Thoracic outlet syndrome Kuhn, John E; Lebus V, George F; Bible, Jesse E
Journal of the American Academy of Orthopaedic Surgeons,
2015-April, Volume:
23, Issue:
4
Journal Article
Peer reviewed
Open access
Thoracic outlet syndrome is a well-described disorder caused by thoracic outlet compression of the brachial plexus and/or the subclavian vessels. Neurogenic thoracic outlet syndrome is the most ...common manifestation, presenting with pain, numbness, tingling, weakness, and vasomotor changes of the upper extremity. Vascular complications of thoracic outlet syndrome are uncommon and include thromboembolic phenomena and swelling. The clinical presentation is highly variable, and no reproducible study exists to confirm the diagnosis; instead, the diagnosis is based on a physician's judgment after a meticulous history and physical examination. Both nonsurgical and surgical treatment methods are available for thoracic outlet syndrome. Whereas nonsurgical management appears to be effective in some persons, surgical treatment has been shown to provide predictable long-term cure rates for carefully selected patients. In addition, physicians who do not regularly treat patients with thoracic outlet syndrome may not have an accurate view of this disorder, its treatment, or the possible success rate of treatment.
Background:
The effect of prior meniscectomy and the resulting reduction in meniscal tissue on a potential National Football League (NFL) player’s articular cartilage status and performance remain ...poorly elucidated.
Purpose/Hypothesis:
(1) To determine the epidemiology, imaging characteristics, and associated articular cartilage pathology of the knee among players with a previous meniscectomy who were participating in the NFL Combine and (2) to evaluate the effect of these injuries on performance as compared with matched controls. The hypothesis was that players with less meniscal tissue would have worse cartilage status and inferior performance metrics in their first 2 NFL seasons.
Study Design:
Cohort study; Level of evidence, 3.
Methods:
All athletes with a history of a meniscectomy and magnetic resonance imaging scan of the knee who participated in the NFL Combine (2009-2015) were identified. Medical records and imaging were analyzed, and surgical history, games missed in college, position played, and draft position were documented. The conditions of the meniscus and cartilage were graded with modified ISAKOS scores (International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine) and ICRS scores (International Cartilage Repair Society), respectively. Players with a previous meniscectomy of at least 10% of total medial or lateral meniscal volume excised (ISAKOS meniscus grade ≤8) and matched controls without a significant pre-Combine injury were similarly evaluated and compared by position of play through analysis of draft position, number of games played and started, and how many eligible plays they participated in (snap percentage) within the first 2 NFL seasons.
Results:
Of the 2285 players who participated in the NFL Combine (2009-2015), 287 players (322 knees) had a prior meniscectomy (206 lateral, 81 medial). Among these players, 247 (85%) had a total of 249 chondral lesions, most commonly on the lateral femoral condyle (111 lesions, 45%). There was a significant inverse correlation found between the ISAKOS medial and lateral meniscus grade and the corresponding compartment chondral lesion grade (P = .001). A poorer meniscus score was also associated with worse chondral pathology, especially in the lateral compartment. After controlling for position of play, the injury-free control group had a significantly greater number of total games played and games started and higher snap percentage versus those with a prior meniscectomy of at least 10% volume (ISAKOS meniscus grade ≤8). Players with severe chondral lesions (ICRS grade 4) in the medial and lateral compartments had significantly worse performance metrics when compared with matched controls.
Conclusion:
Previous meniscectomy of at least 10% of total medial or lateral meniscus volume in prospective NFL players was significantly correlated with larger and more severe chondral lesions. Chondral and meniscal defects of the knee were found to result in a significant decrease in objective performance measures during a player’s initial NFL career versus matched controls. Given these findings, players with a prior meniscectomy with evidence of chondral damage should be evaluated carefully for their overall functional levels; however, additional work is needed to fully clarify the effect of prior knee meniscal surgery on overall NFL performance.
Background:
Acetabular labral reconstruction has demonstrated good results for labral lesions not amenable to labral repair.
Purpose:
To determine the predictors of outcomes at a minimum 2 years ...after labral reconstruction.
Study Design:
Case series; Level of evidence, 4.
Methods:
Patients included in the study underwent labral reconstruction with a minimum 2-year follow-up. The primary outcome variable was the Hip Outcome Score–Activities of Daily Living (HOS-ADL). Secondary outcome measures included the 12-item Short Form Health Survey physical component summary (SF-12 PCS) and patient satisfaction with surgical outcomes. Preoperative and intraoperative variables assessed included demographics, prior surgery, chronicity of symptoms, radiographic measurements, preoperative outcome scores, and findings at arthroscopic surgery. Predictors were assessed using logistic regression with restricted cubic splines. Bivariate statistics assessed risk factors for reoperation including revision arthroscopic surgery and total hip arthroplasty (THA).
Results:
Three hundred seventeen of 368 labral reconstructions were available for follow-up (86.1%). Of these, 42 were converted to THA (13.2%) and 35 required revision arthroscopic surgery after labral reconstruction (11.0%). Factors associated with THA included older age, ≥2 previous surgeries, ≤2 mm of joint space, and lateral center edge angle (LCEA) <25°. Factors associated with revision included female sex, ≥2 previous surgeries, and LCEA <25°. Six patients refused to participate (1.9%), leaving 234 with a minimum follow-up of 2 years (mean, 3.7 years range, 2.0-11.3 years). These patients had significant improvement in HOS-ADL (71 to 90; P < .001), HOS-Sport (47 to 75; P < .001), Western Ontario and McMaster Universities Osteoarthritis Index (27 to 9; P < .001), modified Harris Hip Score (65 to 85; P < .001), and SF-12 PCS scores (41.6 to 53.1; P < .001). Median postoperative satisfaction was 9. Predictors of improvement for the HOS-ADL included higher preoperative HOS-ADL scores (P < .001), joint space >2 mm (P = .004), and no prior surgery (P = .039). Predictors of improvement for the SF-12 PCS included higher preoperative SF-12 PCS scores (P < .001), subacute chronicity (3 months to 1 year) of symptoms (P = .013), and joint space >2 mm (P = .046). Joint space >2 mm (P < .001) and higher preoperative SF-12 scores (PCS: P = .034; mental component summary: P = .039) predicted higher satisfaction.
Conclusion:
At a minimum 2 years’ follow-up, patients who did not undergo conversion to THA (13.2%) or require revision (11.0%), reported significant improvement in outcome scores and high satisfaction with outcomes. Predictors of revision or THA included ≥2 previous surgeries, low LCEA, female sex for revision, and narrowed joint space for THA. Higher preoperative outcome scores were the most significant predictors of improvement after labral reconstruction. Lower preoperative scores, joint space narrowing, and history of surgery were predictive of an inferior result and decreased postoperative satisfaction.
To perform a quantitative anatomic evaluation of the (1) coracoid process, specifically the attachment sites of the conjoint tendon, the pectoralis minor, the coracoacromial ligament (CAL), and the ...coracoclavicular (CC) ligaments in relation to pertinent osseous and soft tissue landmarks; (2) CC ligaments' attachments on the clavicle; and (3) CAL attachment on the acromion in relation to surgically relevant anatomic landmarks to assist in planning of the Latarjet procedure, acromioclavicular (AC) joint reconstructions, and CAL resection distances avoiding iatrogenic injury to surrounding structures.
Ten nonpaired fresh-frozen human cadaveric shoulders (mean age 52 years, range 33-64 years) were included in this study. A 3-dimensional coordinate measuring device was used to quantify the location of pertinent bony landmarks and soft tissue attachment areas. The ligament and tendon attachment perimeters and center points on the coracoid, clavicle, and acromion were identified and subsequently dissected off the bone. Coordinates of points along the perimeters of attachment sites were used to calculate areas, whereas coordinates of center points were used to determine distances between surgically relevant attachment sites and pertinent bony landmarks.
The CAL had a single consistent acromial attachment (mean area 77 mm 51.9, 102.2) and then bifurcated into 2 bundles, anterior and posterior, that separately inserted on the lateral aspect of the coracoid. The footprint areas were 54.4 mm2 31.7, 77.2 and 30.6 mm2 23.4, 37.7 for the anterior and posterior CAL bundles, respectively. These anterior and posterior bundles attached 10.6 mm 8.4, 12.9 and 24.8 mm 12.3, 27.4 medial and proximal to the apex of the coracoid process, respectively. The minimum distance between the coracoid apex and the trapezoid ligament was 25.1 mm 22.1, 28.1 and was noted to be different in males (28.1 mm 25.1; 31.2) and females (22.0 mm 18.2, 25.9). The most lateral insertion of the CC ligaments on the clavicle the AC joint was 15.7 mm 13.1, 18.3. The distance between the most medial to the most lateral point of the CC ligaments on the clavicle was 25.6 mm 22.3, 28.9, which accounted for 18.2% 15.8, 20.6 of the clavicle length.
In contrast to previous findings, 2 different coracoid attachments (anterior and posterior bundles) of the CAL were consistently identified in all specimens. Moreover, a coracoid osteotomy for a bone graft for the Latarjet procedure should be performed at less than 28.1/22 mm from the apex of the coracoid in male/female patients, respectively. The CC ligaments' attachments on the clavicle were located 15.7 mm from the AC joint, which should be considered for reconstruction.
During the Latarjet technique, to maintain the integrity of the CC ligaments, precise knowledge of differences between male and female anatomy is necessary during a coracoid osteotomy. Furthermore, when reconstructing the AC joint, the distance from the lateral aspect of the clavicle and the size of the attachments areas should be considered to better replicate the native anatomy.
To evaluate whether augmenting traditional fixation with a femoral neck buttress plate (FNBP) improves clinical outcomes in young adults with high-energy displaced femoral neck fractures.
Multicenter ...retrospective matched cohort comparative clinical study.
Twenty-seven North American Level 1 trauma centers.
Adult patients younger than 55 years who sustained a high-energy (nonpathologic) displaced femoral neck fracture.
Operative reduction and stabilization of a displaced femoral neck fracture with (group 1) and without (group 2) an FNBP.
Complications including failed fixation, nonunion, osteonecrosis, malunion, and need for subsequent major reconstructive surgery (early revision of reduction and/or fixation), proximal femoral osteotomy, or arthroplasty.
Of 478 patients younger than 55 years treated operatively for a displaced femoral neck fracture, 11% (n = 51) had the definitive fixation augmented with an FNBP. One or more forms of treatment failure occurred in 29% (n = 15/51) for group 1 and 49% (209/427) for group 2 ( P < 0.01). When FNBP fixation was used, mini-fragment (2.4/2.7 mm) fixation failed significantly more often than small-fragment (3.5 mm) fixation (42% vs. 5%, P < 0.01). Irrespective of plate size, anterior and anteromedial plates failed significantly more often than direct medial plates (75% and 33% vs. 9%, P < 0.001).
The use of a femoral neck buttress plate to augment traditional fixation in displaced femoral neck fractures is associated with improved clinical outcomes, including lower rates of failed fixation, nonunion, osteonecrosis, and need for secondary reconstructive surgery. The benefits of this technique are optimized when a small-fragment (3.5 mm) plate is applied directly to the medial aspect of the femoral neck, avoiding more anterior positioning .
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
As the anterior intrapelvic approach (AIP or modified Stoppa) has become more popular, its utility has evolved to address specific problems that are not well addressed by the ilioinguinal approach. ...These include anterior column (AC) fractures associated with medialization of the femoral head (protrusio) and impaction of the superomedial acetabular dome. If left unaddressed, these problems may lead to poor clinical outcomes. The AIP approach, in contrast to the ilioinguinal approach, takes a more direct path to the medial elements of the AC in the true pelvis. This exposure allows access to the impacted dome segment through the displaced AC fracture and wide visualization of the quadrilateral surface, which in turn allows direct reduction and optimal implant placement to neutralize the fracture's deforming forces. The purpose of this article is to discuss the reduction of dome impaction and the quadrilateral surface using the AIP approach.
To provide a quantitative and qualitative anatomic analysis of the pectoralis major, teres major, and latissimus dorsi on the humerus, as well as the deltoid tendinous attachments on the proximal ...humerus and acromion, and to quantitatively characterize the humeral course of the axillary nerve.
Ten nonpaired, fresh-frozen human cadaveric shoulders were analyzed. A portable coordinate-measuring device quantified the location of bony landmarks and tendon attachment areas. The tendon footprints were recorded by tracing their outlines and center points. The footprint areas of the tendons, the distances between the footprint areas and pertinent osseous and soft-tissue landmarks, and the distance between where the axillary nerve courses across the humerus relative to the acromion and greater tuberosity were measured.
Of the 10 specimens, 9 (90%) had 5 distinct tendinous bands attaching the deltoid to the acromion; 1 specimen had 4 bands. The distances between the center of the deltoid footprint on the humerus and the centers of the pectoralis major, latissimus dorsi, and teres major tendon footprints on the humerus were 43.5 mm, 58.5 mm, and 49.4 mm, respectively. The shortest distances from the perimeter of the pectoralis major to the latissimus dorsi and teres major tendon footprints were 3.9 mm and 9.5 mm, respectively. The distance from the superior aspect of the greater tuberosity to the axillary nerve on the humeral shaft was 50.3 mm (95% confidence interval, 47.0-53.5 mm). The distance from the lateral acromion to the axillary nerve was 69.3 mm (95% confidence interval, 64.1-74.5 mm).
The deltoid muscle had 4 to 5 tendinous insertions on the acromion, and the axillary nerve was 50.3 mm from the tip of the greater tuberosity. The distance between the lower border of the pectoralis major and the axillary nerve was 9.4 mm.
Knowledge of the quantitative anatomy of the tendons of the proximal humerus and axillary nerve can aid in identifying structures of interest during open shoulder surgery and in avoiding iatrogenic axillary nerve injury. Furthermore, this study provides direction to avoid injury to the deltoid tendons during open surgery.
Abstract Chronic anterior shoulder instability due to structural failure of the subscapularis muscle and the anterior capsule is a rare and challenging diagnosis for surgeons to manage because ...poor-quality capsular, labral, and rotator cuff tissue often limits effective treatment options. If primary repair is not possible because of retraction and poor tissue quality, reconstruction with an allograft or autograft may be the only joint-preserving option. The purpose of this article is to describe a surgical technique for anterior capsular reconstruction using a human acellular dermal allograft for the treatment of irreparable subscapularis tears.
To evaluate the effect of technical errors (TEs) on the outcomes after repair of femoral neck fractures in young adults.
Multicenter retrospective clinical study.
26 North American Level 1 Trauma ...Centers.
Skeletally mature patients younger than 50 years of age with 492 femoral neck fractures treated between 2005 and 2017.
Operative repair of femoral neck fracture.
The association between TE (malreduction and deviation from optimal technique) and treatment failure (fixation failure, nonunion, malunion, osteonecrosis, malunion, and revision surgery) were examined using logistic regression analysis.
Overall, a TE was observed in 50% (n = 245/492) of operatively managed femoral neck fractures in young patients. Two or more TEs were observed in 10% of displaced fractures. Treatment failure in displaced fractures occurred in 27% of cases without a TE, 56% of cases with 1 TE, and 86% of cases with 2 or more TEs. TEs were encountered less frequently in treatment of nondisplaced fractures compared with displaced fractures (39% vs. 53%, P < 0.001). Although TE(s) in nondisplaced fractures increased the risk of treatment failure and/or major reconstructive surgery (22% vs. 9%, P < 0.001), they were less frequently associated with treatment failure when compared with displaced fractures with a TE (22% vs. 69% P < 0.001).
TEs were found in half of all femoral neck fractures in young adults undergoing operative repair. Both the occurrence and number of TEs were associated with an increased risk for failure of treatment. Preoperative planning for thoughtful and well-executed reduction and fixation techniques should lead to improved outcomes for young patients with femoral neck fractures. This study should also highlight the need for educational forums to address this subject.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Abstract Quadriceps tendinopathy in an increasingly recognized diagnosis can lead to quadriceps tendon rupture, especially in the older population. It can be caused by repeated micro trauma or also ...predisposed by systemic diseases such as diabetes mellitus and connective tissue disorders that can in turn lead to extensor mechanism deficits. Although a trial of conservative treatment is advocated, operative treatment should be performed in cases of persistent pain, extension deficit, or complete rupture of the tendon. The purpose of this Technical Note is to describe in detail a procedure for open repair of a quadriceps tendon, with significant degeneration due to quadriceps tendinopathy, using suture anchors and semitendinosus tendon allograft augmentation.
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