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Arthroscopic treatments of hip synovial osteochondromatosis are mostly performed under traction, resulting in neurovascular injury or iatrogenic damage to the labrum or cartilage. This study aimed to assess the effectiveness of outside‐in hip arthroscopy without traction in treating hip synovial osteochondromatosis. This retrospective study was conducted on a series of patients with hip synovial osteochondromatosis treated using outside‐in hip arthroscopy without traction in our hospital between 2018 and 2020. Plain radiography and magnetic resonance imaging (MRI) scans were obtained. The Harris hip score (HHS), hip range of motion (ROM), and visual analog scale (VAS) scores were analyzed. The preoperative scores and last follow‐up scores were compared with a paired‐sample t test. The complications and recurrence postsurgery were recorded. This study included five patients (three male and two female) with an average age of 41 years (range 28–54 years). The mean follow‐up time was 25.2 months (range 18–36 months). All patients experienced groin pain relief and improved ROM. The mean VAS score was significantly lower postoperatively (0.4 ± 0.5) than preoperatively (3.2 ± 0.8) (p < 0.001). The mean HHS improved from 58.6 ± 12.7 (range 43–73) to 89.8 ± 5.26 (range 81–95) (p < 0.001). No major complications, including infection, perineal numbness and swelling, neurotrosis, thromboembolism, or severe persistent pain, were reported. Synovial osteochondromatosis recurred in one patient after 2 years of follow‐up without any obvious symptoms such as hip pain or joint locking. Therefore, no further treatment was necessary. This study showed that outside‐in hip arthroscopy without traction might be a viable option for treating hip synovial osteochondromatosis, effectively and safely relieving symptoms with minimal complications, especially in patients without lesions in the central compartment. [ABSTRACT FROM AUTHOR]

MicroRNAs (miRNA) are endogenously produced small, non-coded, single-stranded RNAs. Due to their involvement in various cellular processes and cross-communication with extracellular components, miRNAs are often coined the "grand managers" of the cell. miRNAs are frequently involved in upregulation as well as downregulation of specific gene expression and thus, are often found to play a vital role in the pathogenesis of multiple diseases. Central nervous system (CNS) diseases prove fatal due to the intricate nature of both their development and the methods used for treatment. A considerable amount of ongoing research aims to delineate the complex relationships between miRNAs and different diseases, including each of the neurological disorders discussed in the present review. Ongoing research suggests that specific miRNAs can play either a pathologic or restorative and/or protective role in various CNS diseases. Understanding how these miRNAs are involved in various regulatory processes of CNS such as neuroinflammation, neurovasculature, immune response, blood-brain barrier (BBB) integrity and angiogenesis is of empirical importance for developing effective therapies. Here in this review, we summarized the current state of knowledge of miRNAs and their roles in CNS diseases along with a focus on their association with neuroinflammation, innate immunity, neurovascular function and BBB. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare the fused and normal sides of patients who have fused hips to determine the differences in neurovascular structures and factors that increase the risk of neurovascular injury. We evaluated 38 patients who underwent total hip arthroplasty, with a fused hip between 2003 and 2021. Excluding patients who had bilateral lesions, differences in the location of neurovascular structures were measured by comparing the fused side with the normal side. The position of neurovascular structures was measured by the distance from the acetabular rim and the shortest distance to the particular bony structure. In addition, the patient's sex, weight, body mass index cause of fused hips, estimated age of fusion onset, and preoperative range of motion were investigated to examine the correlations with neurovascular deviation and these factors. The neurovascular distances for all the measured neurovascular structures were significantly reduced on the fused side compared with the normal side. Sex-based analysis revealed that women had significantly shorter distances to the femoral neurovascular bundle than men. Although height and body weight were associated with differences in neurovascular distances, body mass index was not associated with significant differences, except for the femoral nerve distance from the nearest bone. When classified by the estimated age of fusion onset, significant differences in neurovascular distances were found between the adolescent- and adult-onset groups. In patients who have fused hips, neurovascular structures are located closer to the bone than on the normal side. Moreover, patients in whom the fusion occurred before the completion of growth may exhibit a shorter neurovascular distance, thereby increasing the potential risk of direct injury during total hip arthroplasty. [ABSTRACT FROM AUTHOR]

Arthroscopic treatments of hip synovial osteochondromatosis are mostly performed under traction, resulting in neurovascular injury or iatrogenic damage to the labrum or cartilage. This study aimed to assess the effectiveness of outside‐in hip arthroscopy without traction in treating hip synovial osteochondromatosis. This retrospective study was conducted on a series of patients with hip synovial osteochondromatosis treated using outside‐in hip arthroscopy without traction in our hospital between 2018 and 2020. Plain radiography and magnetic resonance imaging (MRI) scans were obtained. The Harris hip score (HHS), hip range of motion (ROM), and visual analog scale (VAS) scores were analyzed. The preoperative scores and last follow‐up scores were compared with a paired‐sample t test. The complications and recurrence postsurgery were recorded. This study included five patients (three male and two female) with an average age of 41 years (range 28–54 years). The mean follow‐up time was 25.2 months (range 18–36 months). All patients experienced groin pain relief and improved ROM. The mean VAS score was significantly lower postoperatively (0.4 ± 0.5) than preoperatively (3.2 ± 0.8) (p

Background: Rupture of the pectoralis major (PM) tendon is infrequent but has shown an increased incidence in athletes, particularly weightlifters during bench presses. Various techniques for repair exist, yet no established gold standard has been defined. Methods: We present a modified surgical technique utilizing knotless suture anchors for PM tendon repair. The technique involves bringing the tendon end superiorly and inferiorly to the decorticated bone surface, ensuring broader tendon-to-bone contact. Knotless anchors with a unique suture locking mechanism facilitate tension adjustment. Additionally, the repair's strength is reinforced by employing both surgical tape and high-strength suture. Results: The utilization of both surgical tape and high-strength suture in conjunction with knotless suture anchors provides a secure and stable construct. This approach minimizes the risk of failure, reduces the potential for neurovascular injury associated with bicortical drilling, preserves imaging quality due to the absence of metal artifacts, and helps avoid the risk of fracture associated with traditional methods. However, surgeons should be aware of a potential disadvantage of increased surgical costs compared to traditional techniques. Conclusion: Our modified technique offers multiple advantages, including increased tendon-to-bone contact, enhanced stability, reduced neurovascular risks, and avoidance of potential fractures. This makes it a valuable option for successful PM tendon repairs. Surgeons should consider its benefits and weigh them against the associated costs for optimal patient care.

Many spine surgeons are not optimally acquainted with anatomy anterior to sacrum. Screw malposition injuring these structures can lead to unwanted lethal consequences. We report unusual cases of acute radiculopathy due to misplaced bicortical sacral screw causing L5 nerve root impingement on anterior sacrum. A 39/M patient complained of severe rest pain (VAS 9/10) post TLIF in region of L5 dermatome with sensory deficit along the right lateral leg and straight leg raise less than 30°. X-ray revealed S1 screw protruding beyond the second cortex with a straight trajectory. CT scan revealed a protrusion of 11.4mm beyond anterior cortex. The patient was taken for re-surgery and the trajectory and length of screw was revised. Sciatic pain completely disappeared immediately after surgery. A 61/M patient operated elsewhere with instrumented decompression and fusion with screws passed at L4, L5 and S1 level for lumbar canal stenosis, post-surgery patient developed new onset radicular symptoms in right lower limb. Patient was managed conservatively in the form of L5 selective nerve root block. Pain and numbness improved. Bicortical purchase of S1 screw though improves pull out strength, is associated with a risk of neurovascular complications. Surgeons should be alerted to the misplacement of S1 pedicle screws to avoid involvement not only anterior to the anteromedial neurovascular tissue, but also anterolateral to the arrangement of the L5 nerve root. [ABSTRACT FROM AUTHOR]

Ultrasound is a useful modality for guiding injections and other procedures in the extremities. Its portability and the ability to adjust the probe and needle in real time, as well as lack of radiation exposure make it preferable for many routine procedures. However, ultrasound is highly operator dependent and a firm understanding of regional anatomy is important, including neurovascular structures that are in close proximity during many of these procedures. Knowledge of the characteristic location and appearance of neurovascular structures in the extremities allows safe needle advancement and prevention of iatrogenic complications. [ABSTRACT FROM AUTHOR]

Abstract Background Femoral neurovascular injury is a serious complication in a direct anterior approach (DAA) total hip arthroplasty. However, dynamic neurovascular bundle location changes during the approach were not examined. Thus, this study aimed to analyze the effects of leg position on the femoral neurovascular bundle location using magnetic resonance imaging (MRI). Methods This study scanned 30 healthy volunteers (15 males and 15 females) with 3.0T MRI in a supine and 30-degree hip extension position with the left leg in a neutral rotation position and the right leg in a 45-degree external extension position. The minimum distance from the edge of the anterior acetabulum to the femoral nerve (dFN), artery, and vein were measured on axial T1-weighted images at the hip center level, as well as the angle to the horizontal line of the femoral nerve (aFN), artery (aFA), and vein from the anterior acetabulum. Results The dFN in the supine position with external rotation was significantly larger than supine with neutral and extension with external rotation position (20.7, 19.5, and 19.0; p = 0.031 and 0.012, respectively). The aFA in supine with external rotation was significantly larger than in other postures (52.4°, 34.2°, and 36.2°, p

Background: Femoral neurovascular injury is a serious complication in a direct anterior approach (DAA) total hip arthroplasty. However, dynamic neurovascular bundle location changes during the approach were not examined. Thus, this study aimed to analyze the effects of leg position on the femoral neurovascular bundle location using magnetic resonance imaging (MRI). Methods: This study scanned 30 healthy volunteers (15 males and 15 females) with 3.0T MRI in a supine and 30-degree hip extension position with the left leg in a neutral rotation position and the right leg in a 45-degree external extension position. The minimum distance from the edge of the anterior acetabulum to the femoral nerve (dFN), artery, and vein were measured on axial T1-weighted images at the hip center level, as well as the angle to the horizontal line of the femoral nerve (aFN), artery (aFA), and vein from the anterior acetabulum. Results: The dFN in the supine position with external rotation was significantly larger than supine with neutral and extension with external rotation position (20.7, 19.5, and 19.0; p = 0.031 and 0.012, respectively). The aFA in supine with external rotation was significantly larger than in other postures (52.4°, 34.2°, and 36.2°, p < 0.001, respectively). The aFV in supine with external rotation was significantly larger than in supine with a neutral position (52.3° versus 47.7°, p = 0.037). The aFN in supine and external rotation was significantly larger than other postures (54.6, 38.2, and 33.0, p < 0.001, respectively). Conclusions: This radiographic study revealed that the leg position affected the neurovascular bundle location. These movements can be the risk of direct neurovascular injury or traction. [ABSTRACT FROM AUTHOR]

BackgroundSupracondylar humerus fractures are the most common type of pediatric elbow fracture, accounting for 60-70% of all elbow fractures in children. Initial trauma and subsequent fracture displacement may damage surrounding neurovascular structures, leading to reports of associated neurovascular injury at rates as high as 49%, with vascular compromise reported in 3-19% of cases. This may be attributable to complete transection, kinking of the artery with reduced flow, thrombosis, intimal tear, arterial contusion or spasm, entrapment of the vessel within the fracture site or traumatic aneurysm of the brachial artery with subsequent thrombus formation.PurposeWhile there is general agreement that a child presenting with a pulseless white (dysvascular) hand associated with a displaced supracondylar humerus fracture requires emergent operative management, whether or not surgical exploration of the brachial artery is warranted in a patient with a pulseless pink hand is debatable. Given the lack of consensus, an individualized approach based on clinical findings at initial presentation, including quality of distal perfusion including doppler signal, associated median nerve injury, availability of a surgeon with microvascular skill-set, and access to vigilant post-operative monitoring, combined with an open discussion of the pros and cons of various treatment options with the family is prudent.MethodsHerein we outline our management principles, developed with careful consideration of the available literature and informed by practical experience.ResultsWe recommend emergent management of pulseless supracondylar fractures, especially those that present with a pulseless white hand or with a dense median nerve palsy, with operative fracture reduction and fixation. In all children presenting with a pulseless supracondylar humerus fracture, the vascular status should be reassessed after adequate fracture reduction and fixation, and in patients with continued signs of abnormal distal perfusion, such as weak or absent Doppler signals or sluggish capillary refill, surgical exploration of the brachial artery with reestablishment of adequate distal flow should be conducted immediately.ConclusionMuch of the existing evidence surrounding the supracondylar humerus fracture associated with a pink, pulseless hand is of low quality. This shortcoming should serve as an impetus for establishment of an international registry of all dysvascular pediatric supracondylar fractures, with adequate documentation of the vascular exam before and after reduction, intra-operative and post-operative management and long term follow-up, to provide optimal management guidelines based on robust evidence.

Background: Robotic-assisted total knee arthroplasty may result in array pin-related complications. Lack of knowledge on ideal pin placement results in varied insertion sites and trajectory, with unknown risks to surrounding neurovascular structures. Methods: This study included 10 lower-extremity magnetic resonance images. Images were subdivided into 6 zones of study. Zones consisted of a correlating axial image with femoral pin placement replicated by drawing a line angled 45° from the anterior to posterior reference in the anteromedial to posterolateral femoral quadrants. The distances from the pin paths to the neurovascular structures were measured. Results: Zone 2C demonstrated femoral pin trajectory an average of 14 mm from the femoral artery/vein. In Zone 2B, proximity increased to an average of 30 mm to the femoral artery and 29 mm to the femoral vein. At Zone 1A, the popliteal artery and vein were on average 22 mm from the femoral pin, while the common peroneal nerve was an average of 21 mm. Placing pins in Zone 1A poses a high risk of injury to the genicular arteries. Women demonstrated greater proximity to neurovascular structures than men in 66% of the sites (P < .05). Conclusions: This classification system for safe zones and trajectory of femoral pin placement in robotic-assisted total knee arthroplasty demonstrates that proximally, the profunda femoris and femoral artery/vein are at risk of injury, while distally, the genicular arteries, common peroneal nerve, and popliteal artery/vein are at risk. Caution should be exercised if femoral pins are inserted with an angle less than 45°, especially in women.

Abstract Background Iatrogenic injury to the radial nerve is a risk in surgical treatment for extraarticular fractures of the middle and distal third of the humerus. We aimed to investigate the safety, feasibility and advantages of minimally invasive percutaneous plate osteosynthesis (MIPPO) via an anteromedial approach in the treatment of middle and middle-distal humeral fractures and to evaluate proximity to neurovascular structures. Materials and methods In 2016, 13 adult cadaver arms were used to simulate a minimally invasive surgical approach to the anteromedial humerus followed by fixation with a locking compression plate (LCP), and several sets of anatomical data were measured to clarify the possible risk of iatrogenic vascular and nerve injury in this surgical approach. Then, a case series study of 12 patients with humeral fractures who were treated with this surgical approach was conducted between 2017 and 2020. Results The average humeral length was 29.22 ± 1.62 cm, the average width of the medial epicondyle of the humerus was 1.31 ± 0.17 cm, and the average distance from the vertex of the medial epicondyle to the median nerve was 2.96 ± 1.62 cm. Furthermore, the safe area for distal humeral screw placement was 6.28 ± 0.39 cm, and the average distance from the tip of the distal end of the screw in the medial epicondyle to the ulnar nerve was 1.7 ± 1.25 mm. None of the 12 patients had nerve damage or an incisional infection after the operation. Conclusions The new approach was performed as described, and no cases of iatrogenic nerve palsy occurred. This approach can be used as an alternative for the treatment of extraarticular fractures of the middle and distal thirds of the humerus. Level of Evidence: Level IV, therapeutic study.

Anatomical knowledge of the occipital condyle (OC) and its relationships to surrounding structures is important for avoiding injury during craniovertebral junction (CVJ) surgeries. This study was conducted to evaluate the morphology and morphometry of OC and its relationship to foramen magnum, jugular foramen (JF), and hypoglossal canal (HC). Morphometric parameters including length, width, height, and distances from the OC to surrounding structures were measured. The oval-like condyle was the most common OC shape, representing for 33.0% of all samples. The mean length, width and height of OC were 21.3±2.4, 10.5±1.4, and 7.4±1.1 mm, respectively. Moreover, OC was classified into three types based on its length. The most common OC length in both sexes was moderate length or type II (62.5%). The mean distance between anterior tips and posterior tips of OC to basion, and opisthion were 11.5±1.4, 39.1±3.3, 25.2±2.2, and 27.4±2.7 mm, respectively. The location of intracranial orifice of HC was commonly found related to middle 1/3 of OC in 45.0%. JF was related to the anterior 2/3 of OC in 81.0%, the anterior 1/3 of OC in 12.5%, and the entire OC length in 6.5%. These morphological analysis and morphometric data should be taken into consideration before performing surgical operation to avoid CVJ instability and neurovascular structure injury [ABSTRACT FROM AUTHOR]

Background: Iatrogenic injury to the radial nerve is a risk in surgical treatment for extraarticular fractures of the middle and distal third of the humerus. We aimed to investigate the safety, feasibility and advantages of minimally invasive percutaneous plate osteosynthesis (MIPPO) via an anteromedial approach in the treatment of middle and middle-distal humeral fractures and to evaluate proximity to neurovascular structures. Materials and methods: In 2016, 13 adult cadaver arms were used to simulate a minimally invasive surgical approach to the anteromedial humerus followed by fixation with a locking compression plate (LCP), and several sets of anatomical data were measured to clarify the possible risk of iatrogenic vascular and nerve injury in this surgical approach. Then, a case series study of 12 patients with humeral fractures who were treated with this surgical approach was conducted between 2017 and 2020. Results: The average humeral length was 29.22 ± 1.62 cm, the average width of the medial epicondyle of the humerus was 1.31 ± 0.17 cm, and the average distance from the vertex of the medial epicondyle to the median nerve was 2.96 ± 1.62 cm. Furthermore, the safe area for distal humeral screw placement was 6.28 ± 0.39 cm, and the average distance from the tip of the distal end of the screw in the medial epicondyle to the ulnar nerve was 1.7 ± 1.25 mm. None of the 12 patients had nerve damage or an incisional infection after the operation. Conclusions: The new approach was performed as described, and no cases of iatrogenic nerve palsy occurred. This approach can be used as an alternative for the treatment of extraarticular fractures of the middle and distal thirds of the humerus. Level of Evidence: Level IV, therapeutic study. [ABSTRACT FROM AUTHOR]

Introduction: This simulation study on MRI of the knee was performed to assess the risk of injury to the popliteal artery (PA) and common peroneal nerve (CPN) during all-inside meniscal repairs in adults. Methods: We simulated repair of the posterior horn of both medial (PHMM) and lateral menisci (PHLM) through anteromedial (AM) and anterolateral (AL) portals, using straight and curved devices, on 200 magnetic resonance imaging (MRI) scans taken with the knee in extension. For simulation using straight devices, the shortest distance from the menisco-capsular junction (MCJ) and the free edge of the meniscus to PA and CPN in vectors of AM and AL portals was measured. In curved devices, the closest extracapsular distance from the device tip to PA was measured. Results: With a straight device through AM portal, the mean distance from the MCJ of PHMM to the PA was 20.7 ± 3.15 mm (13.5–27.4). In PHMM repair through AM portal using a curved device, the mean extracapsular distance from the device tip to PA was 18.8 ± 4 mm (7.7–27.2) while pointing toward and 26 ± 4.5 mm (15.5–35.6) while pointing away from the midline. When using straight devices, the average distance from free edge of LM to PA was 18.5 ± 3.3 mm (9.6–31.2) and from MCJ to PA was 8.9 ± 2.4 mm (3.5–18.8). The average distance measured from the MCJ to CPN through AM and AL portals using straight devices was 19.4 ± 2.8 mm (10.2–32.5) and 22 ± 2.8 mm (10.4–36.7) respectively. Conclusion: In adults, PA is safe in PHMM repairs using both straight and curved devices irrespective of depth and direction of insertion. In PHLM repairs, the PA is at risk with both straight and curved devices. We recommend adjusting the depth of insertion to as minimum as possible to just penetrate the capsule. The CPN is safe in LM repairs using all-inside devices. Level of Evidence: Level IV. [ABSTRACT FROM AUTHOR]

To explore how cerebral microbleeds (CMBs) accompanying mild traumatic brain injury (mTBI) reflect white matter (WM) degradation and cognitive decline, magnetic resonance images were acquired from 62 mTBI adults (imaged ∼ 7 days and ∼ 6 months post-injury) and 203 matched healthy controls. On average, mTBI participants had a count of 2.7 ± 2.6 traumatic CMBs in WM, located 6.1 ± 4.4 mm from cortex. At ∼ 6-month follow-up, 97% of CMBs were associated with significant reductions (34% ± 11%, q < 0.05) in the fractional anisotropy of WM streamlines within ∼ 1 cm of CMB locations. Male sex and older age were significant risk factors for larger reductions (q < 0.05). For CMBs in the corpus callosum, cingulum bundle, inferior and middle longitudinal fasciculi, fractional anisotropy changes were significantly and positively associated with changes in cognitive functions mediated by these structures (q < 0.05). Our findings distinguish traumatic from non-traumatic CMBs by virtue of surrounding WM alterations and challenge the assumption that traumatic CMBs are neurocognitively silent. Thus, mTBI with CMB findings can be described as a clinical endophenotype warranting longitudinal cognitive assessment. [ABSTRACT FROM AUTHOR]

Amaç: Ateşli silah yaralanmaları sonucu ekstremitede yumuşak doku, nörovasküler yaralanmalar ve kemik kırıkları görülmektedir. Bu yaralanmaların şiddete yönelik olması ve adli olayların gençlerde daha sık görülmesi tedaviyi daha da zorlaştırmaktadır. Bu çalışmadaki amacımız, ateşli silahlarla ilişkili ekstremite yaralanmalarında nörovasküler, yumuşak doku yaralanmaları ve kemik kırıklarına aşamalı bir yaklaşımın nihai tedavi sonuçlarına etkisini değerlendirmektir. Gereç ve Yöntem: Bu çalışmada 2015-2020 yılları arasında ateşli silahla ilişkili ekstremite yaralanması olan ve cerrahi tedavi uygulanan 18 yaş üstü hastalar retrospektif olarak değerlendirildi. Hastaların demografik özellikleri, yaralanma bölgeleri, eşlik eden nörovasküler yaralanmalar, ilk müdalede yapılanlar, son tedavi sonuçları, gelişen komplikasyonlar ve komplikasyonların yönetimi değerlendirildi. Bulgular: Çalışmaya katılan 54 hastanın (52 erkek, 2 kadın) yaş ortalaması 28.3 (yaş aralığı 19-61) idi. Otuz iki (%59.2)’si alt ekstremite, 22 (%40.7)’si üst ekstremite ve 5 (%9.2)’i hem alt hem üst ekstremite yaralanması tespit edildi. Üç (%5.5) hastada damar yaralanması, 3 (%5.5) hastada amputasyon ve 6 (%11.1) hastada sinir yaralanması tespit edildi. Altı hastanın beşine (%9,2) fasyotomi uygulandı. En sık karşılaşılan komplikasyon olarak 7 (%12,9) hastada eklem hareket açıklığı kaybıydı. Sonuç: Ateşli silah yaralanmalarında multidisipliner ve hasar kontrollü bir yaklaşımla erken dönemde antibiyoterapi, kemik tespiti ve seri debridmanlar sonrası nihai tedaviye geçilmesi tedavi başarısını olumlu yönde etkilemektedir. Anahtar Kelimeler: Ateşli silah yaralanmaları, Nörovasküler yaralanma, Fasiatomi, Komplikasyonlar.

Background: Poor patient positioning during surgeries can result in vascular and peripheral nerve injuries. The purpose of this study was to analyze the various etiologic factors related to positioning detected by intraoperative monitoring (IOM) and make recommendations for prevention of comorbidities. Materials and Methods: The data for a total of 4450 consecutively monitored patients who underwent orthopedic and neurosurgical procedures were retrospectively reviewed. Patients with signal changes related to positioning detected by IOM were analyzed for position, modalities, timing of interventions, duration of surgery, and etiologic factors. Deficit and non-deficit groups were further compared using Wilcoxon rank sum test. Results: Intraoperative evidence of impending neurologic injury was seen 1.1% times, most frequently due to malpositioning of upper extremities (57%) in prone position (55%). Shoulder tape, bootstrap, thigh/hip pads, sitting and lower extremity malpositioning were other etiologic factors. Appropriate intervention was performed within 3min 66% of the time. Four patients developed new postoperative deficits: brachial plexopathy (n = 3) and bilateral sciatic neuropathy (n = 1). The deficit group had longer duration of surgery (P = 0.031), and neurophysiological (NP) signal changes persisted for an increased time interval (P = 0.0084) when compared to the non-deficit group. Conclusion: Prolonged duration of surgery and persistence of NP signal changes can increase the risk of potential neurovascular injury. Intraoperative neurovascular injuries due to positioning can occur in various settings. Early recognition of signal changes during monitoring and immediate intervention is likely to prevent neurological deficits.

Upper limb fractures are common, and potentially disabling, injuries. This article provides an overview of common upper limb injuries in adults that present to the emergency department, and subsequently the fracture clinic. We highlight some of the clinical aspects and pitfalls to consider for each injury, and provide a brief overview of the classification systems often used. Furthermore, we discuss the non-operative and operative management options available. [ABSTRACT FROM AUTHOR]

Abstract Background Femoral and sciatic nerves could be damaged during various stages of the periacetabular osteotomy. Changing the position of the hip could be the most effective way of preventing nerve injuries. The purpose of the present study was to investigate the distances of the nerves to various bony landmarks with different hip positions in computerized pelvic scanograms of healthy adults. Materials and methods Fifteen healthy male adults (30 hips) (age 30 ± 6) were included. Scans were performed at three different hip positions measured by goniometer (neutral “N,” flexion (30–45°) + abduction (30–45°) + external rotation (20°) “F” and neutral+ abduction (30–45°) + external rotation (20°) (Nabext) at three different levels (sourcil “1,” the middle of the femoral head “2,” and lower border of triradiate cartilage “3.” Results At the sourcil level, the femoral nerve was found to be the furthest distance from the anterior acetabulum in the neutral position compared to flexion or neutral plus abduction, external rotation (p < 0.001). For the sciatic nerve, at level 2, hip flexion resulted in a greater distance than in the neutral position (p = 0.001). For level 3, hip flexion caused a decrease in the distance of the sciatic nerve to the acetabulum compared to both neutral positions (N or Nabex) (p = 0.001). Conclusions During a pubic cut of the osteotomy, the femoral nerve moves closer to the anterior acetabulum wall with hip flexion or abduction plus external rotation. During an ischial cut, the sciatic nerve gets closer to the ischium with hip flexion while it moves away from the bone during retroacetabular cut. Level-III Study

Knee joint dislocation is a relatively uncommon injury but its management is important because of the associated high risk of vascular, neurological and multi-ligamentous knee injuries. Clinicians must be aware that not all knee dislocations are diagnosed on plain X-rays; a high index of suspicion is required based on clinical evaluation. Multidisciplinary specialist care is required in all cases to achieve best outcomes. Early one-stage or multiple staged ligament repair and reconstruction offer better outcomes, but most patients have some long-term functional limitation. This article provides insights into the epidemiology and management of this injury and its devastating effects. [ABSTRACT FROM AUTHOR]

Abstract This report presents a case of deep peroneal nerve palsy caused by an injury during drilling for distal locking screws of a T‐shaped locking plate used for osteosynthesis of medial open‐wedge high tibial osteotomy. A cadaveric simulation study reproduced the risk of injury during the surgery.

Introduction: Hand injuries are the most complex injuries when compared to other bodily injuries. A better understanding of the biological, behavioral, and socioeconomic risk factors that are associated with hand injuries is therefore needed. This data can help identify individuals at risk and define preventive measures to help reduce the incidence. Material and Methods: We present a study of 350 consecutive patients of hand injury treated between 2017- 2018. The demographic profile of the patient along with the type & cause of the injury sustained, hand dominance, type of procedure, and requirement of hospital administration was extracted from hospital records. Results: 159 (45.5%) of the patients were in the age group of fewer than 20 years. Out of the 350 patients, 288 (82%) were male. 302 (86%) patients were right-handed. The most common mode of injury was machine injury in 205 (59%) patients. 181 (52%) patients had crush injury, 107 (31%) had the sharp cut injury, and 32 (9%) had blast injury. 94 (27%) patients needed hospital admission for management. 119 ( 34%) patients had the injury to the thumb, 89 (25%) had injury to the middle finger. Primary suturing was done in 116 (33%) patients, tendon and nerve repair in 209 (60%), and 177 (51%) patients respectively. Conclusions: The study describes the demography and etiology of the cases of hand injury. The study has a limitation of having absence of assessment of functional outcome. There is a necessity of hand trauma registry to quantify the burden of hand injuries and formulate a prevention strategy at the national level.

Ultra-low-velocity knee dislocations are historically rare but increasingly common events. They occur most frequently in obese, morbidly obese, and super obese patients during everyday activities, but they can be as severe or more severe than high-velocity knee dislocations. Ultra-low-velocity knee dislocations frequently are associated with neurovascular injury and other complications. Diagnosis, early reduction, and identification and treatment of vascular injuries are critical to reducing the risk of limb ischemia and possibly amputation. Given the size of the limb, maintenance of reduction in these patients almost always requires external fixation. Although surgery on morbidly obese patients may be technically challenging, surgical reconstruction leads to improved subjective and objective results and is recommended. [ABSTRACT FROM AUTHOR]

Purpose: To assess the risk of injury to the neurovascular bundle on the interosseous membrane of the leg during drilling for distal screw insertion in open-wedge high tibial osteotomy (OWHTO), and to investigate the possible influence of the method of plate placement on the risk.Methods: This retrospective study involved, 55 patients (32 with a TomoFix plate, 23 with a TriS plate) who underwent postoperative CT scanning of the knee following OWHTO between 2009 and 2018. The angle and position of the locking plate, and the direction of screw insertion relative to the interosseous membrane were analysed.Results: All distal screws had a risk of neurovascular injury. In particular, 25 screws at the #4 hole (45%) had an extended insertion trajectory that intersected with the interosseous membrane. The angle of the proximal part of the TomoFix plate was a significant risk factor. In contrast, methods of TriS plate placement showed no statistically significant differences.Conclusions: Extended insertion trajectories of distal screws were likely to intersect with the interosseous membrane with the neurovascular bundle potentially on its surface; thus, drilling for bicortical fixation posed a risk of neurovascular injury. The risk increased as the TomoFix plate was placed more medially, suggesting that bicortical drilling must be performed with the utmost attention when the plate is placed at the medial position. Given the particularly high risk at the #3 and #4 screw holes, monocortical fixation of a few distal screws is recommended as long as good stability is ensured. [ABSTRACT FROM AUTHOR]

Background: The 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.Methods: Ten 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.Results: The 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.Conclusion: Arthroscopic 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. [ABSTRACT FROM AUTHOR]

This report presents a case of deep peroneal nerve palsy caused by an injury during drilling for distal locking screws of a T‐shaped locking plate used for osteosynthesis of medial open‐wedge high tibial osteotomy. A cadaveric simulation study reproduced the risk of injury during the surgery. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study was to evaluate the feasibility of the anteromedial minimally invasive plate osteosynthesis (MIPO) approach for distal third humeral shaft fractures and identify neurovascular structures at risk with this approach.Methods: Twenty cadaveric arms were fixed with 12-hole precontoured narrow locking compression plates (LCP) with the anteromedial approach using MIPO technique. The proximal approach was done between the biceps and deltoid muscle directly to the bone. The distal approach involved elevating the brachialis from medial intermuscular septum. The plate was inserted beneath the brachialis tunnel from distal to proximal. Three locking screws were fixed at each end through incisions and the rest of screws were inserted percutaneously. The arms were then dissected to identify damage to or direct contact between the screws and brachial artery (BA), median nerve (MN), musculocutaneous nerve (MCN), and radial nerve (RN). The distances from the screws to structures at risk, humeral length, and length of three distal screws in mediolateral (ML) direction were measured.Results: The average humeral length was 28.97 cm. The average danger zone for the BA and MN were 20.47%-62.66% of the humeral length from the lateral epicondyle, and 20.47%-75.02% for the MCN. The ulnar nerve was not endangered by this approach as it lies posteromedially to the humerus. The danger zone for the RN averaged 27.07%-43.74%, and the most dangerous screw that either penetrated or touched the nerve was at the fifth hole, which lay at 33.14% of the humeral length. The average length of three distal screws in ML direction were 41.4, 25.0 and 22.5 mm.Conclusions: The anteromedial MIPO approach can be performed through the internervous plane beneath the brachialis muscle without exposing any nerves or causing any muscle splitting with a 12-hole plate. Both proximal and distal screw insertion must be done with direct exposure. Insertion of percutaneous screws in the middle part of the plate between the two incisions is not possible. This approach could be an alternative for extra-articular distal third humeral shaft fractures which provides less invasive surgical dissection, allows the use of longer distal screws, and achieves better cosmesis. [ABSTRACT FROM AUTHOR]

Diabetes increases the risk of occurrence and poor functional recovery after ischemic stroke injury. Previously, we have demonstrated greater hemorrhagic transformation (HT), edema, and more severe functional deficits after stroke in diabetic animals that also presented with cerebral vasoregression and endothelial cell death in the recovery period. Given that Toll-like receptor 4 (TLR-4) activation in microvascular endothelial cells triggers a robust inflammatory response, we hypothesized that inhibition of TLR-4 signaling prevents endothelial cell death and improves outcomes after stroke. Animals were treated with vehicle or TLR-4 inhibitor TAK242 (3 mg/kg; i.p.) following middle cerebral artery occlusion (MCAO). Neurobehavioral deficits were measured at baseline and day 3 after ischemic stroke. Primary brain microvascular endothelial cells (BMVECs) from diabetic animals were subjected to oxygen glucose deprivation re-oxygenation (OGDR) and treated with 0.1 mM iron(III)sulfate hydrate (iron) (to mimic the post-stroke bleeding) and TLR-4 inhibitors. Ischemic stroke increased the expression of TLR-4 in both hemispheres and in the microvasculature of diabetic animals. Cerebral infarct, edema, HT, and functional deficits were greater in diabetic compared to control animals. Inhibition of TLR-4 significantly reduced the neurovascular injury and improved functional outcomes. OGDR and iron reduced the cell viability and increased the expression of TLR-4 associated proteins (RIP3, MyD88, phospho-NF-kB, and release of IL-6) in BMVECs from diabetic animals. In conclusion, TLR-4 is highly upregulated in the microvasculature and that beneficial effects of TLR-4 inhibition are more profound in diabetes. This suggests that inhibition of vascular TLR-4 may provide therapeutic benefits for stroke recovery in diabetes. [ABSTRACT FROM AUTHOR]

As part of the neurovascular unit, the blood-brain barrier (BBB) is a unique, dynamic regulatory boundary that limits and regulates the exchange of molecules, ions, and cells between the blood and the central nervous system. Disruption of the BBB plays an important role in the development of neurological dysfunction in ischemic stroke. Blood-borne substances and cells have restricted access to the brain due to the presence of tight junctions between the endothelial cells of the BBB. Following stroke, there is loss of BBB tight junction integrity, leading to increased paracellular permeability, which results in vasogenic edema, hemorrhagic transformation, and increased mortality. Thus, understanding principal mediators and molecular mechanisms involved in BBB disruption is critical for the development of novel therapeutics to treat ischemic stroke. This review discusses the current knowledge of how neuroinflammation contributes to BBB damage in ischemic stroke. Specifically, we provide an updated overview of the role of cytokines, chemokines, oxidative and nitrosative stress, adhesion molecules, matrix metalloproteinases, and vascular endothelial growth factor as well as the role of different cell types in the regulation of BBB permeability in ischemic stroke. [ABSTRACT FROM AUTHOR]

Abstract Diabetes is associated with increased risk and worsened outcome of stroke. Previous studies showed that male diabetic animals had greater hemorrhagic transformation (HT), profound loss of cerebral vasculature, and poor behavioral outcomes after ischemic stroke induced by suture or embolic middle cerebral artery occlusion (MCAO). Females are protected from stroke until reaching the menopause age, but young females with diabetes have a higher risk of stroke and women account for the majority of stroke mortality. The current study postulated that diabetes is associated with greater vascular injury and exacerbated sensorimotor and cognitive outcome after stroke even in young female animals. Male and female control and diabetic animals were subjected to transient MCAO and followed for 3 or 14 days to assess the neurovascular injury and repair. The vascularization indices after stroke were lower in male diabetic animals with 90-min but not 60-min ischemia/reperfusion injury, while there was no change in female groups. Cognitive deficits were exacerbated in both male and female groups regardless of the injury period, while the sensorimotor dysfunction was worsened in male diabetic animals with longer ischemia time. These results suggest that diabetes negates the protection afforded by sex in young female animals, and post-stroke vascularization pattern is influenced by the degree of injury and correlates with functional outcome in both sexes. Vasculoprotection after acute ischemic stroke may provide a novel therapeutic strategy in diabetes. Highlights • Eight week of diabetic state mediates cerebrovascular remodeling and cognitive impairment in both male and female rats. • Ischemic injury amplifies diabetes-mediated vascular cognitive impairment. • Remodeling of the cerebrovascular networks in the post-stroke period is influenced by the degree of ischemia/reperfusion injury. [ABSTRACT FROM AUTHOR]

In the setting of near or complete upper extremity amputations with significant soft tissue loss and neurovascular compromise, upper extremity surgeons are faced with the challenge of limb salvage. There are a multitude of treatment options for managing skeletal and soft tissue injuries including provisional fixation, staged reconstruction, and an acute shortening osteotomy with primary rigid internal fixation. However, many complications are associated with these techniques. Complications of provisional fixation include pin tract infection and loosening, tethering of musculotendinous units, nonunion, and additional surgeries. Staged reconstruction includes a variety of techniques: distraction osteogenesis, bone transport, or vascularized and non‐vascularized structural autograft or allograft, but the risks often outweigh the benefits. Risks include nonunion, postoperative vascular complications necessitating reoperation, and the inability to return to the previous level of function at an average of 24 months. Acute shortening osteotomy with internal fixation offers the advantage of a single‐stage procedure that provides for decreasing the soft tissue loss, provides a rigid platform to protect the delicate neurovascular repair, and alleviates unwanted tension at the repair sites. This review discusses the literature on the surgical treatment of severe upper extremity trauma with associated neurovascular injury over the past 75 years, and aims to evaluate the indications, surgical techniques, clinical and functional outcomes, and complications associated with acute shortening osteotomy with rigid internal fixation. Although this technique is not without risks, it is well‐tolerated in the acute setting with a complication profile comparable to other techniques of fixation while remaining a single procedure.

Background: Talonavicular (TN) fusion using screws dorsomedially and dorsolaterally can cause neurovascular injury. The purpose of our cadaveric study was to evaluate the safety of percutaneous screw insertion in relation to dorsal neurovascular structures. Methods: Ten fresh-frozen cadaver legs were used for this study. Percutaneous cannulated screws were inserted to perform isolated TN arthrodesis. The screws were inserted at 3 consistent sites: a "medial screw" at the dorsomedial navicular where it intersected at the medial plane of the first cuneiform, a "central screw" at the edge of the dorsal navicular between the medial and intermediate cuneiforms, and a "lateral screw" at the edge of the dorsal navicular between the intermediate and lateral cuneiforms. Superficial and deep dissections were carried out to identify any injured nerves, arteries, and/or tendons. Results: The medial screw injured the anterior tibialis tendon in 2 cases (20%), the central screw injured the extensor hallucis longus tendon in 3 cases (30%), and the lateral screw injured the anterior branch of the superior peroneal nerve (SPN), the lateral branch of the SPN, and the medial branch of the distal peroneal nerve (DPN) once each in a total of 3 cases (30%). Despite no direct injury, the central screw indicated a potential risk of neurovascular injury: closest distance to the anterior SPN was 2 mm and to the medial DPN 2 mm. Conclusion: Although neurovascular injury risk exists for all of these screw placements, TN fusion with a central screw introduced a potentially decreased risk of neurovascular injury at the expense of increased risk of tendon injury compared to the lateral screw. Clinical Relevance: Based on these results, we recommend a careful dissection be performed prior to percutaneous screw insertion. [ABSTRACT FROM AUTHOR]

Background: Fractures of the talar neck and body can be fixed with percutaneously placed screws directed from anterior to posterior or posterior to anterior. The latter has been found to be biomechanically and anatomically superior. Percutaneous guidewire and screw placement poses anatomic risks for posterolateral and posteromedial neurovascular and tendinous structures. The objective of this study was to determine the injury rate to local neurovascular and tendinous structures using this technique in a cadaveric model. In addition, we aimed to determine the number of attempts at passing the guidewires required to achieve acceptable placement of 2 parallel screws. Methods: Eleven fresh frozen cadaver limbs were used. Two 2.0-mm guidewires were placed under fluoroscopic guidance, posterior to anterior centered within the talus. The number of attempts required was recorded. A layered dissection was then performed to identify injury to any local anatomic structure. The shortest distance between the closest guidewire and the soft tissue structures was measured. Results: The mean total number of guidewires passed to obtain optimal placement of 2 parallel screws was 2.9 ± 0.7. Direct contact between the guidewire and the sural nerve was seen in 100% of the specimens, with the nerve impaled by the guidewire in 3 of 11 (27.2%) cases. The peroneal tendons were impaled in 1 of 11 (9%) specimens and the Achilles tendon was in contact with the guidewire in 8 of the 11 (72.7%) specimens, and impaled at its most lateral border with the guidewire in 2 specimens (18.2%). Conclusion: The placement of posterior to anterior percutaneous screws for talar neck fixation is technically demanding, and multiple guidewires are needed. Our cadaveric study showed that important tendinous and neurovascular structures were in proximity with the guidewires and that the sural nerve was injured in 100% of the cases. Clinical Relevance: Given the risk of injury to these structures, we recommend a formal posterolateral incision for proper visualization and retraction of the anatomic structures at risk. [ABSTRACT FROM AUTHOR]

Background: Medial epicondyle fractures in pediatric patients might be associated with an occult elbow dislocation and neurovascular damage. Methods: A single case of a medial epicondyle fracture presenting with brachial artery transection was reviewed. Presentation, clinical course, and early outcome are reported. Results: A 14-year-old patient presenting with an apparently isolated medial epicondyle fracture was found to have examination and diagnostic test findings consistent with brachial artery transection. His injury was explored and repaired acutely, resulting in acute return of perfusion. Final follow-up revealed 0° to 130° of flexion-extension arc of motion and full pronation and supination with normal sensory and motor function of the hand. Conclusions: Pediatric medial epicondyle fractures should alert the clinician to the possibility of an occult dislocation of the elbow, and a full neurovascular assessment should be performed. Early recognition and repair of a vascular injury associated with this fracture can lead to a good outcome. [ABSTRACT FROM AUTHOR]

Background The surgical options for revision shoulder arthroplasty and the number of procedures performed are increasing. However, little is known about the risk factors for intraoperative complications associated with this complex surgery. Methods The National Joint Registry (NJR) is a surgeon reported database recording information on major joint replacements including revision shoulder arthroplasty. Using multivariable binary logistic regression modelling, we analyzed 1445 revision shoulder arthroplasties reported to the NJR between April 2012 and 2015. Results The risk of developing a complication during revision surgery was greater than primary arthroplasty (5% versus 2.5%). An intraoperative fracture was the most common complication occurring in 50 (3.5%) cases. Nerve injuries were recorded for two (0.1%) patients and vascular injuries for one (0.1%) patient. The incidence of intraoperative fractures was higher in females than males (relative risk = 3.25; p = 0.005). Periprosthetic fracture as an indication for revision carried the highest risk for any complication (relative risk = 3.00, p = 0.06). Conclusions This is the largest registry study to date investigating the incidence and risk factors for intraoperative complications during revision shoulder arthroplasty. Females have over three times the risk of intraoperative fractures compared to males. This study will help inform surgeons to accurately counsel patients. [ABSTRACT FROM AUTHOR]