Treatment of scaphoid nonunion by arthroscopic cancellous bone grafting

INTRODUCTION

In order to avoid Scaphoid Nonunion Advanced Collapse (SNAC) type osteoarthritis, which progressively affects the radial and midcarpal joints, several vascularized and non-vascularized grafting techniques have been described. Over the past decade, there has been growing interest in arthroscopic cancellous bone grafts for scaphoid nonunion. The aim of this novel prospective study was to assess the healing rate of scaphoid grafts under arthroscopy, and the prognostic factors for healing.

MATERIAL AND METHODS

This prospective study was carried out across 10 centers between September 2019 and April 2021, in patients aged 16 to 65. Scaphoid nonunion grafting was performed arthroscopically. Union was assessed on CT scans and displacement correction angles were measured preoperatively and then at 3 and 6months. We assessed mobility, Jamar wrist strength, functional results as per the Patient Related Wrist Score (PRWE) and the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score. Risk factors for nonunion were assessed.

RESULTS

We included 77 patients with a mean age of 24years (18 to 55years) with a mean time between trauma and treatment of nonunion of 34.8months (6 to 180months). The population was represented by 46 manual workers and 20 were smokers. In 42 cases, the nonunion was proximal, in Schernberg zone I or II. At the last follow-up of 12.9months on average (Standard Deviation: 8.7months), union was achieved in 72 patients (93.5%). The average duration of union was 3.4months (Standard Deviation 1.6). Among the 5 patients who did not heal, grafting was performed in addition to the fixation. We did not identify any contributory factors for nonunion.

CONCLUSION

This study demonstrated the effectiveness of arthroscopic treatment of scaphoid nonunion with a union rate at least equivalent to pedicled vascularized grafts. Smoking and delayed treatment were no longer considered unfavorable prognostic factors in the context of arthroscopic treatment.

LEVEL OF EVIDENCE

III.

Pyrocarbon interposition implant after lunate resection in Kienböck's disease: A case series

In advanced stages of Kienböck's disease, the lunate is no longer conservable. One of the surgical options is to resect the lunate and replace it with a prosthesis. The procedure consisted in lunate resection and interposition of a free APSI® or Pi2® pyrocarbon implant through a dorsal approach. Follow-up was clinical and radiological on QuickDASH and PRWE scores. At a median follow-up of 3 years, 12 patients were reviewed, with a median age of 56 years. Flexion significantly decreased from 42° to 28° (p < 0.01). Extension and pronation-supination were conserved. Strength was 94% compared to the opposite side, with no significant difference from the preoperative measurement. Median QuickDASH and PRWE scores were 15.9 and 23.5 respectively and had significantly improved. One patient underwent scaphocapitate fusion because she was still in pain; the other patients were pain-free. No patients had to change jobs because of their wrist. Radiographically, there was no carpal collapse and carpal height was conserved. Radioscaphoid angle and ulnar translation were stable. There was 1 case of asymptomatic implant dislocation. Interposition of a pyrocarbon implant after lunate resection in advanced Kienböck's disease is a motion-conserving procedure that provides pain relief and functional recovery in the short and medium term. LEVEL OF EVIDENCE: IV.

Nerve regeneration conduit from inverted human umbilical cord vessel in the treatment of proper palmar digital nerve sections

Treatment of digital nerve injuries, particularly in case of a gap, is challenging. Recovery of finger sensitivity is often incomplete and can impair personal and occupational activity. The need for better nerve regeneration has given rise to alternative treatments such as nerve conduits. This study aimed to evaluate the safety and efficacy of a conduit of freeze-dried inverted human umbilical cord vessel for regeneration in digital nerve section. Twenty-three patients with a mean nerve gap of 6.11 mm (range 2-30 mm and static 2-point discrimination (s2PD) > 15 mm underwent surgical repair of digital nerve section using a nerve regeneration conduit. The primary endpoint was recovery of sensitivity after conduit implantation. Secondary endpoints comprised progression of pain, functional symptoms, pressure threshold, hand-specific symptoms and disabilities, and restored innervation. Mean follow-up was 10.1 ± 4.1 months (range 1-14 months). Sensitivity recovered progressively in the months following implantation. There was a mean decrease of 8.54 mm in s2PD between baseline and last follow-up (p < 0.001). Complete innervation recovered in 83.3% of cases at last follow-up. Pressure threshold and hand-related quality of life improved significantly and symptoms due to nerve sectioning (pain, cold intolerance, hypoesthesia, hyperesthesia) resolved almost completely. There were no safety issues related to the nerve conduit. These results indicate that freeze-dried inverted human umbilical vessels can be a safe and effective option as conduit for digital nerve regeneration.

Inverted human umbilical artery as a 3D scaffold for sciatic nerve regeneration in rats

Treatment of peripheral nerve injuries (PNIs) remains a challenge. Interposing a graft delivers better regenerative outcomes. Autografts present major drawbacks which have given rise to the development of alternatives such as artificial scaffolds, some of which are very promising. This study was designed to investigate the potential use of an inverted human umbilical cord artery (iHUA) as a 3D scaffold nerve chamber, for nerve regeneration after transection of the sciatic nerve (SN) in rats. Rats underwent surgical SN transection in their right hindlimb, followed by suture of the device at the resected stumps. Local tolerance, insert biodegradability and nerve reconstruction over time were thoroughly studied by histopathological and morphometric analysis, completed by functional test assessment of sensitivity and motricity recovery. We have demonstrated that nerve reconstruction in the presence of an iHUA insert is effective. The device is well tolerated and highly biodegraded. Although the regenerated nerve is still immature at the end of our study, signs of sensitivity and partial functional recovery were witnessed, confirming our histological findings. Our results support the potential clinical use of iHUA as a 3D scaffold to bridge nerve discontinuity and guide axonal regrowth in selected cases of PNIs.

Radiological and functional correlation following "SLIC" scapholunate-intercarpal ligamentoplasty at minimum 12 months' follow-up

We report outcomes for scapholunate-intercarpal ligamentoplasty ("SLIC procedure"), performed in 22 patients (mean age at surgery, 39.7 years), for reducible static scapholunate (SL) instability without repairable stump. Patients were evaluated for pain and active wrist range of motion, grip strength, functional scores (QuickDASH and PRWE) and radiological appearance (SL gap, SL angle, radiolunate angle, capitolunate angle), preoperatively and at a mean 28.3 months' follow-up (range 12-65). A CT scan without injection was performed at follow-up to measure the posterior radioscaphoid angle (PRSA). The objective was to assess radiological-functional correlations after SLIC ligamentoplasty and to analyze postoperative PRSA correction. The hypothesis was that correcting the PRSA improves clinical and functional outcomes. Pain on a visual analog scale improved significantly, from 2.7 to 0.7 at rest and from 7 to 3.2 during hand use. Mean wrist flexion was 46.4° and extension 59.1°. Grip strength reached 82.8% of the contralateral value. Functional scores improved significantly. Mean SL angle decreased significantly from 81.1° to 73.5°, and static scapholunate gap from 4.7 mm to 3.6 mm. Scaphoid subluxation was fully corrected in 15 cases (68%). PRSA angle was significantly corrected, from a mean 112.7° to 104.2°. Patients in whom PRSA was corrected showed a tendency for better clinical and subjective outcomes. There was 1 case of scaphoid necrosis, 7 of recurrent static instability, including 3 early at 4 months, 3 of scaphocapitate osteoarthritis, and 5 of carpal collapse with SLAC wrist. There were no significant correlations between clinical and radiological results in the medium term after SL ligamentoplasty by the SLIC procedure. The results were quite good in the medium term and pointed to the importance of correcting rotatory subluxation of the scaphoid, revealed by the PRSA, more than correcting the scapholunate gap.

Arthroscopic Bone Grafting for Scaphoid Nonunion: A Retrospective Study of 42 Cases

Background: The purpose of this retrospective study was to report outcomes of arthroscopic bone grafting and K-wire fixation to treat scaphoid non-union. Methods: We included in at two healthcare facilities, 42 consecutive patients (34 men, 8 women) with a mean age of 25 years (range 15-56 years) with scaphoid non-union of the proximal and middle third without intracarpal deformity or SNAC osteoarthritis. All patients were evaluated (pain, range of motion, strength, function, X-rays) by an independent examiner. Results: At the mean follow-up of 18 months (range 12-56), pain was significantly reduced from 7 to 1 on a visual analogue scale (out of 10). The scores on the Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Patient Rated Wrist Evaluation were improved significantly. At the last review, grip strength was 83% of the contralateral side, the average wrist flexion-extension was 125° and the radioulnar deviation was 58°. Bone union was achieved in 37 cases (88%). The mean time of checking the bone union was 3 months (range, 2-8). Four patients required revision surgery because of failed union. Conclusions: Based on our findings, we found that this procedure can be used as a surgical treatment for scaphoid non-union of the proximal and middle third without intracarpal deformity or osteoarthritis. The arthroscopic bone grafting is a reliable, effective, and minimally invasive procedure.

Presence of an intracompartmental septum detected by ultrasound is associated with the failure of ultrasound-guided steroid injection in de Quervain's syndrome

The purpose of this study was to find clinical or ultrasound characteristics that might predict the failure of conservative treatment in de Quervain's syndrome. A total of 42 ultrasound-guided injections have been performed in 41 patients after clinical and ultrasound examination. Patients were immobilized for 3 weeks with a spica splint cast, and clinically evaluated at 3 and 6 weeks and by phone call at the end of the study. Ultrasound showed a septum between the tendons of the first comportment in 34% of the wrists. At last follow-up (mean 15.6 months after the injection) ten patients (24%) had undergone surgery. When comparing ultrasound and clinical characteristics of the operated and non-operated wrists, we found that patients with a high baseline visual analogue scale, with all positive clinical tests and with a persistent intracompartmental septum, had a significantly higher risk of failure following conservative treatment.

LEVEL OF EVIDENCE

III.

Arthrodesis of thumb interphalangeal and finger distal interphalangeal joints using the intramedullary X-Fuse(®) implant: Retrospective analysis of 38 cases

Various indications exist for thumb interphalangeal and finger distal interphalangeal arthrodesis. Various fixation techniques (compression screws, tension band wiring, K-wires) have been described with fusion rates varying between 80 and 100%. The objective of this study was to evaluate the outcomes of interphalangeal arthrodesis using the X-Fuse(®) intramedullary implant in terms of fusion rate and fusion position. A continuous series of 38 arthrodesis procedures was reviewed retrospectively to determine the fusion rate and evaluate complications linked to this fixation technique. The position of the fused joint was compared to that obtained at the end of the procedure so as to evaluate the reliability of implant placement. The fusion rate was 94.8%; two arthrodeses had to be redone with satisfactory results. A moderate change of less than 10 degrees in the arthrodesis position between the immediate postoperative period and fusion was observed in the frontal and sagittal planes that had no clinical consequences. The fusion rate reported here is similar to the best rates published with other fusion techniques, and few complications occurred. Use of this intramedullary implant seems to be a viable alternative to the other techniques.

[Primary flexor tendons repair in zone 2]

Primary flexor tendon repair is still challenging even in the most experienced hands. With atraumatic surgery, the goal is to suture the tendon in a way that it will be strong enough to allow for tendon gliding without the risk of rupture or adhesions during the 12 weeks needed for the tendon to heal. After reviewing the zone 2 anatomy, the authors describe the state of art for flexor tendon repair along with their personal preferences. Although suture methods and postoperative rehabilitation programs are not universal, most specialized teams now use multistrand suturing techniques with at least 4 stands along with protected and controlled early active mobilization. Although the published rates of failure of the repair or postoperative adhesions with stiffness have decreased, these complications are still a concern. They will continue to pose a challenge for scientists performing research into the mechanics and biology of flexor tendon repairs, especially in zone 2.

[Relationship between midcarpal inclination angle and scaphoid kinematic]

OBJECTIVE

To investigate if there is a correlation between the so-called midcarpal inclination angle and the kinematic behavior of the scaphoid.

PATIENTS AND METHODS

The population studied was 60 patients with postero-anterior radiographs of the wrist in full radial and ulnar deviation. Each patient was assessed for the type of lunate by two independent observers. For each pair of radiographs the Midcarpal Inclination Angle and the Scaphoid Flexion Index (SFI) was determined.

RESULTS

Twenty-three cases were classified as lunate type I, 19 cases as type II. The average midcarpal inclination angle was 55.2° (SD±6.1) for wrists with a lunate type I and 63.8° (DE±6.3) for type II (p<0.0001). There was a significant linear relationship between the midcarpal inclination angle and the Scaphoid Flexion Index (p=0.02).

CONCLUSIONS

The wrists with a midcarpal inclination angle greater than 60° (type II lunate) had a scaphoid rotating according to a "columnar pattern", during radioulnar inclinations (predominant rotation along the sagittal plane), while the wrists with a lunate type I behave according to a "row pattern".

Pi2 spacer pyrocarbon arthroplasty technique for thumb basal joint osteoarthritis

Trapeziectomy associated with a pyrocarbon implant is a recent procedure for thumb basal joint osteoarthritis. The investigators report Pi pyrocarbon implant technique (Tornier Bioprofile, Grenoble, France) for primary thumb basal joint osteoarthritis. The key points of the procedure are preservation of the soft tissue environment during the trapeziectomy, partial trapezoidectomy to medialize the implant, and careful capsuloplasty and ligamentoplasty to stabilize the implant.

Reconstruction for failed trapeziometacarpal implant

Trapeziometacarpal prosthesis by metallic implant is used to treat thumb carpometacarpal osteoarthritis. Many causes of failure have been described whereas revision techniques still remain a challenging surgery. In this article, we describe a revision strategy in a failed metallic cemented trapeziometacarpal implant with major first metacarpal shortening.

The dual mobility socket concept: experience with 668 cases

Long-term results of a retrospective series of primary arthroplasty with the original cementless dual mobility socket (A) and the midterm results with the second generation (B) are reported. In series A (follow-up 16.5 years) 437 total hip arthroplasties (THA) were included and in series B (follow-up five years) 231 hips. The 15-year survival rate was 84.4 ± 4.5% (revision for any reason as endpoint); 30 hips (6.8%) were revised for aseptic loosening. Five THA were revised for dislocation: two early and three after ten years or more. With the second generation socket neither dislocation nor revision for mechanical reasons were observed. The survival rate was 99.6 ± 0.4% (revision for any reason). The prevalence of revision for dislocation was very low in our series. This concept does not avoid wear and aseptic loosening, especially in young active patients, but the long-term stability has been confirmed. Dual mobility can be recommended for patients over 70 years of age and for younger patients with high risk of dislocation.

Crippling of CD3-zeta ITAMs does not impair T cell receptor signaling

We evaluated the importance of CD3-zeta ITAMs in T cell responses by breeding the P14 transgenic TCR into mice in which CD3-zeta chains lacking all or part of their ITAMs were genetically substituted for wild-type CD3-zeta chains. In contrast to the H-Y TCR, the P14 TCR permitted the development of peripheral CD8+ T cells harboring signaling-defective CD3-zeta subunits. The absence of functional CD3-zeta ITAMs did not reduce the spectrum of activation events and effector functions that constitute the normal attributes of mature CD8+ T cells. The only detectable differences were quantitative and noted only when T cells were challenged with suboptimal peptide concentrations. Therefore, the ITAMs present in the CD3-gammadeltaepsilon module are sufficient for qualitatively normal TCR signaling and those present in CD3-zeta have no exclusive role during T cell activation.

The CD3-gammadeltaepsilon and CD3-zeta/eta modules are each essential for allelic exclusion at the T cell receptor beta locus but are both dispensable for the initiation of V to (D)J recombination at the T cell receptor-beta, -gamma, and -delta loci

The pre-T cell receptor (TCR) associates with CD3-transducing subunits and triggers the selective expansion and maturation of T cell precursors expressing a TCR-beta chain. Recent experiments in pre-Talpha chain-deficient mice have suggested that the pre-TCR may not be required for signaling allelic exclusion at the TCR-beta locus. Using CD3-epsilon- and CD3-zeta/eta-deficient mice harboring a productively rearranged TCR-beta transgene, we showed that the CD3-gammadeltaepsilon and CD3-zeta/eta modules, and by inference the pre-TCR/CD3 complex, are each essential for the establishment of allelic exclusion at the endogenous TCR-beta locus. Furthermore, using mutant mice lacking both the CD3-epsilon and CD3-zeta/eta genes, we established that the CD3 gene products are dispensable for the onset of V to (D)J recombination (V, variable; D, diversity; J, joining) at the TCR-beta, TCR-gamma, and TCR-delta loci. Thus, the CD3 components are differentially involved in the sequential events that make the TCR-beta locus first accessible to, and later insulated from, the action of the V(D)J recombinase.

The single positive T cells found in CD3-zeta/eta-/- mice overtly react with self-major histocompatibility complex molecules upon restoration of normal surface density of T cell receptor-CD3 complex

CD3-zeta/eta-deficient mice have small thymuses containing cells that show a profound reduction in the surface levels of T cell receptors and terminate their differentiation at the CD4+CD8+ stage. Rather unexpectedly, CD3- or very low single positive T cells accumulate over time in the spleen and lymph nodes of CD3-zeta/eta-deficient mice after a process dependent on MHC expression. Fusion of these peripheral T cells with a CD3-zeta-positive derivative of the BW5147 TCR-alpha-/beta- thymoma resulted in hybridomas that do express an heterogeneous set of T cell receptor alpha/beta dimers at their surface and at density comparable to those found in hybridomas derived from wild-type peripheral T cells. We have investigated the specificities of these T cell receptors using spleen cells from congenic and mutant mouse strains, and showed that the majority of them readily recognized self-MHC class I or class II molecules. These results demonstrate that by increasing the density and/or output of the T cell receptors expressed in peripheral T cells, one can confer them with the capacity to respond to normal density of self-MHC molecules.

Altered T cell development in mice with a targeted mutation of the CD3-epsilon gene

To determine which CD3 components are required for early T cell development, we generated mice with a targeted mutation of the CD3-epsilon gene and characterized their T cell populations relative to those found in CD3-zeta/eta-and recombinase activating gene (RAG)-deficient mice. In the absence of intact CD3-epsilon subunit, thymocytes do not progress beyond the CD44-/lowCD25+ triple-negative stage and appear to be arrested at the very same developmental control point as RAG-deficient thymocytes. In contrast, the disruption of the CD3-epsilon/eta gene does not totally abrogate the progression through this control point. CD3-epsilon-deficient thymocytes do rearrange their T cell receptor (TCR) beta gene segments and produce low levels of full-length TCR beta transcripts. Taken together, these results establish an essential role for the CD3-epsilon gene products during T cell development and further suggest that the CD3-epsilon polypeptides start to exert their function as part of a pre-TCR through which CD44-/lowCD25+ triple-negative cells monitor the occurrence of productive TCR beta gene rearrangements. Finally, the absence of intact CD3-epsilon polypeptides had no discernible effect on the completion of TCR gamma and TCR delta gene rearrangements, emphasizing that they are probably not subjected to the same epigenetic controls as those operating on the expression of TCR alpha and beta genes.

Normal development and function of natural killer cells in CD3 epsilon delta 5/delta 5 mutant mice

The CD3 epsilon polypeptide contributes to the cell surface display as well as to the signal transduction properties of the T-cell antigen receptor complex. Intriguingly, the distribution of CD3 epsilon is not restricted to T cells, since activated mouse, human, and avian natural killer (NK) cells do express intracytoplasmic CD3 epsilon polypeptides. CD3 epsilon is also present in the cytoplasm of fetal thymic T/NK bipotential progenitor cells, suggesting that it constitutes a component of the NK differentiation program. We report here that the genetic disruption of CD3 epsilon exon 5 alters neither NK cell development nor in vitro and in vivo NK functions, although it profoundly blocked T-cell development. These results support the notion that CD3 epsilon is dispensable for mouse NK cell ontogeny and function and further suggest that the common NK/T-cell progenitor cell utilizes CD3 epsilon as a mandatory component only when differentiating toward the T-cell lineage.

[Left ventricular dilatation after primary transmural anterior myocardial infarction. Influence of the percentage of akinesia on echocardiography]

The aim of this study was to determine whether the percentage of akinesia on echocardiography during the acute phase of transmural anterior myocardial infarction could predict secondary left ventricular dilatation. The study group comprised 24 patients (18 men and 6 women) with an average age of 59 years. The patients underwent two echocardiographic examinations, the first during the acute (< 72 hours) phase and the second, 6 months later. Ventricular volumes were calculated by the ellipse monoplane method in the apical 4 chamber view. The percentage of akinesia was defined as the ratio between the length of the akinetic segment and the left ventricular end diastolic perimeter in the apical 4 chamber view. An increase in end diastolic volume (83 +/- 25 vs 62 +/- 18 ml/m2; p < 0.01) and in end systolic volume (51 +/- 27 vs 34 +/- 11 ml/m2; p < 0.01) was observed 6 months after infarction without a significant change in ejection fractions (42 +/- 17% vs 44 +/- 10%). The percentage of akinesia in the acute phase was > 30% in 15 patients (Group I) and < 30% in 9 patients (Group II). The increase in ventricular volumes at 6 months after infarction was significant in Group I (p < 0.02) but not in Group II. At 6 months after infarction, the end systolic volumes were greater (60 +/- 27 vs 37 +/- 22 ml/m2, p < 0.5) and the ejection fractions were lower (35 +/- 13% vs 53 +/- 18%, p < 0.01) in Group I than in Group II.(ABSTRACT TRUNCATED AT 250 WORDS)

[Variations in the distribution of bronchial arteries. Apropos of 72 arteriographies]

Anatomic distribution of bronchial arteries was studied by arteriography, and evaluation conducted of 72 images considered as being complete. Seven frequent types of distribution were note and findings compared with those of previous studies. Frequency of collateral circulation and of anastomosis was comparable with that reported in the literature. One new distribution pattern was observed: common lower trunk, right upper intercostobronchial trunk, left upper trunk.