intraneural oedema.
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Affiliation(s)
- Kerry K Gilbert
- Center for Rehabilitation Research and Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Michael P Smith
- Anatomical Simulation and Research, Patient Safety, and Competency Center, Albany Medical College, Albany, New York, USA
| | - Stéphane Sobczak
- Laboratory of Anatomy, Biomechanics and Organogenesis (LABO), Faculty of Medecine, Université Libre de Bruxelles (ULB), Bruxelles, Belgium
| | - C Roger James
- Center for Rehabilitation Research and Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Phillip S Sizer
- Center for Rehabilitation Research and Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Jean-Michel Brismée
- Center for Rehabilitation Research and Department of Rehabilitation Sciences, School of Allied Health Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
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Gilbert KK, Roger James C, Apte G, Brown C, Sizer PS, Brismée JM, Smith MP. Effects of simulated neural mobilization on fluid movement in cadaveric peripheral nerve sections: implications for the treatment of neuropathic pain and dysfunction. J Man Manip Ther 2016; 23:219-25. [PMID: 26917940 DOI: 10.1179/2042618614y.0000000094] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND AND PURPOSE Neural mobilization techniques are used clinically to treat neuropathic pain and dysfunction. While selected studies report efficacy of these techniques, the mechanisms of benefit are speculative. The purpose of this study was to evaluate the effects of in vitro simulated stretch/relax neural mobilization cycles on fluid dispersion within sections of unembalmed cadaveric peripheral nerve tissue. METHODS Bilateral sciatic nerve sections were harvested from six cadavers. Matched pairs of nerve sections were secured in a tissue tester and injected with a plasma/Toluidine Blue dye solution. Once the initial dye spread stabilized, the experimental nerve sections underwent 25 stretch/relaxation cycles (e.g. simulated neural mobilization) produced by a mechanical tissue tester. Post-test dye spread measurements were compared to pre-test measurements as well as control findings (no simulated mobilization). Data were analyzed using paired t-tests. RESULTS Individual dye spread measurements were reliable [ICC(3,1) = 0·99]. The post-test intraneural fluid movement (dye spread) in the experimental section increased significantly with simulated neural mobilization compared to pre-test measurements (3·2±2·1 mm; P = 0·015) and control measurements (3·3±2·7 mm; P = 0·013). CONCLUSION Repetitive simulated neural mobilization, incorporating stretch/relax cycles, of excised cadaveric peripheral nerve tissue produced an increase in intraneural fluid dispersion. Neural mobilization may alter nerve tissue environment, promoting improved function and nerve health, by dispersing tissue fluid and diminishing intraneural swelling and/or pressure.
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Affiliation(s)
- Kerry K Gilbert
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - C Roger James
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Gail Apte
- Atlas Physical and Hand Therapy Eugene, OR, USA
| | | | - Phillip S Sizer
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jean-Michel Brismée
- Center for Rehabilitation Research, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Van de Velde J, Bogaert S, Vandemaele P, Huysse W, Achten E, Leijnse J, De Neve W, Van Hoof T. Brachial plexus 3D reconstruction from MRI with dissection validation: a baseline study for clinical applications. Surg Radiol Anat 2015; 38:229-36. [DOI: 10.1007/s00276-015-1549-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 08/17/2015] [Indexed: 02/01/2023]
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Van de Velde J, Wouters J, Vercauteren T, De Gersem W, Duprez F, De Neve W, Van Hoof T. Morphometric Atlas Selection for Automatic Brachial Plexus Segmentation. Int J Radiat Oncol Biol Phys 2015; 92:691-8. [PMID: 25956831 DOI: 10.1016/j.ijrobp.2015.02.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/17/2015] [Accepted: 02/23/2015] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study was to determine the effects of atlas selection based on different morphometric parameters, on the accuracy of automatic brachial plexus (BP) segmentation for radiation therapy planning. The segmentation accuracy was measured by comparing all of the generated automatic segmentations with anatomically validated gold standard atlases developed using cadavers. METHODS AND MATERIALS Twelve cadaver computed tomography (CT) atlases (3 males, 9 females; mean age: 73 years) were included in the study. One atlas was selected to serve as a patient, and the other 11 atlases were registered separately onto this "patient" using deformable image registration. This procedure was repeated for every atlas as a patient. Next, the Dice and Jaccard similarity indices and inclusion index were calculated for every registered BP with the original gold standard BP. In parallel, differences in several morphometric parameters that may influence the BP segmentation accuracy were measured for the different atlases. Specific brachial plexus-related CT-visible bony points were used to define the morphometric parameters. Subsequently, correlations between the similarity indices and morphometric parameters were calculated. RESULTS A clear negative correlation between difference in protraction-retraction distance and the similarity indices was observed (mean Pearson correlation coefficient = -0.546). All of the other investigated Pearson correlation coefficients were weak. CONCLUSIONS Differences in the shoulder protraction-retraction position between the atlas and the patient during planning CT influence the BP autosegmentation accuracy. A greater difference in the protraction-retraction distance between the atlas and the patient reduces the accuracy of the BP automatic segmentation result.
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Affiliation(s)
- Joris Van de Velde
- Department of Anatomy, Ghent University, Ghent, Belgium; Department of Radiotherapy, Ghent University, Ghent, Belgium.
| | - Johan Wouters
- Department of Anatomy, Ghent University, Ghent, Belgium
| | - Tom Vercauteren
- Department of Radiotherapy, Ghent University, Ghent, Belgium
| | | | - Fréderic Duprez
- Department of Radiotherapy, Ghent University, Ghent, Belgium
| | | | - Tom Van Hoof
- Department of Anatomy, Ghent University, Ghent, Belgium
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Zhou HS, Chung JS, Yi PH, Li X, Price MD. Management of complications after reverse shoulder arthroplasty. Curr Rev Musculoskelet Med 2015; 8:92-97. [PMID: 25576072 DOI: 10.1007/s12178-014-9252-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Reverse total shoulder arthroplasty (RTSA) has become the treatment of choice for patients with rotator cuff arthropathy. Complication rate after RTSA has been reported to be three to five times that of conventional total shoulder arthroplasty. Intraoperative and postoperative complications include neurological injury, infection, dislocation or instability, acromial or scapular spine fracture, hematoma, and scapular notching. Knowledge of optimal component placement along with preoperative planning and recognition of risk factors are essential in optimizing patient outcome. The purpose of this review article is to identify the most common and serious complications associated with the RTSA and discuss the current methods of management. Complications after RTSA pose a significant challenge for healthcare providers and economic burden to society. Therefore, it is essential to make the proper diagnosis and develop and implement early management plans to improve patient outcome and satisfaction.
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Affiliation(s)
- Hanbing S Zhou
- Department of Orthopaedic Surgery, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Justin S Chung
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Paul H Yi
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Xinning Li
- Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Mark D Price
- Department of Orthopaedic Surgery, University of Massachusetts Medical Center, Worcester, MA, USA.
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Brachial Plexus Injuries During Shoulder Arthroplasty. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2014. [DOI: 10.1097/bte.0000000000000030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wiater BP, Moravek JE, Wiater JM. The evaluation of the failed shoulder arthroplasty. J Shoulder Elbow Surg 2014; 23:745-58. [PMID: 24618199 DOI: 10.1016/j.jse.2013.12.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 12/04/2013] [Accepted: 12/05/2013] [Indexed: 02/01/2023]
Abstract
As the incidence of shoulder arthroplasty continues to rise, the orthopedic shoulder surgeon will be increasingly faced with the difficult problem of evaluating a failed shoulder arthroplasty. The patient is usually dissatisfied with the outcome of the previous arthroplasty as a result of pain, but may complain of poor function due to limited range of motion or instability. A thorough and systematic approach is necessary so that the most appropriate treatment pathway can be initiated. A comprehensive history and physical examination are the first steps in the evaluation. Diagnostic studies are numerous and include laboratory values, plain radiography, computed tomography, ultrasound imaging, joint aspiration, nuclear scans, and electromyography. Common causes of early pain after shoulder arthroplasty include technical issues related to the surgery, such as malposition or improper sizing of the prosthesis, periprosthetic infection, neurologic injury, and complex regional pain syndrome. Pain presenting after a symptom-free interval may be related to chronic periprosthetic infection, component wear and loosening, glenoid erosion, rotator cuff degeneration, and fracture. Poor range of motion may result from inadequate postoperative rehabilitation, implant-related factors, and heterotopic ossification. Instability is generally caused by rotator cuff deficiency and implant-related factors. Unfortunately, determining the cause of a failed shoulder arthroplasty can be difficult, and in many situations, the source of pain and disability is multifactorial.
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Affiliation(s)
- Brett P Wiater
- Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, MI, USA
| | | | - J Michael Wiater
- Department of Orthopaedic Surgery, Beaumont Health System, Royal Oak, MI, USA; Department of Orthopaedic Surgery, Oakland University-William Beaumont School of Medicine, Rochester Hills, MI, USA.
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Van de Velde J, Vercauteren T, De Gersem W, Wouters J, Vandecasteele K, Vuye P, Vanpachtenbeke F, D’Herde K, Kerckaert I, De Neve W, Van Hoof T. Reliability and accuracy assessment of radiation therapy oncology group-endorsed guidelines for brachial plexus contouring. Strahlenther Onkol 2014; 190:628-32, 634-5. [DOI: 10.1007/s00066-014-0657-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/11/2014] [Indexed: 12/25/2022]
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Lädermann A, Stimec BV, Denard PJ, Cunningham G, Collin P, Fasel JHD. Injury to the axillary nerve after reverse shoulder arthroplasty: an anatomical study. Orthop Traumatol Surg Res 2014; 100:105-8. [PMID: 24314820 DOI: 10.1016/j.otsr.2013.09.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 05/12/2013] [Accepted: 09/06/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Subclinical neurological lesions after reverse shoulder arthroplasty are frequent, mainly those involving the axillary nerve. One of the major reported risk factors is postoperative lengthening of the arm. The purpose of this study was to evaluate the anatomical relationship between the axillary nerve and prosthetic components after reverse shoulder arthroplasty. The study hypothesis was that inferior overhang of the glenosphere relative to glenoid could put this nerve at risk. MATERIAL AND METHODS Eleven fresh frozen shoulder specimens were dissected after having undergone reverse shoulder arthroplasty using a classic deltopectoral approach. RESULTS The mean distance from the inferior border of the glenoid to the inferior edge of the glenosphere was 6.0±4.3mm (range, 1.0 to 16.2mm). The axillary nerve was never closer than 15mm to the glenosphere. The main anterior branch of the axillary nerve was in close contact with the posterior metaphysis or humeral prosthetic implant. The mean distance between the nerve and the humeral implants was 5.2±2.1mm (range, 2.0 to 8.1mm). CONCLUSIONS The proximity of the axillary nerve to the posterior metaphysis or humeral implants may be a risk factor for axillary nerve injury after reverse shoulder arthroplasty. CLINICAL RELEVANCE This study quantifies the proximity of the axillary nerve to the implant after reverse shoulder arthroplasty. LEVEL OF EVIDENCE Basic science study, cadaver study.
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Affiliation(s)
- A Lädermann
- Division of Orthopedics and Trauma Surgery, La Tour Hospital, 3, rue J.-D.-Maillard, 1217 Meyrin, Switzerland; Faculty of Medicine, University of Geneva, 1, rue Michel-Servet, 1211 Geneva 4, Switzerland; Division of Orthopedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 21, Switzerland.
| | - B V Stimec
- Faculty of Medicine, Department of Cellular Physiology and Metabolism, Anatomy Sector, University of Geneva, 1, rue Michel-Servet, 1211 Geneva 4, Switzerland
| | - P J Denard
- Southern Oregon Orthopedics, Medford, Oregon, USA; Department of Orthopedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon, USA
| | - G Cunningham
- Division of Orthopedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, 4, rue Gabrielle-Perret-Gentil, 1211 Geneva 21, Switzerland
| | - P Collin
- Saint-Grégoire Private Hospital Center, 6, boulevard Boutière, 35768 Saint-Grégoire cedex, France
| | - J H D Fasel
- Faculty of Medicine, Department of Cellular Physiology and Metabolism, Anatomy Sector, University of Geneva, 1, rue Michel-Servet, 1211 Geneva 4, Switzerland
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Abstract
In addition to neurologic injuries such as peripheral nerve palsy, axillary vessel injury should be recognized as a possible complication of reverse total shoulder arthroplasty. Limb lengthening associated with Grammont-type reverse total shoulder arthroplasty places tension across the brachial plexus and axillary vessels and may contribute to observed injuries. The Grammont-type reverse total shoulder arthroplasty prosthesis reverses the shoulder ball and socket, shifts the shoulder center of rotation distal and medial, and lengthens the arm. This alteration of native anatomy converts shearing to compressive glenohumeral joint forces while augmenting and tensioning the deltoid lever arm. Joint stability is enhanced; shoulder elevation is enabled in the rotator cuff–deficient shoulder. Arm lengthening associated with reverse total shoulder arthroplasty places a longitudinal strain on the brachial plexus and axillary vessels. Peripheral nerve palsies and other neurologic complications of reverse total shoulder arthroplasty have been documented. The authors describe a patient with rotator cuff tear arthropathy and a history of radioulnar synostosis who underwent reverse total shoulder arthroplasty complicated by intraoperative injury to the axillary artery and postoperative radial, ulnar, and musculocutaneous nerve palsies. Following a seemingly unremarkable placement of reverse shoulder components, brisk arterial bleeding was encountered while approximating the incised subscapularis tendon in preparation for wound closure. Further exploration revealed an avulsive-type injury of the axillary artery. After an unsuccessful attempt at primary repair, a synthetic arterial bypass graft was placed. Reperfusion of the right upper extremity was achieved and has been maintained to date. Postoperative clinical examination and electromyographic studies confirmed ongoing radial, ulnar, and musculocutaneous neuropathies.
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Van de Velde J, Audenaert E, Speleers B, Vercauteren T, Mulliez T, Vandemaele P, Achten E, Kerckaert I, D'Herde K, De Neve W, Van Hoof T. An anatomically validated brachial plexus contouring method for intensity modulated radiation therapy planning. Int J Radiat Oncol Biol Phys 2013; 87:802-8. [PMID: 24138919 DOI: 10.1016/j.ijrobp.2013.08.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 07/17/2013] [Accepted: 08/02/2013] [Indexed: 12/25/2022]
Abstract
PURPOSE To develop contouring guidelines for the brachial plexus (BP) using anatomically validated cadaver datasets. Magnetic resonance imaging (MRI) and computed tomography (CT) were used to obtain detailed visualizations of the BP region, with the goal of achieving maximal inclusion of the actual BP in a small contoured volume while also accommodating for anatomic variations. METHODS AND MATERIALS CT and MRI were obtained for 8 cadavers positioned for intensity modulated radiation therapy. 3-dimensional reconstructions of soft tissue (from MRI) and bone (from CT) were combined to create 8 separate enhanced CT project files. Dissection of the corresponding cadavers anatomically validated the reconstructions created. Seven enhanced CT project files were then automatically fitted, separately in different regions, to obtain a single dataset of superimposed BP regions that incorporated anatomic variations. From this dataset, improved BP contouring guidelines were developed. These guidelines were then applied to the 7 original CT project files and also to 1 additional file, left out from the superimposing procedure. The percentage of BP inclusion was compared with the published guidelines. RESULTS The anatomic validation procedure showed a high level of conformity for the BP regions examined between the 3-dimensional reconstructions generated and the dissected counterparts. Accurate and detailed BP contouring guidelines were developed, which provided corresponding guidance for each level in a clinical dataset. An average margin of 4.7 mm around the anatomically validated BP contour is sufficient to accommodate for anatomic variations. Using the new guidelines, 100% inclusion of the BP was achieved, compared with a mean inclusion of 37.75% when published guidelines were applied. CONCLUSION Improved guidelines for BP delineation were developed using combined MRI and CT imaging with validation by anatomic dissection.
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Affiliation(s)
- Joris Van de Velde
- Department of Anatomy, Ghent University, Ghent, Belgium; Department of Radiotherapy, Ghent University, Ghent, Belgium.
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Mahmood A, Malal JJG, Waseem M. Reverse shoulder arthroplasty - a literature review. Open Orthop J 2013; 7:366-72. [PMID: 24082977 PMCID: PMC3785030 DOI: 10.2174/1874325001307010366] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Revised: 01/12/2013] [Accepted: 02/09/2013] [Indexed: 02/01/2023] Open
Abstract
Professor Grammont revolutionised shoulder surgery with his reverse shoulder arthroplasty design. Patients who had poor results from a conventional shoulder replacement because of cuff deficiency can now be treated effectively. Although designed for cuff tear arthropathy, indications continue to evolve and broaden. The initial results look very promising and the implant has gained much popularity over the years. The article provides an extensive literature review of the indications, results and complications for reverse shoulder arthroplasty.
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Van Hoof T, Cromheecke M, Tampere T, D'herde K, Victor J, Verdonk PCM. The posterior cruciate ligament: a study on its bony and soft tissue anatomy using novel 3D CT technology. Knee Surg Sports Traumatol Arthrosc 2013; 21:1005-10. [PMID: 23269474 DOI: 10.1007/s00167-012-2332-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 11/27/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE The bony insertion sites of the PCL have been studied and described extensively using 2D technology such as macroscopic images, plain radiograph, computerized tomography (CT) and MRI. The purpose of this study is to visualize both the tibial and the femoral bony insertion sites but also the soft tissue anatomy of the native PCL using novel 3D CT imaging. In addition, new concepts of best-fit cylinder and central axis are introduced and evaluated. METHODS Nine unpaired knees of embalmed cadavers were used in this study. Following the dissection process, the PCL was injected with a contrast medium for computed tomography (CT) imaging. The obtained CT images were segmented and rendered in 3D allowing morphological and morphometric analysis of PCL. Femoral and tibial footprint surface area, best-fit PCL-cylinder intersection area, best-fit PCL-cylinder/footprint coverage ratio, best-fit PCL-cylinder central axis projections at the tibial and femoral footprint were used to describe the anatomy of the PCL. RESULTS Mean footprint surface area of the tibial and femoral footprint were 189.1 and 293.3 mm², respectively. The mean diameter of the best-fit cylinder was 10.5 mm. The mean coverage of the best-fit cylinder on the tibial and femoral footprint was 76.5 and 46.5, respectively. The best-fit cylinder central axis was located in the anterolateral AL bundle footprint on the femur and more centrally in the PCL footprint on the tibia. CONCLUSION This study is the first to describe the detailed anatomy of the human PCL with respect to its course and footprints using a 3D approach. It confirms the large difference between the tibial and the femoral footprint area with the former being significantly smaller. In addition, a large inter-patient variability is observed. The best-fit cylinder and central axis concept offer additional insights into the optimal tunnel placement at the tibia and femoral footprint in order to cover the largest portion of the native PCL soft tissue.
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Affiliation(s)
- Tom Van Hoof
- Department of Anatomy, Ghent University, Ghent, Belgium
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Brown CL, Gilbert KK, Brismee JM, Sizer PS, Roger James C, Smith MP. The effects of neurodynamic mobilization on fluid dispersion within the tibial nerve at the ankle: an unembalmed cadaveric study. J Man Manip Ther 2012; 19:26-34. [PMID: 22294851 DOI: 10.1179/2042618610y.0000000003] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE To evaluate the effects of neurodynamic mobilization on the fluid dynamics of the tibial nerve in cadavers. BACKGROUND Evidence showing patients benefit from neural mobilization is limited. Mechanisms responsible for changes in patient symptoms are unclear. METHODS Bilateral lower limbs of six unembalmed cadavers (n = 12) were randomized into matched pairs and dissected to expose the tibial nerve proximal to the ankle. Dye composed of Toulidine blue and plasma was injected into the nerve. The longitudinal dye spread was measured pre- and post-mobilization. The experimental group received the intervention consisting of 30 repetitions of passive ankle range of motion over the course of 1 minute. The matched control limb received no mobilization. Data were analysed using a 2×2 repeated measures ANOVA with subsequent t-tests for pairwise comparisons. RESULTS Mean dye spread was 23.8±10.2 mm, a change of 5.4±4.7% in the experimental limb as compared to 20.7±6.0 mm, a change of -1.5±3.9% in the control limb. The ANOVA was significant (P⩽0.02) for interaction between group (experimental/control) and time (pre-mobilization/post-mobilization). t-test results were significant between pre- and post-mobilization of the experimental leg (P = 0.01), and between control and experimental limbs post-mobilization (P⩽0.02). CONCLUSION Passive neural mobilization induces dispersion of intraneural fluid. This may be clinically significant in the presence of intraneural edema found in pathological nerves such as those found in compression syndromes.
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Affiliation(s)
- Cynthia L Brown
- Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Van Hoof T, Vangestel C, Shacklock M, Kerckaert I, D’Herde K. Asymmetry of the ULNT1 elbow extension range-of-motion in a healthy population: Consequences for clinical practice and research. Phys Ther Sport 2012; 13:141-9. [DOI: 10.1016/j.ptsp.2011.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 09/20/2011] [Accepted: 09/22/2011] [Indexed: 11/30/2022]
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Abstract
Reverse total shoulder arthroplasty was initially used to manage complex shoulder problems. Indications have been expanded to include rotator cuff arthropathy, massive rotator cuff tear, failed shoulder arthroplasty, and fracture sequelae. Increased use of primary reverse total shoulder arthroplasty has led to reports of associated problems unique to the procedure. The most common complications include neurologic injury, periprosthetic fracture, hematoma, infection, scapular notching, dislocation, mechanical baseplate failure, and acromial fracture. Little information has been published regarding best practices for managing these complications.
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Lädermann A, Lübbeke A, Mélis B, Stern R, Christofilopoulos P, Bacle G, Walch G. Prevalence of neurologic lesions after total shoulder arthroplasty. J Bone Joint Surg Am 2011; 93:1288-93. [PMID: 21792494 DOI: 10.2106/jbjs.j.00369] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Clinically evident neurologic injury of the involved limb after total shoulder arthroplasty is not uncommon, but the subclinical prevalence is unknown. The purposes of this prospective study were to determine the subclinical prevalence of neurologic lesions after reverse shoulder arthroplasty and anatomic shoulder arthroplasty, and to evaluate the correlation of neurologic injury to postoperative lengthening of the arm. METHODS All patients undergoing either a reverse or an anatomic shoulder arthroplasty were included during the period studied. This study focused on the clinical, radiographic, and preoperative and postoperative electromyographic evaluation, with measurement of arm lengthening in patients who had reverse shoulder arthroplasty according to a previously validated protocol. RESULTS Between November 2007 and February 2009, forty-one patients (forty-two shoulders) underwent reverse shoulder arthroplasty (nineteen shoulders) or anatomic primary shoulder arthroplasty (twenty-three shoulders). The two groups were similar with respect to sex distribution, preoperative neurologic lesions, and Constant score. Electromyography performed at a mean of 3.6 weeks postoperatively in the reverse shoulder arthroplasty group showed subclinical electromyographic changes in nine shoulders, involving mainly the axillary nerve; eight resolved in less than six months. In the anatomic shoulder arthroplasty group, a brachial plexus lesion was evident in one shoulder. The prevalence of acute postoperative nerve injury was significantly more frequent in the reverse shoulder arthroplasty group (p = 0.002), with a 10.9 times higher risk (95% confidence interval, 1.5 to 78.5). Mean lengthening (and standard deviation) of the arm after reverse shoulder arthroplasty was 2.7 ± 1.8 cm (range, 0 to 5.9 cm) compared with the normal, contralateral side. CONCLUSIONS The occurrence of peripheral neurologic lesions following reverse shoulder arthroplasty is relatively common, but usually transient. Arm lengthening with a reverse shoulder arthroplasty may be responsible for these nerve injuries.
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Affiliation(s)
- A Lädermann
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, CH-1211 Geneva 14, Switzerland.
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Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg 2011; 20:146-57. [PMID: 21134666 DOI: 10.1016/j.jse.2010.08.001] [Citation(s) in RCA: 546] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 07/28/2010] [Accepted: 08/07/2010] [Indexed: 02/01/2023]
Affiliation(s)
- Matthias A Zumstein
- Department of Orthopaedic Surgery and Sports Traumatology, Hôpital de L'Archet II, University of Nice Sophia-Antipolis, Nice, France
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Abstract
Reverse total shoulder arthroplasty designs have gained popularity over the last few years due to their satisfactory functional results in patients with cuff-tear arthropathy and other difficult reconstructive shoulder problems. These semiconstrained prostheses improve stability and active elevation in the absence of a functional rotator cuff by coupling a spherical glenoid component with a concave humeral component and increasing deltoid tension. Understanding the anatomy of the shoulder is critical in order to ensure secure fixation of the glenoid component, explore uncemented options for humeral component fixation, and determine the ideal soft-tissue tension to provide the best functional outcome without increasing the risk of complications. Key anatomic elements to be considered for the successful implantation of a reverse prosthesis include the orientation and size of the glenoid vault, the scapular regions with better bone stock (coracoid, spine of the scapula), the internal geometry of the humeral medullary canal, and the effects of reverse arthroplasty on the deltoid and brachial plexus.
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Affiliation(s)
- Joaquin Sanchez-Sotelo
- The Department of Orthopedic Surgery, Mayo Clinic and Mayo Medical School, Rochester, Minnesota 55905, USA.
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