Glenoid conformity is one of the important aspects that could contribute to implant stability. However, the optimal conformity is still being debated among the researchers. Therefore, this study aims to analyze the stress distribution of the implant and cement in three types of conformity (conform, non-conform, and hybrid) in three load conditions (central, anterior, and posterior). Glenoid implant and cement were reconstructed using Solidwork software and a 3D model of scapula bone was done using MIMICS software. Constant load, 750 N, was applied at the central, anterior, and posterior region of the glenoid implant which represents average load for daily living activities for elder people, including, walking with a stick and standing up from a chair. The results showed that, during center load, an implant with dual conformity (hybrid) showed the best (Max Stress-3.93 MPa) and well-distributed stress as compared to other conformity (Non-conform-7.21 MPa, Conform-9.38 MPa). While, during eccentric load (anterior and posterior), high stress was located at the anterior and posterior region with respect to the load applied. Cement stress for non-conform and hybrid implant recorded less than 5 MPa, which indicates it had a very low risk to have cement microcracks, whilst, conform implant was exposed to microcrack of the cement. In conclusion, hybrid conformity showed a promising result that could compromise between conform and non-conform implant. However, further enhancement is required for hybrid implants when dealing with eccentric load (anterior and posterior).
The scapula is a flat, triangular bone overlying the posterior chest wall and forming the posterior aspect of the shoulder girdle. To the best of our knowledge, there is no previous description of a notch of the medial aspect of the superior border of the scapula in the literature. The imaging findings of a supero-medial scapula border notch mimicking a bone tumour are presented in this case report.
Scapular abscess is a rare clinical diagnosis. This is a report of an atypical case of extensive intramuscular scapular abscess involving the anterior and posterior aspects of the scapula with extension into the axillary region following minor trauma in a young healthy adolescent, describing a single posterolateral approach to the scapula to evacuate the abscess. Following surgical drainage and antibiotic treatment, patient recovered without any complication.
We describe the clinical presentation, investigation and management of an eventually fatal case of hypercalcemic crisis due to primary hyperparathyridism (PHPT). A 60 year-old lady with history of urolithiasis presented with worsening generalized bone pain, spinal scoliosis and a limp. Laboratory data showed hypercalcemia and raised alkaline phosphatase. Left hip x-ray revealed a subcapital femoral neck fracture. Intact parathyroid hormone was elevated, 187.6 pmol/L (1.6 – 6.9) and ultrasound showed an enlarged right parathyroid gland. Despite initial reduction of serum calcium with saline infusion and multiple doses of intravenous pamidronate, her calcium increased to 4.14 mmol/L a week following application of Buck’s traction for persistent left hip pain. She succumbed eventually with serum calcium peaking at 6.28 mmol/L despite multiple therapeutic interventions.
KEY WORDS: Primary hyperparathyroidism, hypercalcemic crisis, pathological fracture, urolithiasis
Magnetic resonance imaging is gaining importance in the diagnosis of nerve and muscular disorders. The ability of magnetic resonance imaging to delineate the different muscles and the nerve in any plane has made the differentiation between the changes of neuropathy, denervation, and nerve entrapment possible. Although findings on magnetic resonance imaging are non-specific, their use, coupled with clinical symptoms and electromyographic findings, allow an accurate diagnosis to be made without resorting to invasive biopsies.
Open traumatic scapulothoracic dissociation is a rare and devastating injury. We are reporting a 21-year-old male factory worker who sustained a traumatic open scapulothoracic dissociation. His left arm was caught in conveyer belts resulting the arm, scapula, clavicle, and pectoral muscle torn from the body by tremendous traction force. He presented with pulseless, flail and cold limb and was promptly resuscitated and surgically managed with forequarter amputation.
Forequarter amputation entails surgical removal of entire upper extremity, scapula and clavicle. Several techniques of forequarter amputation have been described. The anterior approach has been the preferred technique of exploration of axillary vessels and brachial plexus. The posterior approach has been condemned to be unreliable and dangerous for most large tumor of the scapula and suprascapular area. We describe a surgical technique using posterior approach of exploration of major vessels for forequarter amputation of upper extremity in eight patients who presented with humeral-scapular tumor. There were six patients with osteosarcoma: three with tumor recurrent and three chemotherapy recalcitrant tumors with vessels involvement. One patient had massive fungating squamous cell carcinoma and another had recurrent rhabdomyosarcoma. Four patients had fungating ulcer and six patients had multiple pulmonary metastases at the time of surgery. The mean estimated blood transfusion was 900 ml (range 0-1600 ml) and two patients did not require transfusion. The duration of surgery ranged 2.5-6.0 hours (mean 3.8 hours). Two patients with known pulmonary metastases required post-operative intensive care monitoring. The mean duration of survival was 5.8 months. The posterior approach of exploring major vessels for forequarter amputation of upper extremity with musculoskeletal tumor is safe and reliable.
The coracoclavicular joints are genetically determined anatomic variants. There are problems in determining their presence by dissection examination of osteologic material as well as by radiography. Based on a survey of published material and a prospective radiological survey carried out in Malaysia, it is clear that the anomaly is more frequent in Asia than in Europe and Africa. There is a high incidence in people from Southern China. The joints are subject to osteophytic marginal lipping without development of symptoms or disability.
The management of post-radiation wound breakdown over the posterior cervico thoracic region can be a challenging task for a surgeon. The aim of the treatment is to produce a well vascularized and a low tensile flap which will close a large defect. We describe the use of the lower trapezius flap to reconstruct the wound breakdown and to obtain stable tissue coverage in a patient with postradiation necrosis. This flap minimizes the disruption of the scapula-thoracic function while preserving the range of movement over the shoulder. From the literature review, it was noted that the dorsal scapular artery (DSA) and transverse cervical artery (TCA) aid in the blood supply to the trapezius muscle and prevent local necrosis during rotation of the flap. The trapezius flap is widely accepted because of the minor donor site morbidity, large arc of rotation and adequate blood supply.
The management of post-radiation wound breakdown over the posterior cervico thoracic region can be a challenging task for a surgeon. The aim of the treatment is to produce a well vascularized and a low tensile flap which will close a large defect. We describe the use of the lower trapezius flap to reconstruct the wound breakdown and to obtain stable tissue coverage in a patient with post- radiation necrosis. This flap minimizes the disruption of the scapula-thoracic function while preserving the range of movement over the shoulder. From the literature review, it was noted that the dorsal scapular artery (DSA) and transverse cervical artery (TCA) aid in the blood supply to the trapezius muscle and prevent local necrosis during rotation of the flap. The trapezius flap is widely accepted because of the minor donor site morbidity, large arc of rotation and adequate blood supply.
Arthroscopic sub acromial debridement surgery with acromioplasty is one of the shoulder surgeries performed to treat chronic shoulder pain. This surgical procedure is usually indicated in sub acromial impingement syndrome of shoulder, degenerative rotator cuff tears, severe functional limitation of shoulder joint and often surgery was performed in cases where all the conservative management had failed in the treatment of chronic shoulder pain. Even though the patient would be referred for early rehabilitation, post operative management of this surgical condition is highly challenging. Movement of the shoulder joint is often related with scapulo-thoracic joint, acromio-clavicular joint and sternoclavicular joint and the shoulder movements are governed by various different muscular forces from these joints. Failure to understand this biomechanical complexity of shoulder joint during post operative rehabilitation results in failure of the surgical outcome and might cause severe functional limitation with recurrent shoulder pain. Often in clinical practice, greater emphasis is given to achieve and regain movements in shoulder joint at the expense of the joint stability. However, inadequate scapular stability might further predispose the shoulder joint to excessive loading and results in repetitive injuries leading to chronic shoulder pain. This might affect the surgical and clinical outcome of the acromioplasty and result in surgical failure. Hence, surgeons and clinicians need to understand the biomechanical contributions in the post operative rehabilitation of the shoulder joint. The present case report emphasises the biomechanical model of post operative rehabilitation of a patient who had arthroscopic sub acromial debridement with acromioplasty.
A 69 year-old man presented with an incidental finding on radiograph of a lesion in the left upper lobe. CT indicated it was likely to be a neoplasm and CT-guided FNA was requested. The lesion was located medial to the scapula so a creative approach was utilised to gain access to the lesion. This study discusses the approach used and why it reduced patient risk compared to a more conventional procedure. The sample was positive for neoplasm and there were no complications arising from the procedure.
Combined latissimus dorsi transfer, subscapularis repair and Latarjet surgery is rare and has never been reported. A 35-year-old man with chronic shoulder pain had a long history of instability of his right shoulder. The first episode occurred during a game of touch rugby followed by multiple episodes of subluxation. MRI was done which showed complete tear of the subscapularis anteriorly which was retracted and atrophied indicating a longstanding tear. There was also significant mid substance supraspinatus tendon tear. Patient then underwent two surgeries. The initial sur- gery found the rotator cuff to be irreparable with glenoid bone loss and only acromioplasty with acromioclavicular joint resection were performed. He then had a single stage surgery consisting of latissimus dorsi transfer, Latarjet procedure and subscapularis repair. A two-stage surgery can be avoided, and good results can be obtained provided that the patient undergo correct rehabilitation regime after undergoing a single stage surgery.
A 29-year-old man, who was a medical intern presented with history of recurrent shoulder dislocation. Radiographs
and computed tomography imaging revealed a bony bankart lesion with glenoid bone loss of 25% with moderate
Hill- Sachs lesion. Latarjet surgery was performed. At post-operative 8 months, the patient experienced pain and
clicking in the left shoulder while performing cardiopulmonary resuscitation. At post-operative 1 year, magnetic resonance arthrography showed a united coracoid graft and intact posterior labrum. Left shoulder diagnostic arthroscopy and removal of Latarjet screws through a limited anterior deltopectoral approach were performed. The symptoms
pain, clicking and instability sense was caused by either the prominent distal screw or the remnant suture material
from the anchor which resulted in impingement of the infraspinatus muscle. We recommend the use of image intensifier to check on the position and length of the screw at the end of the surgery to avoid this complication
Scapulo-thoracic dissociation is an infrequent injury resulting from high energy trauma which is often associated with severe neurological and vascular injuries which may be unrecognised at the time of presentation. A 24 year-old female presented with bilateral rib fractures, pneumothorax, liver and kidney injuries following a road traffic accident. She also sustained fractures of her right scapula, odontoid, right transverse processes of the thoracic and lumbar vertebrae and a closed fracture of her right femur. Her right upper limb was later noted to be flail and pulseless, due to complete right brachial plexus injury, scapula-thoracic dissociation and subclavian artery avulsion. We managed the upper limb injuries non-operatively, and focused on resuscitation of the patient. Early exploration of the complete brachial plexus injury was not undertaken in spite of the possible associated poor functional outcome as there was no life-threatening indication.
Background: Dirofilaria ursi is a filarial nematode that parasitizes the subcutaneous tissues of the American black bear (Ursus americanus) and Japanese black bear (Ursus thiabetanus japonicus). D. ursi that has parasitized black bears has the potential to subsequently infect humans. In addition, extra-gastrointestinal anisakiasis is less common in Japan.
Case presentation: We report a case of ventral subcutaneous anisakiasis and dorsal subcutaneous dirofilariasis that was acquired in Fukushima, in the northern part of Japan. The patient was an 83-year-old Japanese female, and subcutaneous parasitic granulomas were present on her left abdomen (near the navel) and left scapula. A pathological examination of the surgically dissected tissue sections from each region demonstrated eosinophilic granulomas containing different species of parasites. To enable the morphological and molecular identification of these parasites, DNA was extracted from paraffin-embedded sections using DEXPAT reagent, and the cytochrome oxidase 2 (COX2), internal transcribed spacer 1 (ITS1), 5.8S and ITS2 regions of the Anisakis larvae, and the 5S rRNA region of the male Dirofilaria were sequenced. The PCR products were examined and compared with DNA databases. Molecular analysis of the COX2 and 5S rRNA sequences of each worm revealed that the nematode found in the ventral region belonged to Anisakis simplex sensu stricto (s.s.) and the male Dirofilaria found in the dorsal region was classified as D. ursi.
Conclusion: The present case showed a combined human case of D. ursi and A. simplex s.s. infections in subcutaneous tissues. The results of this study will contribute to the identification of unknown parasites in histological sections.