An Anatomical Study to Demonstrate the Proximity of Kirschner Wires to Structures at Risk in Percutaneous Pinning of Distal Radius Fractures

Distal radius fractures are often treated using percutaneous Kirschner wires (K-wires). The sensory nerves in this area, extensor tendons, radial artery and cephalic vein are at risk of injury in this procedure. We undertook a cadaveric investigation to identify probability of damage to these ‘at risk’ structures by measuring their distances in relation to standard K-wire sites. Nine upper limbs from six formalin-preserved cadavers were studied. Four K-wires were placed percutaneously simulating fixation of a distal radius fracture. Careful dissection was done preserving the original position of neurovascular and tendinous structures. Distances to relevant soft-tissue structures from each K-wire were measured using an electronic digital caliper. Distance of superficial nerves from radial styloid and Lister’s tubercle was measured to determine their ‘safe distance’ from these fixed landmarks. None of the superficial nerves were injured by a K-wire. Cephalic vein had been pierced on 4 occasions (4/18) and extensor tendons on 3 occasions (3/18). Wilcoxon signed-rank test was used to compare distance of the superficial nerves from radial styloid and Lister tubercle, and the latter was found to be the safer option. This study highlights the inherent danger in percutaneous K-wire fixation of wrist fractures. Limited size of the area, where K-wires can be positioned, and anatomic variations of neurovascular structures pose obstacles in developing guidelines for reducing risk of injury. We advocate use of mini-open approach and guiding devices to avert complications of inadvertent impalement and damage to these structures.     

Neural Anatomy of the Anterolateral Thigh Flap

The anterolateral thigh (ALT) flap is one of the commonly used sensate flaps for intra-oral, hand, and foot reconstruction. The objective of this study was to describe the anatomic location of the sensory nerves supplying the ALT flap in relation to the surface landmarks and with the vascular pedicles. The dissections were carried out in 28 embalmed specimens. An axial line from the anterior superior iliac spine to the superolateral border of the patella and two circles with radii of 5 and 10 cm centered on the midpoint of the former line were used for the surface landmarks. At the intersection point of the axial line and the 10-cm circle, the main lateral femoral cutaneous nerve (LFCN) and its anterior branch were located within 1 and 2.4 cm, respectively. At the intersection point of the axial line and the 5-cm circle, the anterior branch of the LFCN was located within 2.8 cm. The anterior branch of the LFCN can be detected within 3 cm from the central perforator pedicle in all specimens. The posterior branch of the LFCN, superior perforator nerve, and median perforator nerve were found in more variable locations. The findings from our study provide additional information for clinical use in the planning of sensate ALT flap harvest.     

Platelet—Rich—Plasma Injections in Treating Lateral Epicondylosis: a Review of the Recent Evidence

Lateral epicondylosis is common, with various treatment modalities. Platelet—rich—plasma injections from autologous blood have recently been used in centres worldwide for the treatment of tennis elbow. We review and present the recent published evidence on the effectiveness of PRP injections for lateral epicondylosis. Nine studies met our inclusion criteria including 6 RCT’s for the purpose of analysis. PRP injections have an important and effective role in the treatment of this debilitating pathology, in cases where physiotherapy has been unsuccessful.     

全内镜下可视化经椎弓根上切迹入路手术治疗腰椎侧隐窝狭窄症的疗效分析

目的:分析全内镜(full-endoscopic,FE)下可视化经椎弓根上切迹入路手术治疗腰椎侧隐窝狭窄症的临床疗效。方法:收集2016年6月～2017年12月在我院采用FE下可视化经椎弓根上切迹入路手术治疗的96例腰椎侧隐窝狭窄症患者的临床资料,其中男性62例,女性34例,年龄38～68岁(51.4±13.3岁);L3/4 8例,L4/562例,L5/S1 26例。术前腰、腿痛视觉模拟评分(visual analogue scale,VAS)分别为0～5(3.8±1.6)、3～7 (5.2±1.0);腰椎Oswestry功能障碍指数(ODI)为38%～65%[(53.0±9.1)%];手术节段侧隐窝角和前后径分别为17.6°±1.4°和2.3±0.2mm。术后完成至少2年随访。记录患者手术时间、术中透视次数、住院时间和围手术期并发症,在术后1周的CT/MRI横断面上测量手术节段侧隐窝角和前后径;术后1周、3个月、1年和末次随访时行下肢痛和腰痛VAS评分、ODI评定,并进行统计学分析;末次随访时参照改良MacNab标准评价临床疗效。结果:患者均顺利完成手术,手术时间55.8±14.6min,术中透视次数7.2±2.5次,住院3.7±1.9d。1例术后出现短暂性神经根麻痹,保守治疗1周内症状消失;6例术后症状残留,4例术后症状未改善。至末次随访时共有6例再次后路行翻修手术。术后侧隐窝角和前后径分别为39.5°±4.2°和6.2±0.4mm,均较术前显著性增加(P0.001)。所有患者均获得随访,随访时间24～32(26.6±5.6个月),术后1周、3个月、1年和末次随访时下肢痛和腰痛VAS评分、ODI均较术前显著性改善(P0.05)。末次随访时改良Macnab标准评定:优32例,良54例,一般6例,差4例,优良率为89.6%。结论:FE下可视化经椎弓根上切迹入路手术治疗腰椎侧隐窝狭窄症安全、有效,能够获得良好的短期临床疗效,但需要严格选择适应证,以免影响术后临床症状改善。     

New classification of the distal attachment of the fibularis brevis — Anatomical variations and potential clinical implications

BackgroundAlthough the lateral compartment of the leg is characterized by a high degree of morphological variation, very little information exists on the morphological variability of the fibularis brevis muscle (FBM) and fibularis digiti quinti (FDQ). The main aim of the study was to characterize the morphology of the FBM tendon and its accessory bands, to classify them and to determine the incidence of FDQ. The work attempts to determine the relationship between the types of the insertion of the FBM tendon and the occurrence of FDQ.MethodsClassical anatomical dissection was performed on 102 lower limbs fixed in 10% formalin solution. The morphology of the insertion of the FBM and of the FDQ was evaluated.ResultsThe FBM was present in all specimens. Two types of insertion were observed, the most common being Type I (70.6%): a single distal attachment in which the tendon inserts into the tuberosity at the base of the fifth metatarsal bone. The second most common was Type II (29.4%); this group was divided into three subtypes (A–C). The FDQ was present in 17.7% of specimens and always with Type I FBM.ConclusionBoth the FBM tendon and FDQ present significant morphological variation. Two main types of the FBM tendon determine the presence of the FDQ.Level of evidenceII Basic Science Research.     

Anatomical structures at risk in the arthroscopic Broström-Gould procedure: A cadaver study

BackgroundThe Broström Gould procedure is the gold standard for repair of lateral ankle ligament injury and ankle instability. This procedure has demonstrated excellent short- and long-term outcomes in the orthopedic literature. Arthroscopic Broström Gould techniques have become increasingly popular among some foot and ankle orthopedic surgeons. Typically, this technique requires standard anteromedial and anterolateral portals along with an accessory lateral working portal. The exact location of this portal is variable within the available described surgical techniques. The objective of this cadaveric study is to establish a standard entry point for and to assess the safety of the accessory lateral portal with respect to nearby anatomical structures.MethodsTen fresh-frozen below-knee cadaver specimens were used. The location of the accessory lateral portal was created 1.5 cm anterior to the distal tip of the fibula. A small vertical incision was made at this point, followed by insertion of a Kirschner wire into the joint. The wire was then gently impacted into the fibula. Superficial dissection was subsequently carried out around the entry point to identify the peroneal tendons, superficial peroneal nerve branches, and sural nerve branches. Structures were marked with colored push pins, and distance was measured between the nearest edge of the Kirschner wire and each of the three anatomic structures listed. Any instances of structural contact or damage were documented.ResultsThe average distance from the Kirschner wire to the peroneal tendon was 16.1 (±4.41) mm. The average distance from the wire to the superficial peroneal nerve and sural nerve was 13.11 (±6.79) mm and 12.33 (±4.08) mm, respectively. There were no instances of injury to any of the studied structures. However, there was a notable amount of variability in the proximity of structures in question for each cadaver. A branch of the superficial peroneal nerve was measured as close as 2 mm and as far as 24 mm in separate cadaver specimens.ConclusionArthroscopic Broström Gould procedures are a safe and effective method for lateral ankle ligamentous repair but are not without risk. Accessory lateral portal placement is relatively safe but should be meticulously executed to avoid damage to nearby anatomical structures.     

Systematic Performance Evaluation of a Cross-Correlation-Based Ultrasound Strain Imaging Method

Estimation of tissue motion in the lateral direction remains a major challenge in 2-D ultrasound strain imaging (USI). Although various methodologies have been proposed to improve the accuracy of estimation of in-plane displacements and strains, the fundamental limitations of 2-D USI and how to choose optimal algorithmic parameters in various tissue deformation paradigms to retrieve the full strain tensor of acceptable accuracy are scattered throughout the literature. Thus, this study attempts to provide a systematic investigation of a 2-D cross-correlation-based USI method in a theoretical framework. Our previously developed cross-correlation-based USI method was revisited, and additional estimation strategies were incorporated to improve in-plane displacement and strain estimation. The performance of the presented method using different matching kernel sizes (axial: from 1λ to 14λ, where λ = wavelength; lateral: from 1 to 13 pitches) and two data formats (radiofrequency and envelope) in various kinematic scenarios (normal, shear or hybrid deformation) was investigated using Field II simulations, in which coherent plane wave compounding with 64 steered angles was realized. For radiofrequency-based USI, smaller axial and larger lateral kernel sizes were preferred in scenarios with normal strains, whereas larger kernel sizes along the shearing direction and smaller ones orthogonal to the shearing direction were more suitable in scenarios with shear strains. For envelope-based USI, in contrast, the kernel size requirement was relatively relaxed. A compromise between optimal kernel sizes and estimation accuracy of various strain components was required in complex kinematic scenarios. These practical strategies for accurate motion estimation using 2-D cross-correlation-based USI were further tested in a tissue-mimicking phantom under quasi-static compression and in a preliminary in vivo examination of a normal human median nerve at the wrist during active finger motion.     

Increased Orexin Expression Promotes Sleep/Wake Disturbances in the SOD1-G93A Mouse Model of Amyotrophic Lateral Sclerosis

Background:Sleep/wake disturbances in patients with amyotrophic lateral sclerosis (ALS) are well-documented,however,no animal or mechanistic studies on these disturbances exist.Orexin is a crucial neur...     

Importance of Sample Size for the Estimation of Repeater F Waves in Amyotrophic Lateral Sclerosis

Background:

In amyotrophic lateral sclerosis (ALS), repeater F waves are increased. Accurate assessment of repeater F waves requires an adequate sample size.

Methods:

We studied the F waves of left ulnar nerves in ALS patients. Based on the presence or absence of pyramidal signs in the left upper limb, the ALS patients were divided into two groups: One group with pyramidal signs designated as P group and the other without pyramidal signs designated as NP group. The Index repeating neurons (RN) and Index repeater F waves (Freps) were compared among the P, NP and control groups following 20 and 100 stimuli respectively. For each group, the Index RN and Index Freps obtained from 20 and 100 stimuli were compared.

Results:

In the P group, the Index RN (P = 0.004) and Index Freps (P = 0.001) obtained from 100 stimuli were significantly higher than from 20 stimuli. For F waves obtained from 20 stimuli, no significant differences were identified between the P and NP groups for Index RN (P = 0.052) and Index Freps (P = 0.079); The Index RN (P < 0.001) and Index Freps (P < 0.001) of the P group were significantly higher than the control group; The Index RN (P = 0.002) of the NP group was significantly higher than the control group. For F waves obtained from 100 stimuli, the Index RN (P < 0.001) and Index Freps (P < 0.001) of the P group were significantly higher than the NP group; The Index RN (P < 0.001) and Index Freps (P < 0.001) of the P and NP groups were significantly higher than the control group.

Conclusions:

Increased repeater F waves reflect increased excitability of motor neuron pool and indicate upper motor neuron dysfunction in ALS. For an accurate evaluation of repeater F waves in ALS patients especially those with moderate to severe muscle atrophy, 100 stimuli would be required.