Acromial stress fracture in a young wheelchair user with Charcot-Marie-Tooth disease: a case report

Acromial stress fractures are rare and have not been highlighted as a potential complication of wheelchair use. We report the case of a 22-year old female wheelchair bound patient with Charcot-Marie-Tooth disease who presented with a four-year history of shoulder pain which impaired mobility and quality of life. Plain radiographs showed a cortical irregularity of the acromion but no double-density sign. After CT scans a non-united acromial stress fracture was diagnosed. She had no other shoulder pathology. The new technique of using a superiorly closing wedge osteotomy with cancellous lag screw fixation was successful in correcting the mobile non-united acromial fragment and resolving her pain

Effect of irrigation fluids, local anaesthetics, Glucosamine and Corticosteroids on human articular cartilage: an in vitro study

Background: Animal studies have shown that the commonly used arthroscopic irrigation fluid, 0.9% normal saline, can be toxic to articular cartilage. There have been several reports of chondrolysis following arthroscopy especially with the use of local anaesthetic pain pumps post operatively. In vitro studies have shown severe toxicity of local anaesthetics to articular cartilage but there are currently no published studies looking at methods to prevent this toxicity. Aims: To study the effect of different irrigation fluids and local anaesthetics on human articular cartilage and the ability of Glucosamine or Corticosteroids to protect against or recover from any potential toxicity. Materials and Methods: Chondral explants obtained from human femoral heads were exposed to different irrigation fluids, local anaesthetics, Glucosamine, Methylprednisolone or culture medium (control) for one hour. After exposure, explants were incubated with radio-labelled[superscript 35]SO[subscript 4] and uptake was measured after 16 hours as an indicator of proteoglycan synthesis. Results: The inhibition of [superscript 35]SO[subscript 4] uptake was 10% by Ringer's solution, 24% by 1.5% Glycine, 31% by 5% Mannitol (p=0.03)and 35% by Normal saline (p=0.04). Lidocaine 1 and 2%, Bupivacaine 0.25 and 0.5% and Levobupivacaine 0.5% were all toxic causing inhibition ranging from 61% to 85% (p<0.001). The addition of Glucosamine or Methylprednisolone at the same time as 0.5% Bupivacaine protected articular cartilage and reduced the inhibition by approximately 50% (p<0.001). Conclusions: Ringer's solution was the least toxic arthroscopic irrigation fluid and should replace normal saline in clinical practice. Intra-articular local anaesthetic injections should only be used with careful consideration of risks and benefits. Further clinical studies are required to assess the potential damage to cartilage from local anaesthetics or normal saline and to investigate the protective effect of Glucosamine or Corticosteroids

Trans-triquetral Perilunate fracture dislocation

Perilunate dislocations and perilunate fracture dislocations are rare and serious injuries. Perilunate dislocations represent less than 10% of all carpal injuries of which 61% represent transcaphoid fractures. Because of their rarity, up to 25% of perilunate dislocations are initially missed on first assessment. We present the case of a 66-year-old-gentleman who sustained an isolated trans-triquetral perilunate fracture dislocation while walking his dog. This was diagnosed in the emergency department and he underwent open reduction internal fixation after failed attempts at closed reduction in the ED and in theatre under general anaesthesia. After further removal of his Kirschner wires and physiotherapy he is noted to have had a successful outcome with his treatment at 9 months follow up post operatively. We found that this is the first case of it's kind reported in the literature highlighting the rarity of this injury pattern

A contribution to the calculation of a safe deltoid split

<b>Purpose</b> : Traditional teaching suggests that a safe deltoid split should extend no more than 5 cm from the lateral edge of the acromion. However, there are reports of nerves lying within this distance. Our aim was to redefine the safe maximum split and also to study the influence of arm length and position. <b> Materials and Methods:</b> Thirty cadaveric shoulders were dissected using the deltoid-splitting approach and the acromion-axillary nerve distance was measured in the neutral position, in abduction, and in adduction. This was correlated to upper arm length. Deltoid splits were measured at the end of 13 deltoid-splitting shoulder operations. <b> Results</b> : The mean acromion-axillary nerve distance was 6.0 cm (SD 0.6; range 4.5-6.5). Abduction brought the nerve closer by 1.5 cm. There was a strong correlation with upper arm length (r = 0.82) but the presence of high individual variability did not allow calculation of a safe deltoid split. The mean deltoid split in 13 open shoulder operations was 3.4 cm. <b> Conclusions</b> : Taking the mean acromion-axillary nerve distance minus three standard deviations as the safe deltoid split would protect 99.7&#x0025; of nerves. Therefore we recommend that the maximum deltoid split should be 4.2 cm; this distance would be sufficient to preserve all nerves in our study as well as all those reported by other authors. Splitting the deltoid in abduction should be avoided. <b>Clinical Relevance:</b> The traditional 5-cm deltoid split is probably too generous. We believe 4.2 cm is a safer limit

Glucosamine reduces the inhibition of proteoglycan metabolism caused by local anaesthetic solution in human articular cartilage: an in vitro study

Abstract Background We assessed whether local anaesthetics caused inhibition of proteoglycan metabolism in human articular cartilage and whether the addition of Glucosamine sulphate could prevent or allow recovery from this adverse effect on articular cartilage metabolism. Methods Cartilage explants obtained from 13 femoral heads from fracture neck of femur patients (average age 80 years, 10 female) were exposed to either 1% Lidocaine, 2% Lidocaine, 0.25% Bupivacaine, 0.5% Bupivacaine, 0.5% Levo-bupivacaine or a control solution (M199 culture medium). Glucosamine-6-Sulphate was added during or 1 h after exposure to 0.5% Bupivacaine to assess its protective and reparative effects. After exposure, the explants were incubated in culture medium containing radio labelled 35-sulphate and uptake was measured after 16 h to give an assessment of proteoglycan metabolism. Results The reduction in 35-S uptake compared to control was 65% for 1% Lidocaine (p < 0.001), 79% for 2% Lidocaine (p < 0.001), 61% for 0.25% Bupivacaine (p < 0.001), 85% for 0.5% Bupivacaine (p < 0.001) and 77% for 0.5% Levobupivacaine (p < 0.001). Glucosamine was able to protect the articular cartilage by reducing the inhibition of proteoglycan metabolism of 0.5% Bupivacaine from 85 to 30% (p < 0.001). When added after 0.5% Bupivacaine exposure, Glucosamine allowed some recovery with inhibition of metabolism to 70% (p = 0.004). Conclusion Our results showed that all local anaesthetic solutions inhibited proteoglycan metabolism in articular cartilage and the addition of Glucosamine was able to reduce the inhibition of metabolism caused by 0.5% Bupivacaine. Intra-articular injection of local anaesthetics requires careful consideration of risks and benefits