Anatomy of the terminal branch of the posterior circumflex humeral artery: relevance to the deltopectoral approach to the shoulder

AIMS

Despite the expansion of arthroscopic surgery of the shoulder, the open deltopectoral approach is increasingly used for the fixation of fractures and arthroplasty of the shoulder. The anatomy of the terminal branches of the posterior circumflex humeral artery (PCHA) has not been described before. We undertook an investigation to correct this omission.

PATIENTS AND METHODS

The vascular anatomy encountered during 100 consecutive elective deltopectoral approaches was recorded, and the common variants of the terminal branches of the PCHA are described.

RESULTS

In total, 92 patients (92%) had a terminal branch that crossed the space between the deltoid and the proximal humerus and which was therefore vulnerable to tearing or avulsion during the insertion of the blade of a retractor during the deltopectoral approach to the shoulder. In 75 patients (75%) there was a single vessel, in 16 (16%) a double vessel and in one a triple vessel.

CONCLUSION

The relationship of these vessels to the landmark of the tendon of the insertion of pectoralis major into the proximal humerus is described. Damage to these previously undocumented branches can cause persistent bleeding leading to prolonged surgery and post-operative haematoma and infection, as well as poor visualisation during the procedure. Cite this article: Bone Joint J 2016;98-B:1395-8.

The viability of cells obtained using the Reamer–Irrigator–Aspirator system and in bone graft from the iliac crest

We hypothesised that cells obtained via a Reamer–Irrigator–Aspirator (RIA) system retain substantial osteogenic potential and are at least equivalent to graft harvested from the iliac crest. Graft was harvested using the RIA in 25 patients (mean age 37.6 years (18 to 68)) and from the iliac crest in 21 patients (mean age 44.6 years (24 to 78)), after which ≥ 1 g of bony particulate graft material was processed from each. Initial cell viability was assessed using Trypan blue exclusion, and initial fluorescence-activated cell sorting (FACS) analysis for cell lineage was performed. After culturing the cells, repeat FACS analysis for cell lineage was performed and enzyme-linked immunosorbent assay (ELISA) for osteocalcin, and Alizarin red staining to determine osteogenic potential. Cells obtained via RIA or from the iliac crest were viable and matured into mesenchymal stem cells, as shown by staining for the specific mesenchymal antigens CD90 and CD105. For samples from both RIA and the iliac crest there was a statistically significant increase in bone production (both p < 0.001), as demonstrated by osteocalcin production after induction.

Medullary autograft cells harvested using RIA are viable and osteogenic. Cell viability and osteogenic potential were similar between bone grafts obtained from both the RIA system and the iliac crest.

Cite this article: Bone Joint J 2013;95-B:1269–74.

Co-composting of physic nut (Jatropha curcas) deoiled cake with rice straw and different animal dung

To address the dispensing of this growing volume, a study on utilization of jatropha (Jatropha curcas) deoiled cake through compost production was carried out. The deoiled cake was composted with rice straw, four different animal dung (cow dung, buffalo dung, horse dung and goat dung) and hen droppings in different proportions followed by assessment, and comparison of biochemical characteristics among finished composts. Nutrient content in finished compost was within the desired level whereas metals such as copper, lead and nickel were much below the maximum allowable concentrations. Although a few finished material contained phorbol ester (0.12 mg/g), but it was far below the original level found in the deoiled cake. Such a study indicates that a huge volume of jatropha deoiled cake can be eliminated through composting.

Sciatic nerve injury caused by pre-operative intraneural injection of local anaesthetic during total hip replacement

We report a case of iatrogenic sciatic nerve injury caused by pre-operative intraneural injection of local anaesthetic at total hip replacement. To our knowledge, this is unreported in the orthopaedic literature. We consider sacral nerve blockade in patients undergoing total hip replacement to be undesirable and present guidelines for the management of peri-operative sciatic nerve injury.

Acute tonsillitis: an unusual presentation of Kawasaki syndrome: a case report and review of the literature

Kawasaki syndrome is an acute, self-limiting vasculitis that occurs mainly in children. The disorder is difficult to diagnose, a problem compounded by the lack of a specific diagnostic test. If the condition is unrecognised or treated sub-optimally, there is a 25% risk of developing serious cardiovascular complications. We report the case of an 8-year-old boy presenting with a history of acute tonsillitis and cervical lymphadenopathy in which the diagnosis of Kawasaki syndrome became apparent 4 days after admission. The case emphasises the importance of having a high index of suspicion for Kawasaki syndrome in children presenting with tonsillitis and cervical lymphadenopathy who do not respond to antibiotics or who have atypical features at the time of or after admission. A literature review of previous cases reveals a higher than usual age of presentation for the disease that could result in a greater percentage of cardiac complications.

Endoscopic repair of nasal septal perforation with acellular human dermal allograft and an inferior turbinate flap

Nasal septal perforations present a distinct challenge to the otolaryngologist and a significant cause of symptoms to affected patients. Many surgical techniques for the repair of septal perforations have been described. Connective tissue autografts are commonly used as interpositional grafts between the septal flaps. Recently acellular human dermal allograft has been used with success. In total, 17 patients with symptomatic anterior nasal septal perforations that had failed conservative treatment underwent a closed endoscopic repair of their perforations with acellular human dermal allograft (alloderm) and an anteriorly based inferior turbinate flap; 13 patients had a successful closure of the perforation, two patients, despite initial success, re-perforated as a result of persistent crust picking and, in two patients, the graft failed. With appropriate patient selection and stringent postoperative care the authors consider this technique offers a good surgical outcome for the closure of septal perforations.

Current practices of cocaine administration by UK otorhinolaryngologists

The aim of this study was to determine which anaesthetic and vasoconstrictor preparations UK Otorhinolaryngologists use for rhinological surgery, with particular reference to cocaine and adrenaline. The incidence and types of adverse reactions to cocaine were also recorded. A postal survey of all BAO-HNS consultant members was performed. Of the 360 consultant surgeons included in the survey, the majority still use peri-operative cocaine on a regular basis, 66 per cent use cocaine and adrenaline together and more than 40 per cent use cocaine in paediatric patients. Sixteen per cent of respondents did not use cocaine. Only 11 per cent of surgeons had experienced cocaine toxicity in their patients, with only one recorded case of mortality. Most surgeons in the UK use cocaine because of the superior operative field it provides and because they consider it to be safe even with adrenaline. The actual incidence of adverse reactions to cocaine is low, with serious complications being less common than the risks from general anaesthesia. Cocaine remains a valuable agent in the armamentarium of the rhinologist.

Sudden onset bilateral sensorineural hearing loss: a manifestation of occult breast carcinoma

Diffuse infiltration of the meninges by metastatic carcinoma (meningeal carcinomastosis) is a potential complication of systemic malignancy. It may present with a variety of neurological symptoms as any aspect of the neuraxis can be affected. Often there is a history of pre-existing malignancy. The authors describe a case with an initial presentation of sudden onset profound bilateral sensorineural hearing loss. The underlying pathology was found to be an occult breast carcinoma, a previously unreported finding. The role of cerebrospinal fluid cytology and radio-imaging in diagnosis is discussed. All previously reported cases of sudden hearing loss and meningeal carcinomatosis are reviewed.

Osseo-integration in Paget's disease: the bone-anchored hearing aid in the rehabilitation of Pagetic deafness

The first report of a patient with gross Paget's disease and progressive hearing loss who successfully underwent hearing rehabilitation with an osseo-integrated hearing aid is presented. The otological manifestations of Paget's disease and the principles of osseo-integration are discussed. The use of a bone-anchored hearing aid (BAHA) in selected patients with Paget's disease can provide useful amplification and hearing rehabilitation.

Spontaneous supraglottic haemorrhage in a patient receiving warfarin sodium treatment

A case of spontaneous, isolated supraglottic haemorrhage in a patient recently started with warfarin sodium treatment is described. The symptoms of sore throat, dysphonia, stridor, dysphagia or a neck swelling in a patient taking anticoagulants should alert the clinician to the possibility of this rare but potentially fatal complication.

Extramedullary plasmacytoma of the larynx presenting with upper airway obstruction in a patient with long-standing IgD myeloma

A rare case of upper airway obstruction due to an extramedullary plasmacytoma of the larynx in a patient with long-standing IgD myeloma is presented. Reports of patients with extramedullary plasmacytomas eventually developing multiple myeloma are common, however, the converse appears to be an extremely rare event. Attention is drawn to the problem of acquiring adequate tissue for diagnostic purposes as well as the use of immunohistochemical staining techniques. The patient required an urgent tracheostomy and was treated with radiotherapy.

Actinomycosis of the post-cricoid space: an unusual cause of dysphagia

Cervicofacial actinomycosis is known to affect many soft tissues and bony structures in the head and neck. However to the authors' knowledge, actinomycosis of the post-cricoid region has not been previously reported. A case of a 74-year-old male who developed actinomycosis of the post-cricoid region after radiotherapy for a laryngeal carcinoma is presented. Actinomycosis should be considered in the differential diagnosis of dysphagia following radiotherapy for squamous cell carcinoma of the larynx, as early treatment is likely to result in a favourable outcome.