Reliability of new radiographic measurement techniques for elbow bony impingement

BACKGROUND: Identifying the location and scale of radiographic changes in elbow bony impingement (EBI) is critical in formulating an appropriate diagnosis and treatment plan for such patients. The purpose of present study was to evaluate the intra-rater and inter-rater reliability of the new radiographic parameters, Anterior Impingement angle (AIa) and Posterior Impingement angle (PIa), for EBI. In addition, to determine if there was a relationship between radiographic parameters and clinical evaluation. PATIENTS AND METHODS: Three raters of different levels of training evaluated the radiographs of 60 patients (30 in EBI group and 30 in normal group) twice, at least 2 weeks apart. Intra-rater and inter-rater reliabilities were calculated by Intraclass Correlation Coefficients (ICC) with 95% confidence intervals. Correlation between radiographic parameters and clinical evaluation was calculated by Pearson correlation coefficient. RESULTS: In both groups, intra-rater and inter-rater reliabilities were substantial. There were no significant differences in reliability between upper-hand expert surgeons and resident for either measurement. Good correlation was observed between impingement arcs and range of motion values. CONCLUSIONS: Both AIa and PIa measurements demonstrated substantial intra-rater and inter-rater reliability for normal radiographs and in EBI patients. Good reliability, for either expert surgeons or residents in training, and good correlation between radiographic measurements and manual testing, appoints this method may be easily and reliably used in every day practice

Assessment of coxarthritis risk with dimensionless biomechanical parameters

Unfavourable distribution of contact stress over the load bearing area is considered a risk factor for early coxarthritis and it is of interest to outline respective biomechanical parameters for its prediction. The purpose of the work was to develop a transparent mathematical model which can be used to assess contact stress in the hip from imaged structures of pelvis and proximal femora, in large population studies and in clinical practice. Methods: We upgraded a previously validated three-dimensional mathematical model of the human hip in the one-legged stance HIPSTRESS by introducing parameters independent from the size of the structures in the images. We validated a new parameter % dimensionless peak stress normalized by the body weight and by the radius of the femoral head ( pmaxr 2 /WB) on the population of 172 hips that were in the childhood subjected to the Perthes disease and exhibited increased proportion of dysplastic hips. Results: The dimensionless parameter pmaxr 2 /WB exhibited smaller number of indecisive cases of hip dysplasia predicted by the model than the previously used parameter pmax/WB (6% vs. 81%, respectively). A threshold for an increased risk of early coxarthritis development by the HIPSTRESS parameter H = pmaxr 2 /WB was found to be 2. Conclusions: We proposed a dimensionless peak stress on the load bearing area with the border value of 2 as a decisive parameter over which hips are at risk for early development of degenerative processes and presented a method for determination of biomechanical parameters with the use of nomogra

Psychological Factors of Rehabilitation of Athletes After Knee Injury

Izhodišča. Večina raziskav s področja športnih poškodb se nanaša na specifične značilnosti, ki sprožijo, napovedujejo ali preprečujejo športne poškodbe. Raziskava preučuje možnost napovedovanja uspešnosti rehabilitacije na osnovi psiholoških značilnosti poškodovanih športnikov, in sicer spoprijemanja z bolečino, vedenja v procesu rehabilitacije (SIRBS), motivacije za rehabilitacijo, tesnobe kot stanja in socialne opore. Metode. V raziskavo je bilo vključenih 68 športnikov po operaciji kolena zaradi resne poškodbe, definirane na osnovi izbranega sistema (1). Rehabilitacijski proces je trajal en mesec ali šest mesecev. Udeleženci so bili psihološko obravnavani pred procesom rehabilitacije in po njem. Rezultati. Rezultati so pokazali, da je uspešnost rehabilitacije večja, če se zmanjša anksioznost in poveča dojemljivost ter zaznata samoučinkovitost in katastrofiziranje. Le za 10 % športnikov lahko rečemo, da je bila pri njih rehabilitacija uspešna. Zaključki. Na osnovi raziskave lahko rečemo, da se konstruktivna vedenja, povezana z rehabilitacijo, povezujejo s psihološko rehabilitacijo poškodovanih športnikov

Effect of Lidocaine and Epinephrine on Human Erythrocyte Shape and Vesiculability of Blood Cells

The effect of local anesthetic composed of lidocaine and epinephrine on vesiculability of blood cells and erythrocyte shape was studied. Whole blood and plasma were incubated with lidocaine/epinephrine. Extracellular vesicles were isolated by centrifugation and washing and counted by flow cytometry. Lidocaine/epinephrine and each component alone were added to diluted blood. Shape changes were recorded by micrographs. An ensemble of captured frames was analyzed for populations of discocytes, echinocytes, and stomatocytes by using statistical methods. Incubation of whole blood and blood plasma with lidocaine/epinephrine considerably increased concentration of extracellular vesicles in isolates (for an average factor 3.4 in blood and 2.8 in plasma). Lidocaine/epinephrine caused change of erythrocyte shape from mainly discocytic to mainly stomatocytic (higher than 50%). Lidocaine alone had even stronger stomatocytic effect (the percent of stomatocytes was higher than 95%) while epinephrine had echinocytic effect (the percent of echinocytes was higher than 80%). The differences were highly statistically significant p<10-8 with statistical power P=1. Lidocaine/epinephrine induced regions of highly anisotropically curved regions indicating that lidocaine and epinephrine interact with erythrocyte membrane. It was concluded that lidocaine/epinephrine interacts with cell membranes and increases vesiculability of blood cells in vitro

Fracture Pattern Influences Radial Head Replacement Size Determination Among Experienced Elbow Surgeons

Background: Correct sizing is challenging in radial head replacement and no consensus exists on the implant’s optimal height and width to avoid elbow stiffness and instability. Studies exists, suggesting how to appropriately choose the implant size, but the manner by which the fracture pattern influences the surgeons’ operative choices was not investigated. Methods: The radial heads of four fresh-frozen cadaveric specimens were excised, measured, and fractured to simulate four patterns: three fragments (A); four fragments (B); comminuted (C); comminuted with bone loss (D). Nine examiners were asked to indicate first the maximum diameter of the radial heads with the help of dedicated sizing dishes and then the appropriate implant size with trial implants. Accuracy and precision were determined. A coefficient of variation was calculated and agreement was evaluated with the Bland–Altman method. Results: Accuracy and precision of radial head diameter estimation with dedicated sizing dish were 96.73% and 93.64%, (best pattern, D; worst, C). Accuracy and precision of radial head diameter estimation with trial implants were 99.71% and 90.66% (best pattern, A; worst, D). Frequent modifications occurred between the initial radial head size proposal based on the sizing dish and the radial head size chosen after use of the trial implants (47.2%). Conclusions: Diameter estimation of radial heads with dedicated sizing dishes may be underestimated in comminuted fractures; when bone loss is present, this may lead to an overestimation, especially when using trial implants. Care is essential to determine the optimal size of the implant and to avoid overlenghtening and oversizing, which can be responsible for implant failure. Level of Evidence: Basic Science Study. Clinical Relevance: Knowledge of the manner by which the fracture pattern influences radial head replacement size estimation can help preventing overlenghtening and oversizing during this procedure

Modified anteromedial and anterolateral elbow arthroscopy portals show superiority to standard portals in guiding arthroscopic radial head screw fixation

Purpose Arthroscopic fixation of radial head radial head fractures is an appealing alternative to open reduction and internal fixation, which presents the advantage of minimal surgical trauma. The aim of this study was to evaluate if modifications to the standard anteromedial (AM) and anterolateral (AL) portals could allow screw placement for radial head fracture osteosynthesis closer to the plane of the radial head articular surface. Methods Eight fresh-frozen specimens were prepared to mimic arthroscopic setting. Standard AL (ALst) and AM (AMst) and distal AL (ALdi) and AM (AMdi) portals were established. Eleven independent examiners were asked to indicate the optimal trajectory, when aiming to place a cannulated screw parallel to the radial head surface for radial head osteosynthesis. A three-dimensional digital protractor was used to measure the angle between the indicated position and a Kirschner wire placed parallel to the radial head articular surface (alpha). The Shapiro-Wilk normality test was used to evaluate the normal distribution of the samples. Means, standard deviations, and 95% confidence intervals (95% CI) were calculated for each portal. A coefficient of variation (CoV) was calculated to determine agreement among observers and intra-observer variability. Results Mean alpha angles were 25.1 +/- 11.5 degrees for AMst, 13.8 +/- 4.8 degrees for AMdi, 17.1 +/- 13.4 degrees for ALst, -2.6 +/- 9.2 degrees for ALdi. No overlapping in the 95% CI of ipsilateral standard and distal portals was observed, indicating that the difference between these means was statistically significant. The distal portals showed smaller inter-observer CoV as compared to the standard ones (AMst: 10.0%; AMdi: 4.6%; ALst: 12.5%; ALdi: 10.6%). Intra-observer CoV was similar for all portals (AMst: 5.5%; AMdi: 6.1%; ALst: 7.7%; ALdi: 7.1%). Conclusions The use of distal AM and AL portals permits to obtain alpha angles closer to the radial head articular surface than standard AM and AL portals. This is expected to allow screw placement in a flatter trajectory, which should correlate with a superior biomechanical performance of fixation. Good reproducibility of Kirschner wire placement from distal portals was observer among different examiners. Modifications to the standard AM and AL elbow arthroscopy portals allow to place screws for radial head fracture osteosynthesis in a position which should guarantee superior biomechanical performance of fixation

Locating the ulnar nerve during elbow arthroscopy using palpation is only accurate proximal to the medial epicondyle

Purpose: Knowledge of ulnar nerve position is of utmost importance to avoid iatrogenic injury in elbow arthroscopy. The aim of this study was to determine how accurate surgeons are in locating the ulnar nerve after fluid extravasation has already occurred, and basing their localization solely on palpation of anatomical landmarks. Methods: Seven cadaveric elbows were used and seven experienced surgeons in elbow arthroscopy participated. An arthroscopic setting was simulated and fluids were pumped into the joint from the posterior compartment for 15 min. For each cadaveric elbow, one surgeon was asked to locate the ulnar nerve solely by palpation of the anatomical landmarks, and subsequently pin the ulnar nerve at two positions: within 5 cm proximal and another within 5 cm distal of a line connecting the medial epicondyle and the tip of the olecranon. Subsequently, the elbows were dissected using a standard medial elbow approach and the distances between the pins and ulnar nerve were measured. Results: The median distance between the ulnar nerve and the proximal pins was 0 mm (range 0–0 mm), and between the ulnar nerve and the distal pins was 2 mm (range 0–10 mm), showing a statistically significant difference (p = 0.009). All seven proximally placed pins (100%) transfixed the ulnar nerve versus two out of seven distally placed pins (29%) (p = 0.021). Conclusions: In a setting simulating an already initiated arthroscopic procedure, the sole palpation of the anatomical landmarks allows experienced elbow surgeons to accurately locate the ulnar nerve only in its course proximal to the medial epicondyle (7/7, 100%), whereas a significantly reduced accuracy is documented when the same surgeons attempt to locate the nerve distal to the medial epicondyle (2/7, 29%; p = 0.021). Current findings support the establishment of a proximal anteromedial portal over a distal anteromedial portal to access the anterior compartment after tissue extravasation has occurred with regard to ulnar nerve safety