Amr W. ElMaraghy

A systematic review and comprehensive classification of pectoralis major tears.

BACKGROUND Reported descriptions of pectoralis major (PM) injury are often inconsistent with the actual musculotendinous morphology. The literature lacks an injury classification system that is consistently applied and accurately reflects surgically relevant anatomic injury patterns, making meaningful comparison of treatment techniques and outcomes difficult. MATERIALS AND METHODS Published cases of PM injury between 1822 and 2010 were analyzed to identify incidence and injury patterns and the extent to which these injuries fit into a classification category. Recent work outlining the 3-dimensional anatomy of the PM muscle and tendon, as well as biomechanical studies of PM muscle segments, were reviewed to identify the aspects of musculotendinous anatomy that are clinically and surgically relevant to injury classification. RESULTS We identified 365 cases of PM injury, with 75% occurring in the last 20 years; of these, 83% were a result of indirect trauma, with 48% occurring during weight-training activities. Injury patterns were not classified in any consistent way in timing, location, or tear extent, particularly with regard to affected muscle segments contributing to the PMs bilaminar tendon. CONCLUSIONS A contemporary injury classification system is proposed that includes (1) injury timing (acute vs chronic), (2) injury location (at the muscle origin or muscle belly, at or between the musculotendinous junction and the tendinous insertion, or bony avulsion), and (3) standardized terminology addressing tear extent (anterior-to-posterior thickness and complete vs incomplete width) to more accurately reflect the musculotendinous morphology of PM injuries and better inform surgical management, rehabilitation, and research.

Three-dimensional study of pectoralis major muscle and tendon architecture.

A thorough understanding of the normal structural anatomy of the pectoralis major (PM) is of paramount importance in the planning of PM tendon transfers or repairs following traumatic PM tears. However, there is little consensus regarding the complex musculotendinous architecture of the PM in the anatomic or surgical literature. The purpose of this study is to model and quantify the three‐dimensional architecture of the pectoralis muscle and tendon. Eleven formalin embalmed cadaveric specimens were examined: five (2M/3F) were serially dissected, digitized, and modeled in 3D using Autodesk® Maya®; six (4M/2F) were dissected and photographed. The PM tendon consisted of longer anterior and shorter posterior layers that were continuous inferiorly. The muscle belly consisted of an architecturally uniform clavicular head (CH) and a segmented sternal head (SH) with 6–7 segments. The most inferior SH segment in all specimens was found to fold anteriorly forming a trough that cradled the inferior aspect of the adjacent superior segment. No twisting of either the PM muscle or tendon was noted. Within the CH, the fiber bundle lengths (FBL) were found to increase from superior to inferior, whereas the mean FBLs of SH were greatest in segments 3–5 found centrally. The mean lateral pennation angle was greater in the CH (29.4 ± 6.9°) than in the SH (20.6 ± 2.7°). The application of these findings could form the basis of future studies to optimize surgical planning and functional recovery of repair/reconstruction procedures. Clin. Anat. 22:500–508, 2009.

Subacromial morphometric assessment of the clavicle hook plate

BACKGROUND Clavicle hook plates are an effective plate fixation alternative for distal clavicle fractures and severe acromioclavicular joint dislocations. However, post-operative complications associated with the subacromial portion of the hook include acromial osteolysis and subacromial impingement. We examine and quantify the three-dimensional position of the subacromial portion of the hook plate relative to surrounding acromial and subacromial structures in a series of cadaveric shoulders to determine if hook positioning predisposes the shoulder to these noted post-operative complications. MATERIALS AND METHODS Fifteen cadaveric shoulders (seven males, eight females) were implanted with 15- or 18-mm hook plates. Dimensions of the acromion and hook plate were digitised and reconstructed into a three-dimensional model to measure acromion dimensions and distances of the subacromial hook relative to surrounding acromial and subacromial structures. RESULTS Inter-specimen dimensions of the acromion were highly variable. Mean acromion width and thickness were greater in males than in females (p=0.01). The posterior orientation of the subacromial hook varied widely (mean posterior implantation angle=32.5+/-20 degrees, range 0-67 degrees). The hook pierced the subacromial bursa in 13/15 specimens, made contact with the belly of the supraspinatus muscle in 9/15 specimens, and had focal contact at the hook tip with the undersurface of the acromion in 9/15 specimens. CONCLUSIONS The wide range of acromial dimensions leads to a high degree of variability in the positioning of the subacromial hook. The observed frequency of hook contact with surrounding subacromial structures in a static shoulder confirms that the position of the hook portion of the implant can predispose anatomic structures to the post-operative complications of subacromial impingement and bony erosion.

Improving the Rapid and Reliable Diagnosis of Complete Distal Biceps Tendon Rupture A Nuanced Approach to the Clinical Examination

Background: Diagnosis of complete distal biceps tendon rupture (DBTR) is frequently missed or delayed on clinical examination. No single clinical test, including MRI, has demonstrated 100% efficacy in assessing the integrity of the distal biceps tendon. Hypothesis: Combining 3 validated clinical tests for identifying complete rupture can maximize a true-positive diagnosis for complete DBTR without the need for confirmatory soft tissue imaging when performed in concert with other important factors from the history and clinical examination. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: The hook test, the passive forearm pronation (PFP) test, and the biceps crease interval (BCI) test were applied in sequence in conjunction with a standard patient history and physical examination on 48 patients with suspected distal biceps tendon injuries. If results on all 3 special tests were positive for complete rupture, the patient was referred for surgical repair; diagnosis was confirmed intraoperatively. If results on all 3 special tests were negative, diagnosis was confirmed with soft tissue imaging and patients were managed nonoperatively. If results of the 3 tests were not in agreement, soft tissue imaging was used to clarify the disagreement and to confirm the diagnosis. Results: Thirty-five patients had unequivocal results based on history, physical examination, and special tests. Thirty-two tested in agreement positive for complete rupture, which were confirmed intraoperatively. Three tested in agreement negative, with subsequent imaging confirming partial rupture. Thirteen patients had equivocal special test results; soft tissue imaging suggested complete rupture in 10 and partial rupture in 3. Conclusion: Application in sequence of the hook test, the PFP test, and the BCI test results in 100% sensitivity and specificity when the outcomes on all 3 special tests are in agreement.

Venous thromboembolism after shoulder arthroplasty: a systematic review.

BACKGROUND Shoulder arthroplasty (SA) is a common orthopaedic procedure that is being performed on a more and more frequent basis. Venous thromboembolism (VTE) as a complication has received little attention when it occurs after SA. The literature lacks a comprehensive summary of the incidence, risk factors, and prophylaxis of VTE in this population of patients. METHODS Literature on VTE after SA has been identified from 5 scientific databases: EMBASE, MEDLINE, Web of Science, CINAHL, and Cochrane. All primary full-text articles reporting at least 1 case of deep vein thrombosis or pulmonary embolism after SA were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, thromboprophylaxis, diagnosis, and management of VTE after SA. RESULTS This study included 14 articles. The reported incidence of VTE after SA was 0.2% to 16.0%. The most serious risk factors for development of VTE included history of VTE, thrombophilia, major surgery, advanced age, current malignant disease, immobility, and bed confinement. Diagnosis was typically determined by duplex scan and chest computed tomography scan. VTE prophylaxis was used in 6 (43%) of the included studies, with the ideal method of prophylaxis unknown. CONCLUSIONS Although variability exists in the reported incidence of VTE, surgeons should still be aware of the potential for this serious complication after SA. We recommend assessing the risk factors and estimating the VTE risk status for all patients undergoing SA. The ideal method of prophylaxis for this population of patients remains unknown and should be investigated in future high-quality clinical studies.

Metacarpophalangeal joint extensor tendon subluxation: a reconstructive stabilization technique.

Extensor tendon subluxation can result from a disruption to the extensor retinacular system and/or the sagittal band at the metacarpophalangeal joint. When conservative treatment is insufficient to correct the subluxation, surgical treatment is necessary and various surgical techniques exist. We present a novel stabilization technique to centralize the extensor tendon using a junctura tendinum to lengthen an extensor digitorum communis tendon graft. This technique is simple and effective, creating a strong repair without associated stiffness. To achieve a less morbid, stable repair, we mimicked normal anatomy with minimal disruption to local soft tissue structures. This technique seems to offer biomechanical advantages over previously described techniques and shows successful treatment in the illustrated patient.

Bone tunnel fixation for repair of tibialis anterior tendon rupture

Atraumatic rupture of the tibialis anterior tendon is rare, and due to the mild nature of pain symptoms, affected patients often present weeks or months after rupture. Surgical management is advocated to restore function in active patients, and historically suture anchors have been the preferred method for repairing the ruptured tendon directly to bone. We present a case of acute, atraumatic tibialis anterior tendon rupture that was anatomically repaired using a novel application of a bone tunnel fixation technique. We describe the surgical procedure and the outcome measures used to evaluate post-operative results in this case.

A 3-Dimensional Anatomic Study of the Distal Biceps Tendon: Implications for Surgical Repair and Reconstruction

Background Complete rupture of the distal biceps tendon from its osseous attachment is most often treated with operative intervention. Knowledge of the overall tendon morphology as well as the orientation of the collagenous fibers throughout the musculotendinous junction are key to intraoperative decision making and surgical technique in both the acute and chronic setting. Unfortunately, there is little information available in the literature. Purpose To comprehensively describe the morphology of the distal biceps tendon. Study Design Descriptive laboratory study. Methods The distal biceps terminal musculature, musculotendinous junction, and tendon were digitized in 10 cadaveric specimens and data reconstructed using 3-dimensional modeling. Results The average length, width, and thickness of the external distal biceps tendon were found to be 63.0, 6.0, and 3.0 mm, respectively. A unique expansion of the tendon fibers within the distal muscle was characterized, creating a thick collagenous network along the central component between the long and short heads. Conclusion This study documents the morphologic parameters of the native distal biceps tendon. Reconstruction may be necessary, especially in chronic distal biceps tendon ruptures, if the remaining tendon morphology is significantly compromised compared with the native distal biceps tendon. Knowledge of normal anatomical distal biceps tendon parameters may also guide the selection of a substitute graft with similar morphological characteristics. Clinical Relevance A thorough description of distal biceps tendon morphology is important to guide intraoperative decision making between primary repair and reconstruction and to better select the most appropriate graft. The detailed description of the tendinous expansion into the muscle may provide insight into better graft-weaving and suture-grasping techniques to maximize proximal graft incorporation.

Utility of the Pectoralis Major Index in the Diagnosis of Structurally Significant Pectoralis Major Tears

Background: Diagnosis of pectoralis major tears early in the acute phase is important for optimizing surgical repair and outcomes. However, physical examination of pectoralis major injuries can be misleading, often resulting in a potentially detrimental delay in surgical treatment. Purpose: To establish and validate a quantifiable clinical diagnostic test for structurally significant pectoralis major tears. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A total of 50 healthy male participants (mean age, 43.3 ± 11.9 years) with normal uninjured pectoralis major anatomy were examined. Digital photographs of all participants were taken in the “military press” starting position (90° of shoulder abduction, 90° of shoulder external rotation). The length between the ipsilateral nipple and the apex of the pectoralis major muscle curvature along the anterior axillary fold, known as the pectoralis major distance, was measured bilaterally. Two orthopaedic surgeons measured all photographs on 2 separate occasions. The pectoralis major index (PMI) was calculated as a ratio of pectoralis major distance values to establish normal values. The PMI was also calculated in a cohort of 19 male patients (mean age, 33.8 ± 6.8 years) with a pectoralis major rupture to assess the diagnostic utility of this novel quantifiable physical examination technique. Results: Mean (± standard deviation) PMI for the uninjured group was 1.0 ± 0.07. A diagnostic threshold of a PMI <0.9 resulted in a sensitivity of 79%, specificity of 98%, and overall accuracy of 93% in identifying structurally significant pectoralis major ruptures. There was no correlation between PMI and age or activity level, including participation in sports and/or weight training. The PMI technique demonstrated good to excellent intrarater reliability (intraclass correlation coefficient [ICC] = 0.82, 0.74) and interrater reliability (ICC = 0.63, 0.76). Conclusion: The PMI technique is a simple, quantifiable, and accurate clinical diagnostic test for structurally significant pectoralis major tears. Routine application of the PMI technique by clinicians may improve accurate identification of structurally significant rupture and expedite referral to a surgical specialist for optimal treatment and outcome.

Unrecognized Isolated Medial Trochlear Fracture Leading to Malunion

Case:A twenty-year-old woman presented with an isolated intra-articular fracture of the medial part of the trochlea twelve weeks after a traumatic fall. The fracture had gone undetected during the initial twelve weeks following injury, resulting in an anteriorly and superiorly displaced malunion and severe range-of-motion restrictions of the elbow. Conclusion:Vigilant clinical examination is imperative to avoid missing this uncommon fracture pattern and complication. Prompt surgical management is necessary to ensure that adequate healing is achieved and to avoid unnecessary complications. This case report demonstrates that an excellent clinical outcome can be achieved with intra-articular osteotomy and anatomic fixation of the malunited segment.