Iatrogenic nerve injury in primary and revision reverse total shoulder arthroplasty

INTRODUCTION Iatrogenic nerve injury in orthopedic surgery can impair functional outcomes. During the last years, a steady increase in the number of performed reverse total shoulder arthroplasties has been reported and complications associated with this procedure are continuously described. Neurological complications, however, remain underreported. The aims of this study were to calculate the incidence of iatrogenic nerve injury after primary and revision reverse total shoulder arthroplasty in a large patient cohort, as well as identify associated patient-and surgery-related risk factors. MATERIALS AND METHODS A retrospective review of our institution's internal Reverse Total Shoulder Arthroplasty (RTSA) database from September 2005 to December 2019 was undertaken and 34 patients with iatrogenic nerve injuries were identified, resulting in a neurological complication rate of 2.6%. Group comparisons between patients with nerve injuries (n = 34) and the remaining cohort without nerve injuries (n = 1275) were performed to identify patient- and surgery-related risk factors. RESULTS Of the 34 cases with iatrogenic nerve injury, damage to terminal nerve branches occurred in 21 patients, whereas a brachial plexus lesion was diagnosed in the other 13. Nerve revision surgery was necessary in four patients. At final follow-up 13 patients (45%) had residual motor deficits and 17 (59%) had residual sensory deficits. Higher numbers of previous surgeries of the affected shoulder correlated with subsequent nerve injury (p = 0.035). Operative time was significantly longer in patients, who developed a neurologic deficit, showing a correlation between duration of surgery and occurrence of nerve injury (p = 0.013). Patients with neurologic complications were significantly younger than patients without nerve damage (median 68 vs. 72 years, p = 0.017). CONCLUSIONS In specialists' hands reverse total shoulder arthroplasty is a rather safe procedure regarding the risk of neurologic injury. However, multiple previous surgeries of the affected shoulder increase the risk of neurological complications. Cases with post-operative neurologic compromise are rare and usually recover well, with few patients suffering long-term functional deficits from iatrogenic nerve injury. LEVEL OF EVIDENCE Level III, retrospective cohort study

Functional and Psychosocial Outcomes of Hand Transplantation Compared with Prosthetic Fitting in Below-Elbow Amputees:A Multicenter Cohort Study

BACKGROUND:Hand-transplantation and improvements in the field of prostheses opened new frontiers in restoring hand function in below-elbow amputees. Both concepts aim at restoring reliable hand function, however, the indications, advantages and limitations for each treatment must be carefully considered depending on level and extent of amputation. Here we report our findings of a multi-center cohort study comparing hand function and quality-of-life of people with transplanted versus prosthetic hands. METHODS:Hand function in amputees with either transplant or prostheses was tested with Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP) and the Disabilities of the Arm, Shoulder and Hand measure (DASH). Quality-of-life was compared with the Short-Form 36 (SF-36). RESULTS:Transplanted patients (n = 5) achieved a mean ARAT score of 40.86 ± 8.07 and an average SHAP score of 75.00 ± 11.06. Prosthetic patients (n = 7) achieved a mean ARAT score of 39.00 ± 3.61 and an average SHAP score of 75.43 ± 10.81. There was no significant difference between transplanted and prosthetic hands in ARAT, SHAP or DASH. While quality-of-life metrics were equivocal for four scales of the SF-36, transplanted patients reported significantly higher scores in "role-physical" (p = 0.006), "vitality" (p = 0.008), "role-emotional" (p = 0.035) and "mental-health" (p = 0.003). CONCLUSIONS:The indications for hand transplantation or prosthetic fitting in below-elbow amputees require careful consideration. As functional outcomes were not significantly different between groups, patient's best interests and the route of least harm should guide treatment. Due to the immunosuppressive side-effects, the indication for allotransplantation must still be restrictive, the best being bilateral amputees

Rehabilitation of Upper Extremity Nerve Injuries Using Surface EMG Biofeedback: Protocols for Clinical Application

Motor recovery following nerve transfer surgery depends on the successful re-innervation of the new target muscle by regenerating axons. Cortical plasticity and motor relearning also play a major role during functional recovery. Successful neuromuscular rehabilitation requires detailed afferent feedback. Surface electromyographic (sEMG) biofeedback has been widely used in the rehabilitation of stroke, however, has not been described for the rehabilitation of peripheral nerve injuries. The aim of this paper was to present structured rehabilitation protocols in two different patient groups with upper extremity nerve injuries using sEMG biofeedback. The principles of sEMG biofeedback were explained and its application in a rehabilitation setting was described. Patient group 1 included nerve injury patients who received nerve transfers to restore biological upper limb function (n = 5) while group 2 comprised patients where biological reconstruction was deemed impossible and hand function was restored by prosthetic hand replacement, a concept today known as bionic reconstruction (n = 6). The rehabilitation protocol for group 1 included guided sEMG training to facilitate initial movements, to increase awareness of the new target muscle, and later, to facilitate separation of muscular activities. In patient group 2 sEMG biofeedback helped identify EMG activity in biologically “functionless” limbs and improved separation of EMG signals upon training. Later, these sEMG signals translated into prosthetic function. Feasibility of the rehabilitation protocols for the two different patient populations was illustrated. Functional outcome measures were assessed with standardized upper extremity outcome measures [British Medical Research Council (BMRC) scale for group 1 and Action Research Arm Test (ARAT) for group 2] showing significant improvements in motor function after sEMG training. Before actual movements were possible, sEMG biofeedback could be used. Patients reported that this visualization of muscle activity helped them to stay motivated during rehabilitation and facilitated their understanding of the re-innervation process. sEMG biofeedback may help in the cognitively demanding process of establishing new motor patterns. After standard nerve transfers individually tailored sEMG biofeedback can facilitate early sensorimotor re-education by providing visual cues at a stage when muscle activation cannot be detected otherwise

Axonal mapping of the motor cranial nerves

Basic behaviors, such as swallowing, speech, and emotional expressions are the result of a highly coordinated interplay between multiple muscles of the head. Control mechanisms of such highly tuned movements remain poorly understood. Here, we investigated the neural components responsible for motor control of the facial, masticatory, and tongue muscles in humans using specific molecular markers (ChAT, MBP, NF, TH). Our findings showed that a higher number of motor axonal population is responsible for facial expressions and tongue movements, compared to muscles in the upper extremity. Sensory axons appear to be responsible for neural feedback from cutaneous mechanoreceptors to control the movement of facial muscles and the tongue. The newly discovered sympathetic axonal population in the facial nerve is hypothesized to be responsible for involuntary control of the muscle tone. These findings shed light on the pivotal role of high efferent input and rich somatosensory feedback in neuromuscular control of finely adjusted cranial systems

Influence of FTO rs9939609 and Mediterranean diet on body composition and weight loss: a randomized clinical trial

Background The Mediterranean diet (MeD) plays a key role in the prevention of obesity. Among the genes involved in obesity, the Fat mass and obesity-associated gene (FTO) is one of the most known, but its interaction with MeD remained uncertain so far. Methods We carried out a study on a sample of 188 Italian subjects, analyzing their FTO rs9939609 alleles, and the difference in body composition between the baseline and a 4-weeks nutritional intervention. The sample was divided into two groups: the control group of 49 subjects, and the MeD group of 139 subjects. Results We found significant relations between MeD and both variation of total body fat (ΔTBFat) (p = 0.00) and gynoid body fat (p = 0.04). ∆TBFat (kg) demonstrated to have a significant relation with the interaction diet-gene (p = 0.04), whereas FTO was associated with the variation of total body water (p = 0.02). Conclusions MeD demonstrated to be a good nutritional treatment to reduce the body fat mass, whereas data about FTO remain uncertain. Confirming or rejecting the hypothesis of FTO and its influence on body tissues during nutritional treatments is fundamental to decide whether its effect has to be taken into consideration during both development of dietetic plans and patients monitoring. Trial Registration ClinicalTrials.gov Id: NCT01890070. Registered 01 July 2013, https://clinicaltrials.gov/ct2/show/NCT0189007

Does the pronator-sparing approach improve functional outcome, compared to a standard volar approach, in volar plating of distal radius fractures? A prospective, randomized controlled trial

Abstract Background This study aimed to compare functional outcomes of a volar plate osteosynthesis for distal radius fractures (DRF) performed with either a standard volar approach (SVA), which required detachment of the pronator quadratus muscle, or a pronator-sparing approach (PqSA). Materials and methods This prospective randomized controlled study included 106 patients scheduled for volar plate osteosyntheses. Patients were allocated to either the SVA group (n = 53) or the PqSA group (n = 53). Patients were blinded to treatment until completion of the study. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE). Secondary outcome parameters were the Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Modified Mayo Wrist Score (MMWS). Follow-up examinations were performed at 8 weeks and 3, 6, and 12 months postoperatively. Results Overall, 91 patients were included in the final analysis: 48 in the SVA group and 43 in the PqSA group. The two cohorts were not significantly different in demographic characteristics, including age, sex, injuries on the dominant side, type of injury, and fracture classification. We found significant differences between groups at 6 months in the mean PRWE (SVA: 12.3 ± 10.4, PqSA: 18.9 ± 14.11 points) and in the mean DASH score (SVA: 12.3 ± 11.9, PqSA: 19.3 ± 16.7 points), which favoured the SVA. We found no significant differences between groups in the MMWS or in the PRWE and DASH scores at any other time points. Conclusions This randomized comparative clinical trial failed to demonstrate that a volar plate osteosynthesis performed with a PqSA could improve the outcome, compared to the SVA, in patients with DRF. Level of evidence II Trial registration Comparison of Two Volar Plating Systems for Distal Radius Fractures, ClinicalTrials.gov (NCT03474445), registered 22 March 2018, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03474445?cond=radius&cntry=AT&draw=2&rank=

Impact of a total lockdown for pandemic SARS-CoV-2 (Covid-19) on deep surgical site infections and other complications after orthopedic surgery: a retrospective analysis

BACKGROUND A total lockdown for pandemic SARS-CoV-2 (Covid-19) entailed a restriction of elective orthopedic surgeries in Switzerland.  While access to the hospital and human contacts were limited, hygiene measures were intensified. The objective was to investigate the impact of those strict public health guidelines on the rate of intra-hospital, deep surgical site infections (SSI), wound healing disorders and non-infectious postoperative complications after orthopedic surgery during the first Covid-19 lockdown. METHODS In a single-center study, patients with orthopedic surgery during the first Covid-19 lockdown from March 16, 2020 to April 26, 2020 were compared to cohorts that underwent orthopedic intervention in the pre- and post-lockdown periods of six months each. Besides the implementation of substantial public health measures (promotion of respiratory etiquette and hand hygiene), no additional infection control bundles have been implemented. RESULTS 5791 patients were included in this study. In multivariate Cox regression analyses adjusting for the large case-mix, the lockdown was unrelated to SSI (hazard ratio (HR) 1.6; 95% confidence interval (CI) 0.6-4.8), wound healing disorders (HR 0.7; 95% CI 0.1-5.7) or other non-infectious postoperative complications (HR 0.7, 95% CI 0.3-1.5) after a median follow-up of seven months. CONCLUSION The risks for SSI, wound healing disorders and other complications in orthopedic surgery were not influenced by the extended public health measures of the total Covid-19 lockdown. Trial registration BASEC 2020-02646 (Cantonal Ethics Commission Zurich). LEVEL OF EVIDENCE Level III

Prosthetic Embodiment and Body Image Changes in Patients Undergoing Bionic Reconstruction Following Brachial Plexus Injury

Funding Information: The authors would like to thank Aron Cserveny for the preparation of the illustrations included in the manuscript. Furthermore, we thank Xaver Fuchs, Kristina Staudt, Herta Flor, and Martin Diers from Zentralinstitut f?r Seelische Gesundheit Mannheim (Germany) for their input regarding the formulation of the statements evaluating prosthetic embodiment. Funding. This project has received funding from the European Research Council (ERC) under the European Union's Horizon 2020 research and innovation program (grant agreement No 810346) and the Academy of Finland under project Hi-Fi BiNDIng (No 333149). Publisher Copyright: © Copyright © 2021 Sturma, Hruby, Boesendorfer, Pittermann, Salminger, Gstoettner, Politikou, Vujaklija, Farina and Aszmann. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.Brachial plexus injuries with multiple-root involvement lead to severe and long-lasting impairments in the functionality and appearance of the affected upper extremity. In cases, where biologic reconstruction of hand and arm function is not possible, bionic reconstruction may be considered as a viable clinical option. Bionic reconstruction, through a careful combination of surgical augmentation, amputation, and prosthetic substitution of the functionless hand, has been shown to achieve substantial improvements in function and quality of life. However, it is known that long-term distortions in the body image are present in patients with severe nerve injury as well as in prosthetic users regardless of the level of function. To date, the body image of patients who voluntarily opted for elective amputation and prosthetic reconstruction has not been investigated. Moreover, the degree of embodiment of the prosthesis in these patients is unknown. We have conducted a longitudinal study evaluating changes of body image using the patient-reported Body Image Questionnaire 20 (BIQ-20) and a structured questionnaire about prosthetic embodiment. Six patients have been included. At follow up 2.5–5 years after intervention, a majority of patients reported better BIQ-20 scores including a less negative body evaluation (5 out of 6 patients) and higher vital body dynamics (4 out of 6 patients). Moreover, patients described a strong to moderate prosthesis embodiment. Interestingly, whether patients reported performing bimanual tasks together with the prosthetic hand or not, did not influence their perception of the prosthesis as a body part. In general, this group of patients undergoing prosthetic substitution after brachial plexus injury shows noticeable inter-individual differences. This indicates that the replacement of human anatomy with technology is not a straight-forward process perceived in the same way by everyone opting for it.Peer reviewe

Augmented Reality in Orthopedic Surgery Is Emerging from Proof of Concept Towards Clinical Studies: a Literature Review Explaining the Technology and Current State of the Art

PURPOSE OF REVIEW Augmented reality (AR) is becoming increasingly popular in modern-day medicine. Computer-driven tools are progressively integrated into clinical and surgical procedures. The purpose of this review was to provide a comprehensive overview of the current technology and its challenges based on recent literature mainly focusing on clinical, cadaver, and innovative sawbone studies in the field of orthopedic surgery. The most relevant literature was selected according to clinical and innovational relevance and is summarized. RECENT FINDINGS Augmented reality applications in orthopedic surgery are increasingly reported. In this review, we summarize basic principles of AR including data preparation, visualization, and registration/tracking and present recently published clinical applications in the area of spine, osteotomies, arthroplasty, trauma, and orthopedic oncology. Higher accuracy in surgical execution, reduction of radiation exposure, and decreased surgery time are major findings presented in the literature. In light of the tremendous progress of technological developments in modern-day medicine and emerging numbers of research groups working on the implementation of AR in routine clinical procedures, we expect the AR technology soon to be implemented as standard devices in orthopedic surgery