High Rates of Union Following Arthroscopic Treatment of Scaphoid Non-Union: Systematic Review

PURPOSE

To synthesize and analyze the existing literature and report on the outcomes of arthroscopic surgery for the treatment of scaphoid non-union (SNU).

METHODS

This systematic review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The authors conducted a search using Medline and Embase databases. Studies that reported outcomes on arthroscopic nonvascularized bone graft for SNU treatment, with no limits to follow-up, sample sizes or prevalence were included.

RESULTS

We found 17 eligible studies composed of 20 datasets, and all assessed nonvascularized arthroscopic treatment for SNU, with a mean follow-up that ranged from 6 to 38.5 months. Union rates ranged between 86% and 100%, and none of the studies reported any other complications than non-union following arthroscopic SNU.

CONCLUSIONS

The present systematic review found union rates ranging between 86% and 100%, with a time to union ranging from 2.3 to 7.8 months. Furthermore, the included studies reported satisfactory clinical scores, and the complication rate of non-union ranged between 0% and 14%.

LEVEL OF EVIDENCE

Level IV, systematic review of level II-IV studies.

A New Arthroscopic Classification of Triangular Fibrocartilage Complex Disorders

Introduction  The use of wrist arthroscopy has become a prerequisite for diagnosis and treatment of triangular fibrocartilage complex (TFCC) disorders. Since Palmer's landmark paper, many new arthroscopic descriptions of TFCC tears have been published but there is no currently available updated comprehensive arthroscopic classification of TFCC lesions. Purpose  We recently described the arthroscopic anatomy of the TFCC as viewed from a 3-4 portal. Our purpose was to propose a new TFCC disorders classification based on this new arthroscopic TFCC description. Methods  We included all currently described TFCC disorders to the best of our knowledge into our arthroscopic, functional, and vascular anatomical concept. We also included patient's specific ulnar variance and distal radial ulnar joint coronal inclination as baseline treatment-oriented parameters. The fresh or chronic, reparable or nonreparable nature of some types of TFCC tears were considered as separate parameters. Results  The proposed classification includes disc "D" (degenerative or traumatic), reins "R" (traumatic), and wall "W" (traumatic) lesions. Combined lesions of those three parts of the TFCC may be easily identified. This new classification should facilitate future analysis of isolated or combined TFCC disorders whether they are degenerative and/or traumatic. Discussion  The authors present a new three-dimensional-three-part arthroscopic updated description of TFCC disorders with relevance to etiology and treatment principles.

The impact of war on the development and progression of arterial hypertension and cardiovascular disease: protocol of a prospective study among Ukrainian female refugees

Background

Growing evidence supports the impact of psychological factors such as traumatic experiences and Post Traumatic Stress Disorder (PTSD) on the incidence of arterial hypertension (HTN) and cardiovascular diseases (CVD). The war in Ukraine is exposing million inhabitants to traumatic experiences and severe stress. Part of Ukrainians (mostly women and children) left the country to escape war. We report the protocol of a prospective study aiming at the assessment of the impact of war-induced stress on HTN and CVD in women Ukrainian refugees who moved to Poland.

Methods and design

The study will be conducted in 3 stages. Stage 1 will assess the prevalence of HTN and PTSD among Ukrainian refugees and will estimate the impact of war-related trauma exposure on these parameters. Data on office blood pressure (BP) will be compared to data already collected in STEPS data 2019 and May Measurement Month 2021 in Ukraine, matched for age and sex. Stage 2 will involve subjects diagnosed with HTN and/or PTSD referred for management and follow-up of these conditions. Psychologic targeted therapies will be offered to subjects with confirmed PTSD, with a periodical reassessment of the severity of PTSD-associated symptoms and of its impact on HTN and cardiovascular health. Clinical history and characteristics will be compared among three groups: subjects with HTN and PTSD, with HTN without PTSD, with PTSD but without HTN. Stage 3 will involve a subgroup among those screened in Stage 1, with the objective of investigating the biological mechanisms underlying the relation between HTN and trauma exposure, identifying early signs of subclinical target organ damage in subjects with HTN with/without PTSD.

Discussion

This study will test the hypothesis that trauma exposure and psychological stress contribute to BP elevation and progression of CVD in this population. It will provide new evidence on the effect of an integrated management, including psychological therapy, on BP and cardiovascular risk. Such approach may be further tested and extrapolated to other populations exposed to war and chronic violence, migrants and refugees around the world.

Research Study Registration

number 2022/45/P/NZ5/02812.

Total Wrist Arthroplasty: An International Perspective

Concerns about implant durability and technical difficulty continue to make total wrist arthroplasties a specialized procedure with a narrow scope of indications. As a result, more routinely performed total or partial wrist arthrodesis continues to maintain popularity over arthroplasty. However, wrist motion preservation is undoubtedly preferable for patients and current literature is trending to more favorable outcomes for total wrist arthroplasties. In the setting of the evolving role of wrist arthroplasties in clinical practice, it is important to focus on providing hand surgeons a practical approach to incorporating total wrist arthroplasty into the treatment toolbox available to them when treating patients with painful wrist arthritis.

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.

Role for Wrist Hemiarthroplasty in Acute Irreparable Distal Radius Fracture in the Elderly

Volar locking plates for distal radius fracture (DRF) in the elderly may show complications in the most comminuted osteoporotic cases. The authors provide criteria for DRF in elderly that may not be amenable to volar plating ("irreparable DRF") and review the current results of a preliminary series of wrist hemiarthroplasty for these injuries. Between 2011 and 2019, 28 wrists with acute irreparable intra-articular DRF were treated with wrist hemiarthroplasty (96% female, mean age 79 years). A total of 17 wrists with a mean follow-up of 32 months were reviewed. At follow-up, mean visual analog scale (VAS) pain was 1/10, mean forearm rotation arc was 148°.

Perspectives on improving blood pressure control to reduce the clinical and economic burden of hypertension

The clinical and economic burden of hypertension is high and continues to increase globally. Uncontrolled hypertension has severe but avoidable long-term consequences, including cardiovascular diseases, which are among the most burdensome and most preventable conditions in Europe. Yet, despite clear guidelines on screening, diagnosis and management of hypertension, a large proportion of patients remain undiagnosed or undertreated. Low adherence and persistence are common, exacerbating the issue of poor blood pressure (BP) control. Although current guidelines provide clear direction, implementation is hampered by barriers at the patient-, physician- and healthcare system levels. Underestimation of the impact of uncontrolled hypertension and limited health literacy lead to low adherence and persistence among patients, treatment inertia among physicians and a lack of decisive healthcare system action. Many options to improve BP control are available or under investigation. Patients would benefit from targeted health education, improved BP measurement, individualized treatment or simplified treatment regimens through single-pill combinations. For physicians, increasing awareness of the burden of hypertension, as well as offering training on monitoring and optimal management and provision of the necessary time to collaboratively engage with patients would be useful. Healthcare systems should establish nationwide strategies for hypertension screening and management. Furthermore, there is an unmet need to implement more comprehensive BP measurements to optimize management. In conclusion, an integrative, patient-focused, multimodal multidisciplinary approach to the management of hypertension by clinicians, payers and policymakers, involving patients, is required to achieve long-term improvements in population health and cost-efficiency for healthcare systems.

Outcomes of arthroscopic versus open reduction and internal fixation for the treatment of acute traumatic lunate fractures: a systematic review

The purpose of the study was to compare outcomes of fully-arthroscopic reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) to treat acute traumatic lunate fractures. A literature search was conducted using Medline and Embase. Demographic data and outcomes were extracted for included studies. The search identified 2,146 references: 17 articles were included, reporting on 20 cases (4 ARIF and 16 ORIF). No differences between ARIF and ORIF were found in rate of union (100% vs 93%, P = 1.000), grip strength (mean difference, 8%; 95%CI, -16-31; P = 0.592), rate of return to work (100% vs 100%, P = 1.000), or range of motion (mean difference, 28°; 95%CI, -25-80; P = 0.426). Lunate fractures were not identified in 6 of the 19 radiographs, but were identified in all CT scans. There were no differences in outcome between ARIF and ORIF for the treatment of fresh lunate fracture. The authors recommend surgeons to perform CT scans when diagnosing high-energy wrist trauma so as not to overlook lunate fractures. LEVEL OF EVIDENCE: Level IV.

New Computerized Elbow and Forearm Clinical Scores

Background  Current elbow clinical scores are scarce with limited comparability between them. None of them are computerized yet. There is no forearm clinical score assessing all anatomical components of forearm disorders such as the Essex-Lopresti injuries. The aims of this paper were to present new computerized elbow and forearm clinical scores. Methods  These new computerized elbow and forearm clinical scores include four clinical criteria: pain, function, active range of motion and muscle strength. To each criterion is given a numerical value among 5 grades. The weight of each criterion is equivalent so that patient's and physician's related scores are equally balanced. Results  Clinical scores components are automatically included into diamond-shape graphs and tables that can be directly exported into PowerPoint presentations for demonstration and comparison purposes. Discussion  These user-friendly updatable clinical elbow and forearm scores are based on four classic clinical criteria, pain, function, motion, and strength that are expressed into grades. They were designed to evaluate any osteoarticular elbow or forearm disorder regardless of the etiology. These scores are open since they may be modified in future versions.

Arthroscopically Assisted Treatment of Volar Rim Fractures

Background  Arthroscopically-assisted reduction and internal fixation (AARIF) for distal radius fractures (DRF) has been extensively described. Little information is available about AARIF in AO "B3" and "C" DRF with displaced lunate facet volar rim fragment (VRF) and volar carpal subluxation. However, lunate volar rim fragment (LVRF) may be very difficult to reduce and fix under arthroscopic control using the flexor carpi radialis (FCR) or FCR extended approaches while traction is applied. Purposes  The aims were to describe our surgical technique of AARIF of partial or complete DRF with VRF and provide information about how often this technique may be necessary, based on a large DRF database. Methods  The dual-window volar approach for complete articular AO C DRF with volar medial fragment was described in 2012 for performing open reduction internal fixation (ORIF). Since 2015, we have used the dual-window approach for AARIF of "B3" or "C" DRF with volar carpal subluxation. We analyzed our PAF database, searching for patients treated with AARIF in "B3" and "C" fractures. Results  The dual-window volar approach is very useful when using AARIF for AO "B3" and "C" DRF with displaced VRF and volar carpal subluxation. The anteromedial part of the exposure allows a direct access to reduction and fixation of the LVRF under traction and arthroscopic control. Overall, 1% of all articular DRF in this series showed a displaced LVRF amenable to the dual-window volar approach. Conclusion  It is almost impossible to access and properly fix a VRF using traction and arthroscopic control through the FCR or FCR extended FCR approach because of the stretched flexor tendon mass. The use of the dual-window approach during AARIF of AO "B3" or "C" DRF has not previously been reported. Displaced VRF are rare whether they were part of "B3" or "C" fractures. If AARIF is chosen, we strongly recommend the use of the dual-window volar approach for AO "B3" and "C" fractures with VRF. A single anteromedial approach can also be used for isolated "B3" anteromedial DRF.

Reverse Perilunate Injuries-The "Extended Scaphoid" Sign

Background  Reverse perilunate injuries (REPLI) are rare variants of the classic radial-sided perilunate injuries (PLI) whose mechanism was described by Mayfield in 1980. Classic radial-sided nontranscaphoid dorsal PLI invariably display a flexed, foreshortened position of the scaphoid on their initial posteroanterior (PA) and lateral radiographs. We observed that some dorsal perilunate dislocations displayed an extended position of the scaphoid on their initial radiographs. Our hypothesis is that this extended position of the scaphoid was associated with a REPLI pattern. Methods  The PA and lateral initial emergency radiographs of our specialized wrist surgery series of 114 dorsal pure ligamentous PLI (within a 186 cases series of PLI treated between 2004 and 2020) were reviewed as well as the available figures of the current REPLI literature. Results  A total of seven cases of cases within our dorsal PLI series displayed an extended position of the scaphoid on their initial PA and lateral radiographs, while 107 cases displayed a flexed, foreshortened position. The PA and lateral radiographs available in the REPLI literature displayed an extended position of the scaphoid, a lunotriquetral dissociation, and a dorsal dislocation of the capitate with respect to the lunate. Discussion  This study confirms our hypothesis. By contrast to the dorsal classic radial-sided pure ligamentous PLI pattern of scaphoid displacement (scaphoid flexed and foreshortened with scapholunate gap), the dorsal REPLI pattern displays an extended position of the scaphoid with scapholunate step-off and overlap rather than a gap. The combination of a lunotriquetral dissociation with a dorsal dislocation of the capitate from the lunate yet an extended position of the scaphoid with almost normal radioscaphoid relationships should raise a high suspicion for REPLI.

Does Proximal Hamate Graft for Proximal Scaphoid Reconstruction Restore Native Wrist Kinematics?

BACKGROUND

The objective of this study was to determine whether reconstruction of the proximal pole of the scaphoid with a proximal hamate graft restores native carpal kinematics.

METHODS

A cadaveric study was designed assessing wrist kinematic after proximal hamate graft for proximal pole of the scaphoid nonunion. Wireless sensors were mounted to the carpus using a custom pin and suture anchor system to 8 cadavers. A wrist simulator was used to move the wrist through a cyclical motion about the flexion/extension and radial/ulnar deviation axes. Each specimen was tested under a series of 3 conditions: (1) a native state, "Intact"; (2) fractured scaphoid proximal pole, "Fracture"; and (3) post-reconstruction of the proximal pole of the scaphoid using a proximal hamate graft, "Graft."

RESULTS

The fracture condition resulted in a statistically significant change in scapholunate kinematics across the entire arc of motion relative to the intact condition. Reconstruction with proximal hamate grafts restored scapholunate kinematics close to the intact state in both flexion/extension and radial/ulnar deviation axes. The lunocapitate flexion during wrist flexion was significantly different after the hamate graft reconstruction.

CONCLUSIONS

Proximal hamate to scaphoid transfer resulted in restoration of near normal carpal kinematics to the intact state.

Arthroscopic Anatomy of the TFCC with Relevance to Function and Pathology

Introduction  The authors present a new comprehensive arthroscopic anatomical description of the fibrocartilage complex "TFCC" which is related to the current TFCC functional and pathological knowledge. Methods  Our description of the TFCC is based on an arthroscopic view from the 3-4 portal as observed in more than 100 wrist arthroscopies in fresh cadavers and more than 1000 diagnostic and/or therapeutic wrist arthroscopies. Results  TFCC is considered as a 3-D-3-part box-like structure (Reins, Wall and Disc). The first TFCC component ("R") corresponds to 2 strong radio-ulnar ligamentous Reins, one dorsal (DRUL) and one palmar (PRUL). This "V-shaped" RUL reins diverge from the fovea and ulnar styloid to the volar and dorsal edges of the sigmoid notch. It is a main stabilizer of the DRUJ. The second TFCC component ("W") is a continuous, radially concave Peripheral Capsular Wall attached and perpendicular to the RUL reins. It surrounds the ulnar aspect of the ulno-carpal interval while attaching to the RUL reins proximally and to the medial carpus distally. Along with the radiocarpal ligaments, the TFCC peripheral capsular wall contributes to the stability of the carpus with respect to the radius-ulna entity. This is especially true for the thick volar TFCC capsular wall. The third TFCC component ("D") is the disc proper which is a static and dynamic shock absorber intercalated between the ulnar head and the medial proximal row in the coronal/sagittal planes and between the two strands of the RUL in the axial plane. Its pathology is influenced and related to the ulnar variance. Discussion  This new arthroscopic description of the TFCC provides a comprehensive anatomical, functional ant pathological background for TFCC disorders analysis and treatment. Currently known disorders are included as "R 1,2,3,4", "W 1, 2, 3, 4", and "D 1, 2". Combined TFCC disorders and further new pathology descriptions may be included in this open classification.

Comparative Analysis of 3 Techniques of Scapholunate Reconstruction for Dorsal Intercalated Segment Instability

PURPOSE

The combination of scaphoid rotatory subluxation, dorsal intercalated segment instability, and dorsal scaphoid translation (DST) constitutes stage 5 scapholunate dissociation in the modified classification system of Garcia-Elias. The purpose of this study was to compare the static radiographic outcomes of reduction and association of the scaphoid and lunate (RASL), three-ligament tenodesis (TLT), and anatomic front and back (ANAFAB) reconstructions for stage 5 scaphoid and lunate malrotation and translation.

METHODS

Stage 5 scapholunate dissociation was created in 15 fresh-frozen specimens by cutting the scapholunate interosseous ligament, long radiolunate ligament, dorsal intercarpal ligament, and scaphotrapeziotrapezoid ligament complex. Specimens were randomized to receive 1 of the 3 reconstructive techniques. Radiolunate angle (RLA), scapholunate angle, scapholunate gap, and DST were measured in static fluoroscopic posteroanterior and lateral views in 3 conditions: baseline, injured, and reconstructed.

RESULTS

Reduction and association of the scaphoid and lunate showed an improved correction of scapholunate gap compared with TLT and ANAFAB. Anatomic front and back demonstrated an improved correction in RLA and scapholunate angle compared with RASL but not TLT. When the reconstruction was compared with baseline, there was a persistent lunate extension for TLT (RLA and scapholunate angle) and RASL (RLA); however, no significant difference in any parameter was found with ANAFAB. Anatomic front and back significantly improved DST, whereas TLT and RASL did not.

CONCLUSIONS

In this cadaveric model of scapholunate dissociation with dorsal intercalated segment instability and DST, each of the 3 repairs had different effects on carpal posture and alignment. While only RASL statistically improved scapholunate gap, only ANAFAB significantly improved DST. Both TLT and RASL improved radiographic parameters; however, each had a persistent increase in the lunate extension following reconstruction.

CLINICAL RELEVANCE

It may be prudent to consider different reconstructive techniques for different stages of scapholunate instability. Anatomic front and back, a repair that addresses both dorsal and volar ligament stabilizers, provides improved reduction of dorsal intercalated segment instability and DST in stage 5 scapholunate dissociation.

Dry Wrist Arthroscopy in the Management of Ulnar Wrist Pain Disorders

The use of wrist arthroscopy has evolved to being a powerful tool to not only diagnose but also treat wrist disorders. With the improvement in technology and surgical technique, many of the procedures can be done using dry wrist arthroscopy (DWA). DWA can be used to treat a wide spectrum of ulnar wrist disorders. In this article, we aim to highlight some technical pearls as well as show its use to treat common ulnar wrist pain disorders.

Revision Elbow Arthroplasty Using a Proximal Ulnar Allograft with Allograft Triceps for Combined Ulnar Bone Loss and Triceps Insufficiency

BACKGROUND

When revision elbow arthroplasty is required in the presence of structural proximal ulnar bone loss and triceps insufficiency, structural ulnar bone-grafting and triceps reconstruction are both required to reconstruct the skeleton and to restore active extension. We have developed a technique utilizing a structural proximal ulnar allograft with its attached triceps as an allograft-prosthetic composite (APC) to provide reconstruction of the proximal ulnar bone and deficient extensor mechanism with the same allograft.

METHODS

Between 2010 and 2017, the senior author performed 10 revision elbow arthroplasties using a proximal ulnar allograft with its intact triceps tendon allograft. The allograft ulna was combined with an ulnar component in an APC fashion, whereas the remaining triceps was repaired to the triceps allograft. Indications for a revision surgical procedure included aseptic loosening in 4 elbows, periprosthetic ulnar fracture with component loosening in 2 elbows, and the second stage of a 2-stage reimplantation in 4 elbows. Two elbows also required humeral APCs due to associated structural humeral bone loss. Postoperatively, all elbows were immobilized in extension for 6 weeks. The mean follow-up time was 45 months (range, 24 to 76 months).

RESULTS

Revision elbow arthroplasty resulted in pain improvement in all elbows in a 10-point visual analog scale. The mean flexion-extension arc was 95°, the mean Mayo Elbow Performance Score was 76 points (range, 45 to 95 points), and the mean triceps strength score was 4. There were 6 reoperations: 3 for humeral loosening, 1 for deep infection, 1 for fracture of the ulnar allograft, and 1 for wound debridement and closure. For the 8 elbows with an intact ulnar reconstruction, no ulnar components were radiographically loose, and the ulnar graft was considered radiographically intact and healed in 8 elbows.

CONCLUSIONS

Reconstruction of the proximal part of the ulna and triceps in failed elbow arthroplasties with structural ulnar bone loss can be effectively accomplished using a structural proximal ulnar allograft as an APC with the preserved triceps tendon for the extensor mechanism reconstruction, but the procedure is associated with an expected high reoperation rate, as is the case in complex revision elbow arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Team-based care intervention: views and perspectives from patients and healthcare professionals

Background

Blood pressure (BP) control is poor in European countries. Team-based care (TBC) intervention involving different healthcare professionals has the potential to improve BP control. Within a patient-centered approach, we evaluated patients' and healthcare professionals' opinion about a TBC intervention involving nurses, pharmacists, and physicians (MD).

Methods

As part of the TBC study, a pragmatic randomized controlled study to evaluate the impact of a TBC interprofessional intervention on BP control, we collected opinion of patients and team-based members (nurses, community pharmacists, and MD) at the end of study period using specific questionnaires. A mean TBC-satisfaction score was computed, assessing various aspects of the intervention, and ranged from 0 to 60, where a higher score represents a greater satisfaction.

Results

All patients (100%), pharmacists (100%), MD (92%) and nurses (80%) were satisfied with TBC intervention. Most patients considered that TBC can help improving BP control (92%), drug intake (71%), and lifestyle habits (84%). Furthermore, patients reported that TBC improved their relationship with nurses (66%), pharmacists (55%), and MD (50%). Patients also reported that their discussion with nurses (95%) and pharmacists (89%) helped improve medication intake. Healthcare professionals considered that TBC improve the quality of care (91%) and an added value for the management of chronic disease (79%). Mean TBC-satisfaction score was higher among MD [42 (SD: 9)] and pharmacists [45 (SD: 6)] compared with nurses [36 (SD: 9)].

Conclusions

Overall, patients and healthcare professionals were highly satisfied regarding TBC engaging different healthcare professionals in a primary care setting.

Key messages

TBC intervention seem to be well appreciated by patients and healthcare professionals. Favourable patients’ and healthcare professionals’ perspectives will help implementing TBC intervention.

Team-based Care for Improving Hypertension Management Among Outpatients

Background

Innovative models of care are needed to reduce poor blood pressure (BP) control in European countries. The TBC-HTA study evaluated the effects of an interprofessional team-based care (TBC) intervention, involving nurses, community pharmacists, and physicians, on BP control compared to usual care.

Methods

We conducted a pragmatic randomized controlled study in ambulatory clinics and community pharmacies in Lausanne and Geneva, Switzerland (ClinicalTrials.gov: NCT02511093). Uncontrolled treated hypertensive patients were randomized to TBC (N = 46) or usual care (UC: N = 43). The TBC intervention was led over 6 months. Nurses and pharmacists met patients every 6 weeks to measure BP, assess lifestyle and medication adherence, and provide health education. After each visit, they wrote a report with recommendations to the physician who could adjust antihypertensive therapy accordingly. The outcome was ambulatory BP measured at 6 and 12 months.

Results

A total of 60 men and 29 women [mean (SD) age: 61(12) year; mean (SD) number of antihypertensive drugs: 2 (1)] were included. At baseline, mean (SD) BP was 144(10)/90(8) and 147(12)/87(11) mmHg in the TBC and UC care groups. 76 patients were followed up to 12 months. At 6 months, the between-group difference in mean BP was -3/+2 mmHg [95% CI: -10 to + 5 / -2 to + 5]; BP control was 38% in the TBC group and 33% in the UC group, respectively. At 12 months, the between-group difference in mean BP was -8/-3 mmHg [95% CI: -14 to -1/-7 to + 1]; BP control was 34% in the TBC group and 20% in the UC group, respectively.

Conclusions

This TBC intervention helped long-term BP control among hypertensive outpatients in Switzerland. In line with recent European guidelines (ESC/ESH), this type of care should be more widely implemented.

Key messages

A TBC of hypertension helped control BP in a Swiss healthcare setting. Policymakers should evaluate how to implement such intervention.

Pectoralis Major and Anterior Latissimus Dorsi Transfer for Subscapularis Tears

PURPOSE OF REVIEW

Irreparable subscapularis tears represent a challenging entity, especially when they occur in younger patients with high functional demands. Tendon transfers are one of the options considered for surgical management for this pathology. The purpose of this article is to review the surgical technique and outcome of the two most common tendon transfers considered for irreparable subscapularis tears: pectoralis major and latissimus dorsi.

RECENT FINDINGS

Transfer of the pectoralis major has been considered for decades the transfer of choice for irreparable subscapularis tears. Recently, a series with long-term follow-up (over 18 years) supported the reduction in pain and improvement in functional scores and patient satisfaction after pectoralis major transfer. However, the range of motion and the force in internal rotation were not maintained over time. Transfer of the latissimus dorsi to the lesser tuberosity has been recently described as an alternative with a sound biomechanical rationale and encouraging short-term results. Transfer of the pectoralis major and the transfer of latissimus dorsi to the lesser tuberosity are the two transfers most commonly considered for patients with irreparable subscapularis tears. Transfer of the pectoralis major has a much longer track record. Both procedures seem to improve outcomes. Comparative studies are needed to determine the relative indications of these two procedures.

Isolated Arthroscopic Radial Styloidectomy: The Three-Portal Approach

Background  The current gold-standard technique for radial styloidectomy is arthroscopic. The use of only two dorsal portals may not allow a crystal-clear view of the dorsal arthritic rim of the radius because of the dorsal capsule synovitis. Objectives  To propose a new technique for isolated arthroscopic radial styloidectomy. The addition of a volar radial portal and a sequential procedure are presented. Patients and Methods  Two trochars for alternatively viewing from volar radial or 3-4 are used. A 1-2 portal is used for instrumentation with a motorized burr. We have been using the three-portal technique in 34 cases (26 isolated). Results  This modification of the classic arthroscopic radial styloidectomy is technically easy and the view of the dorsal rim of the radius provides a clear definition and treatment of the dorso-radial arthritic pathology. Conclusions  The authors recommend this technical trick to perform an easy and comprehensive isolated palliative or curative arthroscopic radial styloidectomy.

Dry Wrist Arthroscopy for Radial-Sided Wrist Disorders

The development of wrist arthroscopy has been useful in diagnosis, prognosis, and treatment of both ligament and osseous injuries. As the treatment indications and techniques become more refined, this article explores the role of dry arthroscopy to treat radial-sided disorders of the wrist.

Screening for hypertension at the hairdresser: a feasibility study in France and Morocco

Purpose: Worldwide, hypertension awareness remains largely insufficient. This is particularly true in some population subgroups with a low socioeconomic status or in young adults who have limited interactions with healthcare systems. Performing Blood Pressure (BP) screening in non-conventional settings, such as in barbershops, has been suggested by a number of American authors. Whether this approach is feasible in Europe or in North Africa has not been evaluated, however. We, therefore, undertook a study to assess the value of BP screening at hairdressers in France and in Morocco.Materials and Methods: This was a prospective multicenter feasibility study. Twenty-three hairdressers in France and six in Morocco participated in the study. After being provided the relevant information, all consenting customers aged over 18 years were included. Three BP measurements were performed by the customers themselves using a validated Omron M7 automatic BP device connected to a printer.Results: In France, 1025 subjects were enrolled, while 300 subjects participated in Morocco. Three hundred and seventy French participants (36%) had an elevated BP. Among the subjects claiming to be normotensive or who did not know their hypertension status, 31.7% had a BP ≥ 135/85 mmHg. Only 42% of the subjects with an elevated BP contacted their physician within 3 months, although hypertension was confirmed in ¾ of them. In Morocco, the participants were older, with only 11.7% of the subjects aged <50 years. They more frequently had unknown elevated BP values (71.9%). The rate of BP monitoring in known hypertensive individuals was 42.7% in France and 17.1% in Morocco. The procedure was very well accepted and considered to be useful in both countries.Conclusion: BP screening at hairdressers is feasible and well-accepted, although it does suffer somewhat from a relatively low efficacy.

P2641Renal and cardiovascular benefits of treatment with angiotensin receptor blockers in patients with hypertension and chronic kidney disease: A systematic review and meta-analysis

Background

Blood pressure (BP) control is critical in delaying the progression of chronic kidney disease (CKD), which otherwise results in an increased risk of cardiovascular morbidity and mortality. Angiotensin II receptor blockers (ARBs) or angiotensin-converting enzyme inhibitors, are recommended by several guidelines as first-line treatment for patients with hypertension and CKD.

Purpose

We reviewed and analysed the effect of ARB treatment on BP and renal outcomes (estimated glomerular filtration rate (eGFR), serum creatinine (SCr), creatinine clearance (CrCl) or proteinuria) in patients with hypertension and CKD with or without diabetes, including large clinical trials such as RENAAL and IDNT.

Methods

MEDLINE, EMBASE, and BIOSIS databases were searched for literature from the earliest available date to July 2017. Randomised (parallel-group) controlled trials of ≥8 weeks assessed the impact of ARBs on systolic/diastolic BP (SBP/DBP), eGFR, SCr, CrCl or proteinuria were included in the analysis. Meta-analysis (post- versus pre-treatment) and meta-regression were conducted in R-statistical software (v3.4.1) using meta- and metafor-packages. Mean difference (MD, generic inverse variance) with 95% confidence intervals (CIs) was used to pool data for an outcome in a single forest plot. The risk of bias (quality) of included studies was assessed by the six items of the Cochrane instrument.

Results

Of the 165 articles assessed for eligibility, 24 studies were included in the analysis (19 evaluated ARBs as monotherapy, 4 evaluated ARBs in combination with other antihypertensives and 1 evaluated ARBs both as mono- and combination therapy). Treatment with ARBs as monotherapy for ≥8 weeks to <1 year significantly reduced mean office SBP (MD, −12.60 mmHg; 95% CI, −18.53 to −6.67)/DBP (−6.52 mmHg; −11.27 to −1.77) (p<0.01). BP reduction was also significant (p<0.01) with ARB monotherapy for ≥1 year SBP (−14.84 mmHg; −17.82 to −11.85)/DBP (−10.27 mmHg; −12.26 to −8.27). ARBs also significantly reduced SBP/DBP when combined with other antihypertensive treatments for ≥8 weeks to <1 year as well as for ≥1 year (Figure). Moreover, ARBs induced significant reductions (p<0.01) in proteinuria (≥8 weeks to <1 year [MD, −0.6 g/L; 95% CI, −0.93 to −0.26; ≥1 year [−0.9 g/L; −1.22 to −0.59]), but no significant changes in eGFR, CrCl or SCr levels. The beneficial effect of ARBs was maintained overtime with no significant additional impact on SBP change (estimate: 0.025; 95% CI, –0.14 to 0.19) or eGFR (estimate: 0.068; 95% CI, −0.14 to 0.28; p=0.53). The overall risk of bias was judged to be low.

Effect of ARBs on blood pressure changes

Conclusion

Treatment with ARBs effectively and sustainably lowered BP and proteinuria with no significant change in eGFR in patients with hypertension and CKD with or without diabetes.

Isolated open anterior shoulder release in brachial plexus birth palsy

BACKGROUND

In children with brachial plexus birth palsy (BPBP), a shoulder joint internal contracture is commonly observed, which may result in glenohumeral osseous deformities and posterior joint subluxation. The purpose of this retrospective study was to evaluate the impact of an isolated anterior shoulder release on osteoarticular disorders and assess the subsequent clinical improvements.

METHODS

Forty consecutive BPBP patients with glenohumeral dysplasia underwent an open anterior shoulder release. Shoulder scans (ie, magnetic resonance imaging preoperatively and computed tomography postoperatively) were conducted to assess glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa. Clinical data including analytical shoulder range of motion and modified Mallet scores were collected.

RESULTS

After a mean follow-up period of 23 months, glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa significantly improved from -32° and 18%, respectively, to mean postoperative values of -12° (P < .001) and 45% (P < .001), respectively. Passive and active external rotation increased from -2° and -43°, respectively, to 76° (P < .001) and 54° (P < .001), respectively. The mean modified Mallet score significantly improved from 14.2 to 21.4 points (P < .001). In 8 children with satisfactory passive motion, a latissimus dorsi transfer was performed secondarily to obtain satisfactory active motion.

CONCLUSION

In BPBP patients with glenohumeral deformities, isolated open anterior release of the shoulder induces significant remodeling of the joint, reducing posterior joint subluxation and improving both passive and active shoulder ranges of motion. Additional latissimus transfer remains mandatory in selected cases to achieve satisfactory function.

Atypical schwannoma of the median nerve. A case report

Schwannomas of the hand are very rare tumors and represent less than 3% of all soft tissue tumors in the hand. These tumors share clinical, epidemiological and imaging characteristics with the other soft tissue and peripheral nerve tumors; thus, it can be difficult to make a preoperative diagnosis. Here we report the case of a 48-year-old woman who presented with a schwannoma arising from the palmar branch of the median nerve. The tumor measured 54 × 41 x 52 mm and was located in the thenar eminence. The first hypothesis was a vascular tumor. After surgery and histological analysis, the final diagnosis of an atypical schwannoma was established. The presence of shared immunohistochemical characteristics with cellular histiocytoma and myoepithelial tumors forced us to adopt an aggressive follow-up protocol. As of the last follow-up at 9 years, the patient had good clinical outcomes and no recurrence. This case highlights the difficulties encountered in clinical practice to diagnose such tumors.

Arthroscopic Treatment of Translunate Perilunate Injuries, Not Dislocated (PLIND)

Background  Translunate perilunate dislocations were recently described as well as perilunate injuries, not dislocated (PLIND). The authors present a case of transradial styloid, translunate PLIND which sustained a full arthroscopic reduction and internal fixation. Case Description  A 33-year-old man sustained a transradial styloid, translunate PLIND due to a fall from a truck with his wrist in hyperextension. The diagnosis was made at the acute stage. Full arthroscopic reduction and internal fixation with Kirschner wires was performed, followed by a 6 weeks' immobilization period. Uneventful healing of both the lunate and radial styloid were observed at 6 weeks and confirmed with a computed tomography scan. At 4 years of follow-up, the Lyon wrist score was 78% (good). Literature Review  Very few lunate fractures are described in the literature. Translunate perilunate dislocations were recently described as well as PLIND. To the best of the authors' knowledge, a case of transradial styloid, translunate PLIND which sustained a full arthroscopic reduction and internal fixation has never been reported so far. Clinical Relevance  This case reports a unique pattern of transradial styloid, translunate PLIND and outlines the usefulness of a full arthroscopic treatment. An open reduction for this pattern of injury would have been extensive, difficult, and probably unreliable.

Shoulder and Elbow Fractures in Athletes

PURPOSE OF REVIEW

The purposes of this review are to discuss the management of shoulder and elbow fractures in athletes to optimize the return to sport and to highlight treatment impact on the return to play.

RECENT FINDINGS

Fractures of the shoulder and elbow can have profound implications in an athlete career. Recent technique of fractures management trended toward to preserve soft tissue which is critical for an early recovery in athletic population. Arthroscopy presents a strong interest for the treatment of intra-articular fracture, and minimally invasive approach as developed in humeral shaft fracture can be considered to avoid soft tissue damage. Non-articular, stable, and minimally displaced fractures are mainly treated conservatively. However, we encourage a more aggressive approach in shoulder and elbow injuries in the athletes including minimally invasive and stable fixation to preserve vascularity and muscle environment.

L5 incidence: an important parameter for spinopelvic balance evaluation in high-grade spondylolisthesis

BACKGROUND

In high-grade spondylolisthesis (HGSPL), the pelvic incidence (PI) is not a reliable measurement because of doming of the sacrum. Measurement of L5 incidence (L5I) was described as a tool to measure pelvic morphology in HGSPL and for surgical follow-up.

OBJECTIVE

We aimed to evaluate L5I in HGSPL and its relationship to other spinopelvic parameters.

STUDY DESIGN

A retrospective study of a cohort of 184 patients with HGSPL was carried out.

METHODS

Whole spine radiographs were analyzed for PI, pelvic tilt (PT), sacral slope, lumbar lordosis (LL), L5I, L5 tilt (L5T), L5 slope, lumbosacral kyphosis, and slip percentage. Statistical analysis and correlation were made (Pearson correlation test; p<.05). In accordance to Cohen, statically significant correlation were considered strong if R>0.5, moderate if 0.3<R<0.5, and small if R<0.3.

RESULTS

A total of 184 cases were analyzed, with a female-to-male ratio of 2.35 and a mean age of 20.1 years. Sacral doming was present in 73% of the cases. Mean L5I incidence was 65.2° and strongly correlated to other sagittal parameters, especially PT (R=0.7), LL (R=0.7), L5T (R=0.77), and L5 slope (R=0.83). There was less but still strong correlation to Dubousset lumbosacral kyphosis (Dub-LSK) angle (R=-0.63) and percentage of slippage (R=0.56). L5 tilt showed nearly perfect correlation to PT (R=0.95). Forty-four percent of the cases were balanced HGSPL, whereas 56% of the cases were unbalanced HGSPL. L5 incidence was found to be a good predictor of local imbalance with a cutoff of L5I=61.

CONCLUSION

This paper describes L5I, which is a positional parameter in HGSPL. L5 incidence is a simple and reliable measure in the preoperative setting in HGSPL. Its correlation with spinal sagittal parameters (especially PT and LL) is strong and was found to be better than Dub-LSK. There is also a good correlation between L5I and HGSPL pelvic parameters (slip percentage and lumbosacral kyphosis). We recommend its use for evaluation of surgical correction and recommend the value of 60° as cutoff value to define spinopelvic balance in HGSPL.

Copeptin and insulin resistance: effect modification by age and 11 β-HSD2 activity in a population-based study

PURPOSE

Arginine vasopressin (AVP) may be involved in metabolic syndrome (MetS) by altering liver glycogenolysis, insulin and glucagon secretion, and pituitary ACTH release. Moreover, AVP stimulates the expression of 11β-hydroxysteroid-dehydrogenase-type 2 (11β-HSD2) in mineralocorticosteroid cells. We explored whether apparent 11β-HSD2 activity, estimated using urinary cortisol-to-cortisone ratio, modulates the association between plasma copeptin, as AVP surrogate, and insulin resistance/MetS in the general adult population.

METHODS

This was a multicentric, family-based, cross-sectional sample of 1089 subjects, aged 18-90 years, 47% men, 13.4% MetS, in Switzerland. Mixed multivariable linear and logistic regression models were built to investigate the association of insulin resistance (HOMA-IR)/fasting glucose and MetS/Type 2 Diabetes with copeptin, while considering potential confounders or effect modifiers into account. Stratified results by age and 11β-HSD2 activity were presented as appropriate.

RESULTS

Plasma copeptin was higher in men [median 5.2, IQR (3.7-7.8) pmol/L] than in women [median 3.0, IQR (2.2-4.3) pmol/L], P < 0.0001. HOMA-IR was positively associated with copeptin after full adjustment if 11β-HSD2 activity was high [β (95% CI) = 0.32 (0.17-0.46), P < 0.001] or if age was high [β (95% CI) = 0.34 (0.20-0.48), P < 0.001], but not if either 11β-HSD2 activity or age was low. There was a positive association of type 2 diabetes with copeptin [OR (95% CI) = 2.07 (1.10-3.89), P = 0.024), but not for MetS (OR (95% CI) = 1.12 (0.74-1.69), P = 0.605), after full adjustment.

CONCLUSIONS

Our data suggest that age and apparent 11β-HSD2 activity modulate the association of copeptin with insulin resistance at the population level but not MeTS or diabetes. Further research is needed to corroborate these results and to understand the mechanisms underlying these findings.

Wrist hemiarthroplasty for irreparable DRF in the elderly

INTRODUCTION

The authors update their results of wrist hemiarthroplasty for irreparable distal radius fracture in the elderly, at a minimum of 2-year follow-up.

MATERIALS AND METHODS

Between 2011 and 2018, 25 consecutive independent elderly patients (24 female, 27 wrists) were treated with wrist hemiarthroplasty for distal radius fracture at a single institution. The average age was 77 years (range 65-88). They all were independent at home. A total of 19 wrists were treated at the acute stage, and 8 secondary procedures. The average follow-up was 32 months (range 24-44).

RESULTS

There was no dislocation, loosening, infection nor removal of the implants. We observed 3 CRPS. At final follow-up, the average VAS pain was 1/10, mean forearm pronation/supination arc was 150°, and mean active flexion-extension arc was 60°. Average wrist extension was 36°. Mean grip strength was 68% of contralateral side. Mean Lyon wrist score was 74%. Mean Quick DASH score was 26%, and mean PRWE score was 25%.

DISCUSSION

Our data suggest that treatment of acute irreparable distal radius fracture in the independent elderly patient with a bone-preserving primary wrist hemiarthroplasty may be a viable option. Longer-term follow-up are needed to confirm these preliminary data.

A New Wrist Clinical Evaluation Score

Background  The number of available wrist scoring systems is limited; some of them do not include forearm rotation criteria. Purpose  To describe a new electronic wrist clinical score and to present a new patient's generated wrist evaluation criterion, the subjective wrist value (SWV). Materials and Methods  A new electronic wrist clinical score, the Lyon wrist score (LWS) including wrist VAS pain and function, active range of motion and strength was built into an excel file. VAS flexion-extension pain and function were evaluated independently from pronation-supination pain and function. A new patient's generated wrist evaluation criterion, SWV was described. Results  The LWS is available in two versions, standard and full (the latter including forearm rotation strength). Both standard and full LWS are displayed into an automatically generated diamond-shaped graph providing a comprehensive visual display of the clinical status of most osteoarticular wrist disorders. The graph also includes SWV. The LWS, combined with SWV into a graph that may be directly exported to a PowerPoint presentation, provide a new practical and comprehensive tool for following/comparing wrist osteoarticular clinical status/outcomes. Both standard and full LWS charts are available in colored versions on a related website for free download. Conclusion  A comprehensive updated electronic display of osteoarticular wrist clinical status including forearm rotation criteria is provided and displayed into a graph which may be exported as such into a PowerPoint presentation for clinical analysis/comparisons. Level of Evidence  Level II.

Treatment of intra-articular fracture of distal radius fractures with fluoroscopic only or combined with arthroscopic control: A prospective tomodensitometric comparative study of 40 patients

BACKGROUND

Considering articular distal radius fractures treated with volar plate, we hypothesized that articular radio-carpal displacement was better reduced with arthroscopic control than with only fluoroscopic control.

METHODS

Forty patients with similar articular radius fracture (type C according to AO classification) and high functional needs were treated with volar plate fixation. They were divided in two comparative groups: 20 patients in Fluoroscopic group and 20 patients in Arthroscopic group. Pre and postoperative radiographs and tomodensitometric images were analysed by an independent observer. We evaluate extra and intra-articular displacements according to "Patient Accident Fracture" classification.

RESULTS

We observed a better reduction of the radio-carpal step-off and gap in the arthroscopic group, with a statistically significant difference (p<0.05). The index of postoperative intra-articular reduction was better in the fluoroscopic group (5.5) than in the arthroscopic group (2.2) with a significant difference (p<0.05).

CONCLUSIONS

According to these results, arthroscopy is useful to perform a better articular radio-carpal reduction in distal radius fracture.

LEVEL OF EVIDENCE

Level 3.

Hemi-arthroplasty for distal radius fracture in the independent elderly

INTRODUCTION

The authors report their experience with hemi-arthroplasty in irreparable fresh distal radius fracture in independent elderly patients as first-line treatment (12 fractures in 11 women; mean age, 74 years) or in second line after clinically disabling primary failure (4 fractures in 4 women; mean age, 78 years).

RESULTS

In the 12 primary surgeries, at a mean 32 months' follow-up, there were no complications requiring implant ablation; mean pain score was 1/10, flexion-extension 62°, Lyon Wrist score 75%, and Patient-Related Wrist Evaluation (PRWE) 22 points. In 2 of the 4 secondary surgeries, at a mean 24 months' follow-up, there were no complications requiring implant ablation; mean pain score was 2.5/10, flexion-extension 62°, Lyon Wrist score 58%, and PRWE 50 points: i.e., slightly poorer results than in primary surgery.

CONCLUSION

Salvage of complex fracture in independent elderly patients by hemi-arthroplasty, whether primary or secondary to failure, seems to be a considerable progress, to be confirmed in larger series.

Seasonality of sodium and potassium consumption in Switzerland. Data from three cross-sectional, population-based studies

BACKGROUND AND AIM

Blood pressure displays a seasonal pattern. Whether this pattern is related to high sodium and/or low potassium intakes has not been investigated. We assessed if sodium and potassium consumption present a seasonal pattern. We also simulated the impact of seasonality of sodium consumption on systolic blood pressure levels.

METHODS AND RESULTS

Data from three Swiss population-based studies (n = 2845). Sodium and potassium consumption were assessed by urinary excretion using 24 h urine collection. Seasonality was assessed using the cosinor model and was adjusted for study, gender, age, body mass index, antihypertensive drug treatment, urinary creatinine and atmospheric relative humidity. The effect of sodium variation on blood pressure levels was estimated using data from a recent meta-analysis. Both sodium and potassium excretions showed a seasonal pattern. For sodium, the nadir occurred between August and October, and the peak between February and April, with a multivariate-adjusted seasonal variation (difference between peak and nadir) of 9.2 mmol. For potassium, the nadir occurred in October and the peak in April, with a multivariate-adjusted seasonal variation of 4.0 mmol. Excluding participants on antihypertensive drug treatment or stratifying the analysis by gender cancelled the seasonality of sodium consumption. The maximum impact of the seasonal variation in sodium consumption on systolic blood pressure ranged from 0.4 to 1.1 mm Hg, depending on the model considered.

CONCLUSION

Sodium and potassium consumptions present specific seasonal variations. These variations do not explain the seasonal variations in blood pressure levels.

Treatment of unstable proximal interphalangeal joint fractures with hemi-hamate osteochondral autografts

The primary aim of this study was to assess the clinical and radiological results after hemi-hamate resurfacing arthroplasty in patients with acute or chronic unstable fractures of the base of the middle phalanx and to describe technical features that can facilitate the surgical procedure. Hemi-hamate arthroplasties were done in 19 patients (mean age 39 years) with an isolated fracture at the base of the middle phalanx that involved more than 40% of the articular surface. We assessed ten chronic cases (treated >6 weeks after fracture) and nine acute ones (<6 weeks) at a mean of 24 months. Pain scores, QuickDASH scores, grip strengths, range of motion and radiological findings were recorded at follow-up. At follow-up, the mean active flexion at the proximal interphalangeal joint was to 83° with a mean fixed flexion of 17° (active range of motion 66°). The mean active distal interphalangeal motion was 41°. The mean visual analogue scale score was 1.1. The mean QuickDASH score was 11. The mean pinch strength was 82% of the opposite side. Radiographs revealed one partial graft lysis.

LEVEL OF EVIDENCE

IV.