Intramedullary Nailing of Humeral Shaft Fractures: Percutaneous Nailing in the lateral position through the Neviaser approach is a reliable Technique

BACKGROUND

Displaced humeral shaft fractures are frequently treated by osteosynthesis in the active patient. We aimed to evaluate the results of intra-medullary nailing (IMN) in the lateral position with the Neviaser approach and to compare them with those from IMN nailing in the standard position and conventional approach.

METHODS

In the retrospectively evaluated, single-center study, we compared 20 cases of long IMN for fractures of the proximal or middle third of the humerus shaft (Multilock; Synthes Laboratory) in the lateral position with the percutaneous Neviaser approach with 52 cases of IMN in the standard position. The mean age of patients was 62+/-21 years. Clinical outcomes were analyzed: Constant score, subjective shoulder evaluation (SSV) score and range of motion (ROM). Radiographically, entry point at the proximal part of the humerus, the healing rate and the possible association between the critical shoulder angle (CSA) and the correct positioning of the nail were assessed.

RESULTS

With a mean follow-up of 26+/-2 months, the healing rate was 89% (64/72) in the overall series, (8 patients in non-union), with no difference between the 2 groups. The overall mean active anterior elevation (AAE) was 125+/-22 degrees, mean external rotation (ER1) was 35+/-17 degrees, and mean internal rotation (IR) was at L3. The mean Constant score was 58+/-23 and SSV score 73+/-12%. ROMs were better in the lateral than standard position group (AAE 133+/-17 vs 122+/-23, p=0.03; ER1 47+/-13 vs 30+/-16, p<0.001; IR T12 vs L5, p=0.02). The nail was less often protruding in the lateral than standard position group (1/20 [5%] vs 20/52 [38.5%], p=0.002). The nail was better positioned from the anteroposterior view (nail centered: 16/20 [75%] vs 26/52 [50%], p=0.047) and lateral view (nail centered: 18/20 [90%] vs 34/52 [65.4%], p=0.02) in the lateral than standard position group. We found no association between nail position, type of approach and CSA.

CONCLUSIONS

In the short-term follow-up, osteosynthesis of humeral shaft fractures by using long IMN in the lateral position with the Neviaser approach is a reliable technique. The positioning of the nail, in particular its entry point, and the clinical results were better with the lateral position and Neviaser approach than with the standard position and conventional approach. Further studies with a larger number of patients, assessment of the learning curve, and analysis of the impact of this technique on comorbidities (unchanged cerebral perfusion) are needed to fully validate this technique.

Management of advanced metacarpal aneurysmal cysts: Surgical technique

The hand is a rare site for aneurysmal bone cysts (ABCs). Depending on their degree of invasiveness, treatment of ABCs ranges from medical therapy to surgical curettage and bone filling. In the most advanced cases, bone resection and reconstruction, with or without adjuvant or neoadjuvant treatment, are indicated. We describe a technique involving segmental bone resection and structural iliac graft reconstruction with carpo-metacarpal plate arthrodesis, for the management of advanced ABC involving the base of the metacarpals. The radio-clinical results of two patients operated on using this technique are presented, at 18 and 36 months. At the last follow-up, the results showed a QDASH of 15 and 10, and a PRWE of 9 and 11. Satisfaction was 10/10 in both cases. Grasp strength was 25 kg and 42 kg versus 28 kg and 40 kg on the opposite side. Pinch strength was 6 kg and 11 kg versus 7 kg and 10 kg. Metacarpophalangeal flexion was 80° and 90°. Extension was complete in both cases. Radiographs showed good graft fusion, with no lysis or signs of ABC recurrence at the last follow-up. Segmental bone resection and iliac autograft reconstruction with carpo-metacarpal plate arthrodesis represents a therapeutic option in the management of advanced ABCs of the metacarpal base.

Incongruity of the scapulohumeral arch: an indirect sign of posterior subluxation of the humeral head in primary glenohumeral osteoarthritis

BACKGROUND

In symptomatic glenohumeral osteoarthritis, arthroplasty is the gold standard to restore a mobile and painless shoulder. The kind of arthroplasty chosen is mainly based on the evaluation of the rotator cuff and the type of glenoid. The aim of this study was to analyze the scapulohumeral arch in primary glenohumeral osteoarthritis (PGHOA) with an uninjured cuff and to determine whether posterior humeral subluxation influences the Moloney line, which corresponds to an intact scapulohumeral arch.

MATERIALS AND METHODS

Between 2017 and 2020, 58 anatomic total shoulder arthroplasties were implanted in the same center. We included all patients with complete preoperative imaging (radiographs and magnetic resonance imaging or arthro-computed tomography scans) assessing an intact rotator cuff. A total of 55 shoulders that had undergone surgery with a total anatomic shoulder prosthesis were analyzed after determination of the type of glenoid in the frontal plane according to the Favard classification on an anteroposterior radiograph and in the axial plane according to the Walch classification on computed tomography scans. The grade of osteoarthritis was evaluated according to the Samilson classification. We analyzed whether there was a rupture of the Moloney line on the frontal radiograph and assessed the acromiohumeral distance.

RESULTS

After preoperative analysis of 55 shoulders, 24 shoulders had type A glenoids and 31 had type B glenoids. Scapulohumeral arch rupture was observed in 22 shoulders, and posterior subluxation of the humeral head was found in 31 shoulders, of which 25 had type B1 glenoids and 6 had type B2 glenoids according to the Walch classification. Most glenoids were type E0 (n = 47.85%). Incongruity of the Moloney line was more frequent in shoulders with type B glenoids (20 of 31 [65%]) than those with type A glenoids (2 of 24 [8%], P < .001). No patient with a type A1 glenoid (0 of 15) had a rupture of the Moloney line, and only 2 patients with a type A2 glenoid (2 of 9) had incongruity of the scapulohumeral arch.

CONCLUSION

In PGHOA, rupture of the scapulohumeral arch seen on anteroposterior radiographs, also known as the Moloney line, may be an indirect sign of posterior humeral subluxation, corresponding to a type B glenoid per the Walch classification. Incongruity of the Moloney line may indicate a rotator cuff injury or posterior glenohumeral subluxation with an intact cuff in PGHOA.

Comparative study of a Y- anatomical and innovative locking plate versus double plate for supracondylar humeral fracture

INTRODUCTION

There is no "gold standard" for the type of plate to be used for distal extra-articular humeral fractures; the most used is plating of each column. The objective was to evaluate the short-term clinical and radiological results of a Y- anatomical and innovative locking plate (YALP).

HYPOTHESIS

The hypothesis is: this anatomical and innovative locking plate will produce satisfactory and reliable results on extra-articular distal humerus fracture superior to double plate fixation.

MATERIALS AND METHODS

In a retrospective observational multicenter study, all patients with a distal humerus fracture type 13 A2.2 according to AO classification fixed with a new Y-plate (YALP) were compared to the results of double plate fixation for the same type of fracture. With a follow-up of more than 12 months, the objective and subjective clinical elbow criteria as well as the overall function of the upper limb and radiological assessment were collected.

RESULTS

With an average follow up of 24±11 months, 26 patients met the inclusion criteria and received a YALP and 24 patients received double plate. All patients whose fracture had healed except one were pain-free (mean VAS 0.3±0.6). All patients had good subjective results (mean SEV 96%±4). Elbow function was excellent (mean total MEPS 96±4) with normal triceps strength (23/24 patients had a triceps strength graded 5/5 and one patient 4/5) and range of motion (flexion 139±8, extension -7±8 and pronosupination greater than 155 degrees). The operating time was shorter in the YALP group (84 ± 23minutes versus 97 ± 28minutes, p=0.03). The double plate group had more complications; the overall complication rate was significantly higher (p=0.02) in the double 90-degree plate group (12/24, 50%) with four nonunions, four symptomatic ulnar nerves, three hardware removals for pain and one radial nerve injury versus 5/26 complications (19%, p=0.02) in the Y-plate group: one iliac graft for nonunion, 1 plate removal due to functional discomfort, 1 twisted YALP, 1 broke interfragmentary screw and one symptomatic ulnar nerve. DASH, SEV, MEPS scores and flexion-extension range were better in the YALP group.

DISCUSSION

YALP produces satisfactory results in supracondylar fractures of the distal humerus. The results of YALP appear to be better than the results with two 90° plates for the same fracture type with a shorter operative time and easier management of fractures with proximal diaphyseal extension.

LEVEL OF EVIDENCE

III; case control study.

Prospective study of 90 arthroscopic rotator cuff repairs for isolated distal supraspinatus tear, assessing the impact of cardiovascular risk factors on tendon healing

INTRODUCTION

Cardiovascular risk factors have been shown to be relevant to onset of rotator cuff tear, but their influence on healing remains to be determined.

OBJECTIVE

To assess the individual and cumulative impact of cardiovascular risk factors on tendon healing after arthroscopic rotator cuff repair.

MATERIAL AND METHOD

A single-center prospective study included 90 patients undergoing arthroscopic repair of isolated distal supraspinatus tendon tear. Only isolated full-thickness tears without anteroposterior extension, retraction (Patte stage ≤ 2) or fatty involution were included. Tendon healing was assessed on ultrasound according to the 5 types of the Sugaya classification. Clinical and functional assessment at 12 months used Constant score. Cardiovascular comorbidities were screened for in the preoperative anesthesiology consultation and control consultation: smoking, high blood pressure, dyslipidemia, diabetes, obesity, cardiovascular history, and obstructive sleep apnea syndrome.

RESULTS

Ninety patients with a mean age of 59.6±6.95 years were included for analysis. 77.7% of cuffs showed healing on ultrasound, without signs of retear (stage 1-3), 16.6% showed partial retear (stage 4) and 6.6% showed no healing, with tendon retraction (stage 5). Mean Constant score improved by 37.5 points (p=0.001), for a global score of 78 at 12 months. Multivariate analysis identified several significant cardiovascular factors for poor healing: active smoking (p=0.002), dyslipidemia (p=0.006), high blood pressure (p≤0.001) and obesity (p=0.02). Cumulative comorbidity was associated with poor tendon healing, with significant impact as of 2 cardiovascular risk factors. Constant score decreased significantly according to healing stage (p≤0.001).

CONCLUSION

The present study confirmed the involvement of cardiovascular risk factors in bone-tendon healing disorder, with significant impact as of 2 factors.

LEVEL OF EVIDENCE

IV; low-power prospective clinical series.

Long-term survival analysis of 191 MAÏA® prostheses for trapeziometacarpal arthritis

Surgery for trapeziometacarpal osteoarthritis after failure of medical treatment remains controversial. The aim of this study was to determine the long-term results of the MAÏA® trapeziometacarpal prosthesis (Lépine, Genay, France). This was a retrospective clinical and radiographic study of 191 MAÏA® trapeziometacarpal prostheses implanted between 2001 and 2016 from a single centre. The survival rate of the implants at the final follow-up of 12 years (range 17 days to 140 months) was 88%. Median pain score was 1/10. The median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 20. The rate of major complications was 9% (5% dislocations and 4% loosening) with all dislocations needing revision surgery. The risk of prosthetic dislocation was highest during the first 3 years, most often related to malposition of the trapezium implant. The MAÏA trapeziometacarpal prosthesis represents a long-term solution for surgical treatment of thumb rhizarthrosis. Level of evidence: IV.

Morbidity of long head of the triceps motor branch neurotization to the axillary nerve: Retrospective subjective and objective assessment of triceps brachii strength after transfer

INTRODUCTION

Morbidity is considered to be negligible in Leechavengvongs transfer (LT) of the long head of the triceps onto the axillary nerve, but the assessment methods used may lack reproducibility. We assessed triceps strength after LT objectively by the isokinetic technique, addressing the following questions: Is strength lowered after LT compared to the healthy limb? And 2) is there a good correlation between isokinetic dynamometry and subjective assessment?

HYPOTHESIS

Isokinetic measurement shows a decrease in triceps strength at peak torque after LT compared to the healthy limb, and this morbidity is underestimated on subjective assessment.

MATERIAL AND METHODS

This single-center retrospective study included patients undergoing LT for axillary nerve trunk palsy between 2008 and 2020, with M5 triceps preoperatively on the British Medical Research Council (BMRC) scale. Twenty patients, with a mean age of 25±9years (range, 15-48years) were assessed at a mean 58±47months (range, 6-174months). Elbow extension strength was assessed on a standardized questionnaire, BMRC isometric test and isokinetic test on an angular course of 90° at 60°/sec and 180°/sec concentrically and 30°/sec excentrically.

RESULTS

Strength at 60°/sec and 180°/sec concentrically and 30°/sec excentrically was significantly lower than in the healthy limb: respectively, -17Nm, -15Nm, and -16Nm, (p<0.001) for a mean -23%. Loss of strength was mainly severe on isokinetic testing and mild on isometric testing. Seven patients reported contracture (35%), 12 fatigue (60%), and 3 weakness (15%). Satisfaction with extension strength was excellent or good for respectively 12 (60%) and 8 patients (40%). Triceps strength was graded BMRC M4 in 9 triceps (11%) and M5 in 11 (55%).

DISCUSSION

After LT, isokinetic measurement found generally severe loss of triceps strength, but without subjective impact on everyday life.

LEVEL OF EVIDENCE

IV; retrospective study.

Perilunate dislocation and fracture dislocation of the wrist: Outcomes and long-term prognostic factors

INTRODUCTION

Perilunate dislocations and fracture-dislocations are severe injuries that often have serious functional sequelae. Our goal was to evaluate the long-term clinical and radiological results of these perilunate injuries, and to look for prognostic factors of a poor clinical outcome.

HYPOTHESIS

All patients who suffered perilunate injuries in their wrist have functional sequelae and long-term radiographic changes despite optimal treatment with anatomical surgical reduction.

MATERIALS AND METHODS

We did a single-center, retrospective study of 32 patients who had either an isolated perilunate dislocation (n=7) or fracture-dislocation (n=25) in their wrist. Pain, range of motion, strength and functional scores (MWS, PRWE, QuickDASH) were evaluated. Radiographs were analyzed to look for signs of osteoarthritis or carpal instability.

RESULTS

The mean follow-up time was 9.9years (3.5-24). The wrist joint had a mean flexion-extension of 86° (0-140), radioulnar deviation of 38° (0-65) and pronosupination of 153° (120-180). The mean grip strength was 35kg (5-56). The mean MWS, PRWE and QuickDASH scores were 65/100, 32/100 and 29/100, respectively. At the final assessment, 23 patients (79%) had radiographic signs of osteoarthritis while 5 patients (16%) had residual carpal instability. Three patients subsequently underwent palliative treatment. Opening the carpal tunnel and the magnitude of the lunate's displacement are significant predictors of a poor long-term functional outcome (p<0.05). Older age at the time of injury was a predictor for the development of osteoarthritis.

DISCUSSION

Despite optimal treatment, perilunate dislocations and fracture-dislocations at the wrist cause functional sequelae such as pain, stiffness, strength deficit and posttraumatic arthritis in nearly 80% of patients. The functional outcomes are determined by the amount of lunate displacement (stage) and the patient's age. We do not recommend opening the carpal tunnel, even when signs of median nerve compression are present; reducing the dislocation helps to relieve the neurological symptoms.

LEVEL OF EVIDENCE

IV; retrospective observational study.

Clinical Impact of Malunion After All-Arthroscopic Coracoclavicular Stabilization for Displaced and Unstable Lateral Clavicle Fractures

OBJECTIVE

To evaluate the clinical outcome of lateral clavicle malunion treated with all-arthroscopic coracoclavicular (CC) stabilization.

DESIGN

Retrospective, case series.

SETTING

Department of hand and upper extremity surgery, university hospital center.

PATIENTS

Forty-five patients with unstable and displaced lateral clavicle fracture treated between January 2015 and August 2019 were included in the study.

INTERVENTION

Closed reduction and arthroscopic CC stabilization using cortical buttons.

MAIN OUTCOME MEASUREMENTS

Shoulder pain and active motion. Patient-reported outcome measures included the Constant score, the Subjective Shoulder Value, the AcromioClavicular Joint Instability score, and the Specific AcromioClavicular Score. Radiographic evaluation assessed bony union and malunion.

RESULTS

Mean duration of follow-up was 25 months (12-60 months). Five patients (11%) had lateral clavicle nonunion and 7 (16%) had lateral clavicle malunion (5 in the coronal plane and 2 in the axial plane). Lateral clavicle malunion did not significantly affect clinical or functional outcomes (P > 0.05). Mean active shoulder motion was forward flexion 163 degrees (SD 28), abduction 162 degrees (SD 26), and external rotation 63 degrees (SD 21). On average, the patients scored 88.3 (SD 17.7) in the Constant score, 90% (SD 12) in the Subjective Shoulder Value, 88.8 (SD 9.4) in the AcromioClavicular Joint Instability score, and 11.4 (SD 8.5) for SACS. The overall complication rate was 38% (including 7 malunions, 5 nonunions, 2 adhesive capsulitis, and 3 button malpositions).

CONCLUSIONS

Closed reduction and internal fixation of lateral clavicle fracture with all-arthroscopic CC stabilization using cortical button potentiates bony union but may generate lateral clavicle malunion, which does not affect the clinical or functional outcome. This result can be attributed to CC ligament healing and acromioclavicular joint congruence. All-arthroscopic CC stabilization is a minimally invasive but demanding surgical alternative for managing unstable and displaced lateral clavicle fracture.

LEVEL OF EVIDENCE

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

The IBTIS score; a new prognostic score for arthroscopic biceps tenotomies

INTRODUCTION

Shoulder pain associated with tendinopathy of the long head of biceps (LHB) is common. Surgical treatment with arthroscopic tenotomy of the LHB has been shown to be effective. However, it's efficacy is inconsistent. The objective of this study was to assess the pre-operative clinical and radiological prognostic factors of arthroscopic tenotomy of the long head of biceps, and to establish a predictive score for good responses to treatment; the IBTIS score (Isolated Biceps Tenotomy Index Score).

HYPOTHESIS

Prognostic factors representing a good response to treatment of LHB tendinopathy by arthroscopic tenotomy exist.

MATERIALS AND METHODS

We conducted a retrospective monocentric study including 64 patients who underwent surgery of the LHB by arthroscopic tenotomy (with or without tenodesis) between January 2018 and March 2020. We identified 2 patient groups (good responder group and poor responder group) from a 3-month post-operative clinical assessment, which included a subjective assessment comprising Single Shoulder Value (SSV), Constant score, C-Test, and pain level. Prognostic factors of a good response were then sought from the 2 groups using interviews, clinical examinations and pre-operative imaging. Based on these findings, a predictive score for a good response was established.

RESULTS

All evaluation criteria demonstrated post-operative improvement: mean SSV (72.2 vs 50.7; p<0.001), relative constant (78.2 vs 64.3; p<0.001), pain level (3.2 vs 7; p<0.001) and C-Test (94.1 vs 85.6; p=0.07). 34 patients (58.6%) were considered good responders, while 24 patients (41.38%) were considered poor responders. There was a trend towards a favourable result for: age>65 years (p=0.01), rotator cuff rupture on preoperative imaging (p=0.01), Cross Arm Test (p=0.02), nocturnal pain (p=0.08), Yergason's test (p=0.16) and Speed's Test (p=0.22). Manual labour appeared to be an unfavourable factor (p=0.07). These factors were incorporated into the 10-point IBTIS score. A score greater than 5 was associated with a favourable result in more than 80% of patients (p<0.001).

DISCUSSION

Our score consists of 7 items. We identified 7 pre-operative prognostic factors for a good result after LHB tenotomy. Over 65 years of age was found to be statistically significant in univariate analysis, as was visualization of rotator cuff rupture on pre-operative imaging. The Cross Arm Test was included given its high statistical significance. The Speed's Test and Yergason's Test are ubiquitous in the literature. Nocturnal pain was found in more than 80% of patients. Undertaking manual labour represented an unfavourable prognostic factor after arthroscopic surgery of the LHB.

CONCLUSION

The IBTIS score (Isolated Biceps Tenotomy Index Score) is a pre-operative clinico-radiological score for the surgical treatment of arthroscopic tenotomy of the long head of biceps. Further studies are required to validate its prognostic accuracy.

LEVEL OF EVIDENCE

III; case-control.

Diagnosis and treatment of hand tumors

Hand tumors are a very common problem in hand surgery. While these lesions are most often benign, malignant lesions often have an atypical presentation and are discovered late, very often during an inappropriate treatment. To optimize the care of hand tumors and to reduce diagnostic and treatment errors, we will review the broad diagnostic and therapeutic principles and the most common clinical presentations.

Tendon transfers to restore elbow flexion

Elbow flexion paralysis is one of most significant deficiencies in the upper limb. When secondary to brachial plexus palsy or nerve trunk lesions, restoration of elbow flexion by means of early nerve surgery or palliative transfers should be part of a comprehensive treatment plan. Tendon transfers are indicated in long-standing palsies, in those who are poor candidates for nerve surgery or when the results of nerve surgery are inadequate. A regional pedicled muscle transfer is performed if available. In this case, a "strong" donor is preferred (pectoralis major with pectoralis minor transfer, triceps brachii to biceps brachii transfer, or bipolar latissimus dorsi transfer). A "weak" transfer is indicated in patients who have incomplete recovery of elbow flexion (MRC 2 strength): isolated pectoralis minor transfer, medial epicondylar muscle transfer according to Steindler technique, or advancement of biceps brachii tendon on forearm. When no donor muscle is available, a free reinnervated muscle transfer may be indicated if age and nerve regeneration conditions are favorable.

Metacarpophalangeal joint instability in trapeziometacarpal osteoarthritis: A systematic review

Thumb metacarpophalangeal instability is commonly found in conjunction with trapeziometacarpal osteoarthritis. If not corrected, it can have detrimental effects on the outcome. The authors describe the two types of metacarpophalangeal deformities - hyperextension and valgus - their pathophysiology and the surgical repair techniques available to surgeons. An algorithm for treating this instability is presented.

Modification of matched distal ulnar resection for distal radio-ulnar joint arthropathy: Analysis of distal instability and radio-ulnar convergence

BACKGROUND

In palliative surgery on the distal radio-ulnar joint (DRUJ), ulnar head resection and the Sauvé-Kapandji procedure are often followed by instability and radio-ulnar convergence. The objective of this study was to evaluate the stability of the DRUJ after modified matched distal ulnar resection performed alone or with partial or complete wrist arthrodesis.

HYPOTHESIS

A modification of matched distal ulnar resection, consisting in reconstruction of the sixth compartment and dorsalisation of the extensor carpi ulnaris, minimises these complications, regardless of the cause and associated procedures.

PATIENTS AND METHODS

A single-centre retrospective study was conducted in 46 patients (50 wrists) who underwent modified matched distal ulnar resection. The 50 wrists fell into three groups: total wrist arthrodesis according to Millender, n=21 (TWA group); radius to proximal row arthrodesis, n=17 (RPRA group); and isolated matched distal ulnar resection, n=12 (IMDUR group). Seventy per cent of patients had rheumatoid arthritis. Each patient underwent a clinical and radiographic assessment, with an analysis of radio-ulnar convergence, DRUJ stability, and ulno-carpal impingement, as well as of ulnar translation of the carpus in the IMDUR group.

RESULTS

After the mean follow-up of 8.2±5.4 years, 62% of patients were pain-free, with a mean VAS pain score of 1.3±2.1, and 90% of patients said they would have the procedure again. Clinical and radiographic instability due to excessively proximal resection was noted in 2 (4%) wrists, of which 1 required repeat surgery. Ulno-carpal impingement due to excessively distal resection occurred in 2 (4%) wrists. No significant ulnar translation of the carpus was noted in the IMDUR group (DiBenedetto: 0.011±1.9). Range of motion was similar in the three groups (mean pronation=77±17°; and mean supination=79±8°) (p>0.05). Mean grip strength was 85±35% compared to the other side.

DISCUSSION

Our modification of matched distal ulnar resection minimises the complications specific of other ulnar head resection techniques or of the Sauvé-Kapandji procedure, namely, radio-ulnar convergence and DRUJ instability.

LEVEL OF PROOF

IV; retrospective comparative study.

Comparison of clinical outcomes of three-corner arthrodesis and bicolumnar arthrodesis for advanced wrist osteoarthritis

We retrospectively compared results of 27 wrists with bicolumnar arthrodesis with mean follow-up of 67 months to 28 wrists with three-corner arthrodesis adding triquetral excision with mean follow-up of 74 months in 54 patients (55 wrists). Minimal follow-up was 2 years for all patients. Capitolunate nonunion occurred in three wrists with bicolumnar arthrodesis and six wrists with three-corner arthrodesis, and radiolunate arthritis developed in four wrists with three-corner arthrodesis. Among patients with bicolumnar arthrodesis, hamatolunate arthritis occurred in seven wrists, all with a Viegas type II lunate; and pisotriquetral arthritis occurred in three wrists. At mean 5 years after surgery, 45 wrists had not needed revision surgery, and both groups had similar revision rates. The wrists with three-corner arthrodesis and bicolumnar arthrodesis had similar functional outcomes, and range of wrist motion was not significantly different between the two groups. We concluded that bicolumnar arthrodesis results in greater longevity than three-corner arthrodesis for a type I lunate. We do not recommend bicolumnar arthrodesis for type II lunate. We also concluded that three-corner arthrodesis has a greater incidence of radiolunate arthritis and capitolunate nonunion.Level of evidence: III.

Can objective criteria for poor tolerance of proximal humerus malunion be identified?

BACKGROUND

Malunion of the proximal humerus is common and variably tolerated. Classifications developed for proximal humerus malunion (PHM) rely on standard radiographs, which underestimate bone fragment displacement and lack accuracy. The clinical tolerance of PHM is subjective, and revision surgery is not always necessary. The primary objective of this study was to assess the reproducibility and relevance of four CT angle measurements for objectively quantifying the morphological disharmony caused by PHM in a control population then in a population with PHM. The secondary objectives were to identify angle cut-offs and to assess the correlations between angle values and the clinical tolerance of PHM.

HYPOTHESIS

Objective criteria for assessing proximal humerus malunion can be identified using CT scans.

MATERIALS AND METHODS

Four angles were chosen to quantify proximal humerus disharmony: the angles between the humeral head and the glenoid in the coronal plane (HGCo) and axial plane (HGAx), the angle of tuberosity divergence in the axial plane (TDAx), and the centrum collum diaphyseal angle (CCD). The reproducibility of measurements of the four angles on computed tomography (CT) views was evaluated in a control population and in 46 patients with PHM. To this end, the reproducibility of reference slice selection was determined and intra- and interobserver reproducibility of the angle measurements was then assessed. Patients with PHM were divided into two groups based on clinical tolerance to allow testing for disharmony parameters associated with poor clinical tolerance, which was defined as functional impairment and surgical revision.

RESULTS

Slice selection was found to be reproducible. The Bland-Altman plot indicated that the angle measurements in both the controls and the patients were reproducible within ±2 SDs. Intraclass correlation coefficient values ranged from fair to excellent for all angles in both the controls and the patients. The mean TDAx was higher in the patients than in the controls (72.0° vs. 56.1°, P<0.05) and, within the PHM group, was higher in the subgroup with good vs. poor clinical tolerance (75.8° vs. 69.5°, P<0.05). The CCD angle was greater in the controls than in the patients (129.8° [range, 128.3°-131.3°] vs. 125.9° [range, 122.9°-128.9], respectively) and was significantly greater in the PHM subgroup with good vs poor clinical tolerance (131.4° vs. 122.3°, respectively; P=0.007). The HGCo and HGAx angles were significantly greater in the patients than in the controls (HGCo: 66.6° vs. 52.2°, respectively; HGAx: 17.5° vs. 13.3°, respectively, P=0.55).

DISCUSSION

The measurement method described here provides a quantitative assessment of postfracture disharmony based on four angles, the HGCo, HGAx, and TDAx. Measurement of these four angles on CT images was found to have good intra- and interobserver reproducibility. The angle values were significantly greater in the patients with PHM than in the controls. Within the patient group, the subgroup with poor clinical tolerance had smaller values of the TDAx, CCD, and HGAx angles and a greater value of the HGCo angle.

LEVEL OF EVIDENCE

IV, retrospective observational study.

Arthrodesis Versus Carpometacarpal Preservation in Key-Grip Procedures in Tetraplegic Patients: A Comparative Study of 40 Cases

PURPOSE

Constructing a lateral key pinch (KP) is a universal aim of any functional upper limb surgery program for tetraplegia. Three stages are required: (1) activating the pinch mechanism by flexor pollicis longus tenodesis to the radius or by tendon transfer to the flexor pollicis longus, (2) simplifying the polyarticular chain, and (3) positioning the thumb column. We compared 2 techniques for accomplishing the latter stage, 1 utilizing arthrodesis of the carpometacarpal joint (CMC) and 1 that did not require arthrodesis of the CMC.

MATERIALS AND METHODS

We reviewed 40 cases of KP reconstruction at a mean follow-up of 7.4 years: 17 who had undergone CMC arthrodesis and 23 without CMC arthrodesis. In this group, an abductor pollicis longus tenodesis was necessary to properly position the thumb column in 17 patients.

RESULTS

Active KP cases with CMC arthrodesis were significantly stronger than those without an arthrodesis. For passive KP cases, the difference between those cases with CMC arthrodesis and those without was not significant. Regarding opening, for active KP cases with CMC preservation alone, the mean distance between the thumb pulp and the index finger was 4.0 cm at rest and 5.8 cm when passively grasping large objects; for active KP cases without arthrodesis, these values were 3.4 and 6.8 cm, respectively, with the wrist in flexion. For passive KP cases, these values were 2.2 and 3.5 cm with CMC arthrodesis compared with 2.4 and 6.9 cm without arthrodesis. Overall, 23.5% of patients with CMC arthrodesis could not maintain contact between the thumb and the index finger compared with 30.4% without arthrodesis.

CONCLUSIONS

Active KP is stronger with than without CMC arthrodesis; however, the KP reconstruction does not open as far when grasping large objects. For passive KP, CMC arthrodesis significantly limits passive opening, with no gain in strength. Neither technique is superior in terms of KP stability.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Coracoid bone block transfer procedure: Correlation between subscapularis volume below the bone graft and shoulder stability

INTRODUCTION

Coracoid bone graft transfer has become the gold standard in patients with recurrent anterior shoulder instability associated with bony defect. Several studies have shown that the main stabilizing component of this procedure is the sling effect by the conjoint tendon and the lower portion of subscapularis (SS). The purpose of this study was to determine whether a larger SS volume below the bone block was correlated to greater postoperative shoulder stability.

MATERIALS AND METHODS

This prospective study included a cohort of patients who underwent open coracoid bone graft transfer for post-traumatic recurrent anterior shoulder instability. Forty patients were reviewed at 2 years with a clinical and CT scan evaluation. A correlation analysis assessed the relation between the SS volume index (ratio of SS volume below the bone block to volume over the bone block) and Rowe and Walch-Duplay instability scores.

RESULTS

There exists a positive and significant correlation between SS volume index and postoperative Rowe score, r=0.37 (P=0.03). The same trend was observed for Walch-Duplay score without statistical significance. A larger inferior SS volume did not result in a limitation of external rotation, greater fatty infiltration, or malposition of the coracoid graft.

CONCLUSION

A larger SS volume below the bone block is related to greater postoperative shoulder stability. We recommend performing the split in the middle of the SS or higher instead of the junction of the superior two-thirds and inferior one-third as usually reported.

LEVEL OF EVIDENCE

III, prospective study.

Giant Cell Tumor of the Capitate Treated with Excision and Midcarpal Fusion

Background  Giant cell tumor (GCT) of bone is rare in the carpus, and only 11 cases have been reported in the capitate bone. The problem with this location is the high recurrence rate due to easy extension to the adjacent joint spaces and bones. We describe a case of GCT on the capitate bone and the treatment in comparison with the previously reported cases. Case Description  The case report concerns a 48-year-old woman with a GCT of the capitate diagnosed on curettage. The treatment consisted of large resection with the lunatum and third metacarpal arthrodesis, with a successful union at 2 years follow-up, no recurrence, and an improved function of the wrist. Literature Review  When treated by curettage (alone or with adjuvant procedures), the GCT of the capitate recurred in four out of five cases. All tumors treated with large resection did not recur. Clinical Relevance  Recommended treatment of GCT of the capitate is resection with carpometacarpal arthrodesis.

Interest in the glenoid hull method for analyzing humeral subluxation in primary glenohumeral osteoarthritis

BACKGROUND

Posterior humeral subluxation is the main cause of failure of total shoulder arthroplasty. We aimed to compare humeral head subluxation in various reference planes and to search for a correlation with retroversion, inclination, and glenoid wear.

MATERIALS AND METHODS

We included 109 computed tomography scans of primary glenohumeral osteoarthritis and 97 of shoulder problems unrelated to shoulder osteoarthritis (controls); all computed tomography scans were reconstructed in the anatomic scapular plane and the glenoid hull plane that we defined. In both planes, we measured retroversion, inclination, glenohumeral offset (Walch index), and scapulohumeral offset.

RESULTS

Retroversion in the scapular plane (Friedman method) was lower than that in the glenoid hull plane for controls and for arthritic shoulders. The threshold of scapulohumeral subluxation was 60% and 65% in the scapular plane and glenoid hull plane, respectively. The mean upward inclination was lower in the scapular plane (Churchill method) than in the glenoid hull plane (Maurer method). In the glenoid hull plane, 35% of type A2 glenoids showed glenohumeral offset greater than 75%, with mean retroversion of 25.6° ± 6° as compared with 7.5° ± 7.2° for the "centered" type A2 glenoids (P < .0001) and an upward inclination of -1.4° ± 8° and 6.3° ± 7° (P = .03), respectively. The correlation between retroversion and scapulohumeral offset was r = 0.64 in the glenoid hull plane and r = 0.59 in the scapular plane (P < .05).

CONCLUSION

Measurement in the glenoid hull plane may be more accurate than in the scapular plane. Thus, the glenoid hull method allows for better understanding type B3 of the modified Walch classification.

Composite reverse shoulder arthroplasty can provide good function and quality of life in cases of malignant tumour of the proximal humerus

PURPOSE

Management of proximal humeral tumours remains a surgical challenge. No study to date has assessed the quality of life scores following the composite reverse shoulder arthroplasty for this indication. We, therefore, evaluated function and quality of life following reconstruction with allograft for malignant tumour of the humerus.

METHODS

A series of six cases of humeral tumour treated by a single surgeon in a single centre was reviewed after a mean follow-up of 5.9 years. The tumours included two chondrosarcomas, one plasmocytoma and three metastases. Resection involved bone epiphysis, metaphysis and diaphysis in five cases (S3S4S5A) and epiphysis and metaphysis in one case (S3S4A). For reconstruction, an allograft composite reverse shoulder arthroplasty was used in all the cases. Outcomes were assessed with range of motion, the QuickDash score and the Short Form 12 (SF-12) Health Survey. Radiographs assessed osseointegration and complications.

RESULTS

At the final follow-up, the mean shoulder range of motion were respectively 95°, 57° and 11° for forward flexion, abduction and external rotation. Mean QuickDASH score improved from 28 to 41 and VAS-pain scores improved from 5.1 to 2.3. The post-operative MSTS score was 73% and the Constant score was 46.1/100. The SF-12 PCS and MCS scores were also improved, respectively from 44.4 and 39.7 to 45.5 and 56.1. The mean satisfaction score was 8.1/10.

CONCLUSIONS

Composite reverse shoulder arthroplasty is a viable alternative for reconstruction after resection of malignant humeral tumour. Although total tumour resection was the most important objective, the functional and quality of life scores were satisfactory.

Clinical outcomes of proximal row carpectomy by preoperative midcarpal joint morphological classification: Viegas type I versus type II

The midcarpal joint can be classified into two anatomical types - Viegas type I and Viegas type II - based on the absence or presence of a medial facet for the hamate on the lunate (lunohamate facet). Type I is associated with a round capitate shape, which theoretically allows better congruence with the lunate fossa of the distal radius following proximal row carpectomy (PRC). This morphological feature has never been considered as a predictive factor of clinical outcome for this surgical procedure. This study aimed to compare the clinical and radiological outcomes of the two Viegas types following PRC. A retrospective single-center study was carried out on patients who underwent PRC for wrist osteoarthritis. Minimum follow-up was 2 years. Lunate type was determined based on preoperative CT arthrography. The clinical evaluation included range of motion (ROM) and strength as well as the functional DASH, Mayo Wrist scores and a VAS for pain. The outcome of radiocapitate osteoarthritis was assessed on plain radiographs. Forty patients were reviewed with a mean follow-up of 57 months. Twenty-one Viegas type I and 19 Viegas type II were identified on preoperative CT arthrography. The etiologies included 23 SLAC wrists (12 Viegas type I, 11 type II), 8 SNAC wrists (4 Viegas type I, 4 type II), 6 cases of Kienböck's disease (3 type IIIa, 3 type IIIb with 3 Viegas type I and 3 type II), 1 Preiser's disease and 2 cases of transscaphoid perilunate dislocation of the carpus. Patients with a Viegas type I lunate had significantly greater flexion-extension ROM: 83.5° vs. 71° (P=0.04) and radial deviation: 12° vs. 7° (P=0.013) than those with Viegas type II. However, three cases of complex regional pain syndrome (CRPS) were reported in the Viegas type II group vs. zero in the Viegas type I group. There were no differences between the two groups in terms of strength, functional scores or VAS pain. The outcome of radiocapitate osteoarthritis was similar in both groups. Considering the number of CRPS cases in the Viegas type II group and similar functional results in both groups, the worse outcomes of the Viegas type II patients in terms of ROM cannot be considered as clinically relevant. This comparative study does not provide a reasonable basis for concluding that Viegas type I patients are better candidates for PRC than Viegas type II patients.

Arthroscopic arthrodesis of the shoulder in brachial plexus palsy

BACKGROUND

Shoulder arthroscopic arthrodesis is an uncommon and non-standardized procedure. Results are poorly evaluated. We describe the findings in 8 patients who underwent shoulder arthroscopic arthrodesis for brachial plexus injury.

METHODS

The humeral head and glenoid were excised through standard arthroscopic portals. A Hoffmann external fixator and cannulated screws were used to stabilize the shoulder. Standard clinical assessment and radiographic evaluation were performed each month until bony fusion occurred. With a mean follow-up of 28 months, functional evaluation included pain level (on a 0- to 10-mm visual analog scale); American Shoulder and Elbow Surgeons index; Disabilities of the Arm, Shoulder and Hand score; and Simple Shoulder Test score. Mobility was systematically investigated. Blood loss was assessed by measuring hematocrit proportion.

RESULTS

Glenohumeral fusion was achieved in all 8 patients. The mean time to arthrodesis was 3 months (range, 2-8 months). At last follow-up, the mean pain level was 1 (range, 0-4); the mean American Shoulder and Elbow Surgeons score was 69; the mean Disabilities of the Arm, Shoulder and Hand score was 36; and the mean Simple Shoulder Test score was 4. Mean active flexion and abduction were 80° (range, 60°-90°) and 59° (range, 40°-80°), respectively. Mean blood loss during the perioperative period was 432 mL (range, 246-792 mL). We observed one superficial wound infection and one migration of an acromiohumeral screw. These complications did not compromise the final results.

CONCLUSIONS

Arthroscopic arthrodesis of the shoulder can be a reliable procedure and associated with a low rate of complications.

[Extra-articular distal radius fractures in young adults]

Extra-articular distal radius fractures in young active patients are typically the result of sport injuries or traffic accidents. Displaced fractures are less well tolerated in young patients than in older people, especially in terms of dorsal tilt and radial shortening. Non-surgical treatment is only indicated when the fracture is minimally or not displaced. No fracture fixation method is superior to another, however, the treatment goal is a rapid return to previous activities.

Extensive limb-sparing surgery with reconstruction for sarcoma of the hand and wrist

BACKGROUND

Sarcoma rarely involves the hand or wrist. Extensive surgical excision is the current standard of care. At the extremities, such as the hand and wrist, limb-sparing surgery with reconstruction to provide optimal function is increasingly performed. A descriptive case-series study of 16 patients with sarcoma of the hand and wrist managed using limb-sparing surgery is reported here.

MATERIAL AND METHODS

Of 19 patients with sarcoma of the hand or wrist treated between 1999 and 2012, 16 were managed using limb-sparing surgery. These were consecutive patients managed at a single-centre and studied retrospectively. The tumour involved the hand in 7 patients and the wrist in 9 patients. The procedure was primary in 6 patients, whereas 10 patients underwent secondary revision surgery. In 12 patients, reconstruction was performed for one or more of the following structures: nerves (n=2), tendons (n=3), bone (n=3), and/or skin (n=8). After surgical excision, the margins were R0 in 15 patients and R1 in 1 patient. At last follow-up, survival, pain, and function as reflected by the DASH and MSTS scores were assessed.

RESULTS

After the median follow-up of 4.5years [1-13], 15 patients were alive with no local recurrence and 1 patient had lung metastases. Mean values were 18 [0-49] for the DASH score and 88.8% [53-100] for the MSTS score.

DISCUSSION

Limb-sparing surgery reconciles the need to achieve complete tumour excision with the need to restore function. No limits should be placed on tumour excision, given the availability of effective reconstructive methods. The functional outcome depends on the tolerance of adjuvant treatments, most notably radiotherapy.

LEVEL OF EVIDENCE

IV, retrospective study.

The effect of the anatomy of the distal humerus and proximal ulna on the positioning of the components in total elbow arthroplasty

Determining and accurately restoring the flexion-extension axis of the elbow is essential for functional recovery after total elbow arthroplasty (TEA). We evaluated the effect of morphological features of the elbow on variations of alignment of the components at TEA. Morphological and positioning variables were compared by systematic CT scans of 22 elbows in 21 patients after TEA. There were five men and 16 women, and the mean age was 63 years (38 to 80). The mean follow-up was 22 months (11 to 44). The anterior offset and version of the humeral components were significantly affected by the anterior angulation of the humerus (p = 0.052 and p = 0.004, respectively). The anterior offset and version of the ulnar components were strongly significantly affected by the anterior angulation of the ulna (p < 0.001 and p < 0.001). The closer the anterior angulation of the ulna was to the joint, the lower the ulnar anterior offset (p = 0.030) and version of the ulnar component (p = 0.010). The distance from the joint to the varus angulation also affected the lateral offset of the ulnar component (p = 0.046). Anatomical variations at the distal humerus and proximal ulna affect the alignment of the components at TEA. This is explained by abutment of the stems of the components and is particularly severe when there are substantial deformities or the deformities are close to the joint.

Radial nerve palsy in surgical revision of total elbow arthroplasties: A study of 4 cases and anatomical study, possible aetiologies and prevention

BACKGROUND

Damage to the radial nerve in the arm during revision of total elbow arthroplasty is a serious complication; which is still not well documented. The aim of this study was to define a way on how to avoid this complication and to prevent it.

PATIENTS AND METHODS

Four patients underwent radial palsy after revision of total elbow arthroplasty. An anatomical study on 20 upper limbs was performed to define landmarks for the radial nerve in the arm and elbow.

RESULTS

Radial nerve damage occurred near the proximal tip of the stem in all four patients, due to cement seepage caused by cortical effraction in two patients, and to damage caused by the retractors in the two other patients. The anatomical study made it possible to specify landmarks for the radial nerve in relation to the humerus. A high-risk area located 14cm away from the tip of the olecranon fossa, and 15.5cm from the medial epicondyle, was identified.

CONCLUSION

A high-risk area for the radial nerve was defined and suggested targeted landmarks with a posterior proximal counter-incision situated at about 14cm above the olecranon fossa.

LEVEL OF EVIDENCE

IV.

Proximal row carpectomy in total arthrodesis of the rheumatoid wrist

BACKGROUND

Advanced proximal carpal row damage is common in rheumatoid arthritis (RA). Proximal row carpectomy (PRC) simplifies total wrist arthrodesis, obviating the need for an iliac bone graft. In theory, PRC also improves the chances of healing, as fusion of a single joint space is needed for the procedure to be successful. Potential effects of the loss of carpal height related to PRC are unknown.

HYPOTHESIS

We hypothesised that PRC performed concomitantly with total wrist arthrodesis in patients with RA produces good clinical and radiological outcomes, without inducing loss of strength or digital deformities.

MATERIAL AND METHODS

In 38 total arthrodeses of rheumatoid wrists, a clinical evaluation was performed, including a visual analogue scale (VAS) pain score, the Patient-Rated Wrist Evaluation (PRWE), grip strength, digital deformities, and patient satisfaction. A standard radiographic workup was obtained to assess healing and carpal height indices.

RESULTS

After a mean follow-up of 50 months, the mean VAS pain score was 0.4 (range: 0-7), the mean PRWE score was 21 (range: 0-80.5), and grip strength as a percentage of the contralateral limb was 76%. The healing rate was 92% (35/38 wrists), and 34 (90%) patients reported being satisfied or very satisfied. No effects of carpal height loss on clinical or radiographic parameters was detected.

DISCUSSION

Total wrist arthrodesis combined with PRC provides reliable and reproducible benefits. This study found no evidence of adverse effects related to the loss of carpal height.

LEVEL OF EVIDENCE

IV, retrospective study.

Impact of cardiovascular risk factor on the prevalence and severity of symptomatic full-thickness rotator cuff tears

INTRODUCTION

The natural history of rotator cuff (RC) tears is likely multifactorial. Two theories have been put forward to explain them: extrinsic and intrinsic. Cardiovascular (CV) risk factors may be important in the context of the intrinsic theory.

OBJECTIVES

The objectives of this study were to demonstrate the influence of CV risk factors and their cumulative effect on the prevalence of symptomatic full-thickness RC tears and on the severity of these lesions.

MATERIAL AND METHODS

A prospective observational case-control study was carried out with 206 consecutive patients undergoing arthroscopic rotator cuff repair. The control population consisted of 100 consecutive patients of the same age who had asymptomatic unoperated shoulders and were being operated in the orthopedics unit. The full-thickness RC tears were classified intraoperatively using the Southern California Orthopaedic Institute (SCOI) classification described by Snyder. CV risk factors were rated as either present or absent: smoking, high blood pressure (HBP), diabetes, alcoholism, dyslipidemia, obesity and CV history.

RESULTS

Using a multivariate analysis, two factors were identified as having a significant influence on the prevalence of RC tears: smoking (OR=8.715, 95%CI=4.192-18.118, P<0.0001) and dyslipidemia (OR=4.920, 95%CI=2.046-11.834, P=0.0004). The following factors had a significant effect on the severity of RC tears: smoking (OR=1.98, P=0.0341, 95%CI=1.05-3.74), HBP (OR=3.215, P=0.0005, 95%CI=1.67-6.19) and history of CV disease (OR=6.17, P<0.0001, 95%CI=2.5-14.78). The case patients had an average of 2.09 CV risk factors while the control patients had an average of 0.74 (OR=3.56, 95%CI=2.18-6.33, P=0.0012). The average number of CV risk factors increased as the severity of the tear increased: 0.19 for stage 1, 1.75 for stage 2, 2.75 for stage 3 and 2.90 for stage 4.

DISCUSSION

Modification of the vascular background appears to influence the severity and prevalence of tears. This corroborates anatomical studies in which a hypovascular area was identified in the tendon, 10-15 mm from the lesser trochanter attachment. Smoking, high blood pressure and obesity have been identified in other published studies as risks factors for the severity and prevalence of RC tears. However, it will be important to dissociate prevalence issues from that of RC healing in patients with compromised vascularity.

CONCLUSION

Cardiovascular risk factors have a significant role in the pathology of RC tears. The prevalence of RC tears is greater in patients who smoke or have dyslipidemia. Their severity is greater in patients who smoke, have high blood pressure or have experienced at least one CV event. The next step will be to study how these factors affect tendon healing, as this information could change our indications for cuff repair.

Total elbow arthroplasty: Influence of implant positioning on functional outcomes

BACKGROUND

Restoring the axis of rotation is often considered crucial to achieving good functional outcomes of total elbow arthroplasty. The objective of this work was to evaluate whether variations in implant positioning correlated with clinical outcomes.

HYPOTHESIS

Clinical outcomes are dictated by the quality of implant positioning.

MATERIAL AND METHODS

A retrospective review was conducted of data from 25 patients (26 elbows). Function was assessed using a pain score, the Disabilities of the Arm, Shoulder, and Hand (DASH) Score, and the Mayo Elbow Performance Score (MEPS). The patients also underwent a clinical evaluation for measurements of motion range and flexion/extension strength. Position of the humeral and ulnar implants was assessed by computed tomography with reconstruction using OsiriX software. Indices reflecting anterior offset, lateral offset, valgus, height, and rotation were computed by subtracting the ulnar value of each of these variables from the corresponding humeral value. These indices provided a quantitative assessment of whether position errors for the two components had additive effects or, on the contrary, counterbalanced each other. Elbows with prosthetic loosening or extensive epiphyseal destruction were excluded.

RESULTS

Of the 26 elbows, 5 were excluded. In the remaining 21 elbows, the discrepancy between the humeral and ulnar lateral offsets was significantly associated with pain intensity (P ≤ 0.05) and the MEPS (P ≤ 0.05). Anterior position of the ulna relative to the humerus was associated with decreased extension strength (P ≤ 0.05) and worse results for all functional parameters (P ≤ 0.05).

DISCUSSION

In the absence of loosening, positioning errors seem to adversely affect functional outcomes, probably by placing inappropriate stress on the soft tissues.

LEVEL OF EVIDENCE

III.

Radiocapitate congruency as a predictive factor for the results of proximal row carpectomy

PURPOSE

To evaluate whether the congruency between the joint surfaces of the lunate fossa of the distal radius and the proximal capitate might be a prognostic factor for functional, clinical, or radiographic results after proximal row carpectomy (PRC).

METHODS

After reconstructing the computed tomographic arthrogram of patients with PRC, we evaluated the shape of the proximal capitate by measuring the radius of curvature of the tip of the capitate. The congruency of the future radiocapitate joint was then evaluated by the radiocapitate index in the frontal and sagittal planes. This was calculated by dividing the radius of curvature of the tip of the capitate by the mean radius of curvature of the lunate fossa. We determined the relationship between these morphological results and the functional (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Wrist score, and pain relief), clinical (mobility and strength) and x-ray results (radiocapitate arthrosis).

RESULTS

A total of 27 patients were reviewed at a mean follow-up of 59 months. The shape of the proximal capitate did not affect outcomes. In the frontal plane, a better radiocapitate congruency was significantly associated with an increase in wrist flexion and better functional results for the DASH. There was a non-significant relationship between congruency and improvement of Mayo Wrist score and pain relief. In the sagittal plane, the DASH score tended to improve when congruency was better.

CONCLUSIONS

The shape of the capitate was not a prognostic factor for functional outcome after PRC. The radiocapitate index seems more relevant in predicting results at last follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Idiopathic avascular necrosis of the scaphoid: 10 new cases and a review of the literature. Indications for Preiser's disease

INTRODUCTION

Avascular necrosis of the scaphoid (Preiser's disease) is a rare entity for which there are no treatment guidelines to date. The aim of this study was to delineate the optimal treatment at different stages of this disease, based on an analysis of the cases treated in our department.

MATERIALS AND METHODS

Ten wrists (nine patients) were retrospectively reviewed after a mean 92 months of follow-up. The initial diagnosis was stage II avascular necrosis in four cases, stage III in four cases and stage IV in two cases. These patients were treated by conservative treatment (non surgical) in three cases, vascularized bone graft in two and palliative treatments (proximal row carpectomy or partial fusion) in five. Radiological examination, sometimes completed by MRI, and functional assessment of range of motion, grip strength and Mayo Wrist Score were performed.

RESULTS

Completely different results were obtained in the two stage II cases treated by conservative treatment, while functional results improved in the two cases treated by vascularized bone graft with regression of necrosis on MRI. Pain improved following palliative treatment in 4/5 stage III and IV wrists. Functional results were satisfactory with conservative treatment in one stage IV case for 13 years but worsened at the final follow-up assessment.

DISCUSSION

A review of the literature, including 126 cases in 29 articles clarified the role of conservative treatment, vascularized bone grafts and proximal row carpectomy in the treatment of avascular necrosis of the scaphoid. Conservative treatment is ineffective in the early stages and nearly always results in disease progression. In contrast vascularized bone grafts can stop or even reverse damage at stage II. Palliative treatment is indicated when facing irreversible lesions.

LEVEL OF EVIDENCE

Level IV - Retrospective study.

A new single volar approach for epiphyseal ulnar and radial-sided comminutive fracture of the distal radius: the mediolateral windows approach

Articular comminuted distal radius fractures are still a surgical challenge. The development of volar locking plate device allows a stable and anatomic restoration of the distal radius. We propose a modification of the classic anterior approach for articular fracture of the distal radius with ulnar impaction. By a single incision, we realize 2 windows to expose the medial and lateral column of the distal radius. This technique is indicated for complex articular distal radius fractures associated with an ulnar comminution. The dissection is extended superficially to the ulnar side of the carpal tunnel elements by a blunt dissection of the anterior part of the wrist between the skin and the superficial layer of the flexor carpi radialis, in subcutaneous tissues and the antebrachial fascia to preserve the sensitive branch of the median nerve. This new approach allows reduction of each fragment of a comminutive articular fracture without exposing the flexor tendon and median nerve to excessive tension. In our surgical armatorium, we reserved this technique for distal radius fractures with articular ulnar damage because of the possible risk to the median cutaneus branch.

[Long-term results of surgical treatment of scaphoid non union: influence of the correction of dorsal intercalated segment instability]

OBJECTIVES

The publications dealing with scaphoid non-union emphasize importance of correction of the Dorsal Intercalated Segment Instability (DISI) to achieve good functional results and to prevent osteoarthritis. The purpose of this study was to assess, over 10 years follow-up, the functional outcomes of 25 patients with scaphoid non-union surgery. X-ray and DISI deformity were assessed.

METHODS

Between 1994 and 1998, 53 patients underwent surgery for scaphoid non-union. Over 10 years follow-up, functional evaluation based on pain, QuickDASH and Mayo Wrist Score was performed, and a physical examination including mobility, strength and pain on the region of the scaphoid. Outcomes on X-rays were assessed by searching osteoarthritis damages and by measuring carpal height index and intracarpal angles.

RESULTS

Eight patients had pain on the scaphotrapeziotrapezoidal joint without degenerative lesions on radiography. Compared to other patients, they had worse functional results, decrease of scapholunate angle, decrease of the DISI and increase of carpal height.

CONCLUSIONS

The correction of the DISI is not always associated with good functional results. Although there were no osteoarthritic changes on the radiography, residual pain may be related to affection of the scapho-trapezo-trapezoidal joint. Surgical treatment with osteotomy of the scaphoid seems to be dangerous because of the moderate impact on function for these patients.

Is distal ulna resection influential on outcomes of distal radius malunion corrective osteotomies?

INTRODUCTION

The mechanical repercussions of distal radius malunion on the distal radio-ulnar (DRU) joint are common and inconsistently corrected by radius osteotomy alone. Ulnar resection has thus become a palliative solution.

HYPOTHESES

Does ulna resection influence the outcomes of distal radius malunion corrective osteotomies? What preoperative factors warrant preserving the distal radio-ulnar joint?

PATIENTS AND METHODS

Twenty-one corrective osteotomies of the radius were retrospectively reviewed. Ulna resection was performed in cases of cartilage damage, joint incongruence, or persistent stiffness in pronosupination after osteotomy of the radius. After the osteotomies, two groups were identified: 10 cases with preservation of the distal end of the ulna (DRU+) and eleven with distal resections (DRU-).

RESULTS

At review, all the osteotomies had united, with comparable anatomical restoration of the radial epiphysis for the two groups. We noted a statistically significant gain in mobility after osteotomy for both techniques (but no difference between them) and comparable grip strengths with 89.8% of the contralateral side for the DRU+ group versus 90.4% for the DRU- group. Pain (scale, 0-3) had significantly diminished for both groups decreasing from 1.9 to 0.3 for the DRU+ group and from 2.5 to 1.1 for the DRU- group, with no significant difference between them. The Mayo Clinic Wrist Score and the DASH score did not differ significantly with 73/100 and 13.5 for the DRU+ group compared with 68.2/100 and 20.2 for the DRU- group, respectively.

DISCUSSION

These results show that the impact of ulna resection after distal osteotomy of the radius is limited as reflected by radiological correction, mobility and grip strength. However, after resection pain in the ulnar tilt of the wrist due to instability of the distal ulnar stump was noted. Besides cartilage damage, ulnar deviation of over 5mm was, for this series, a constant factor in non-preservation of the DRU joint.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

A comparison of intercostal and partial ulnar nerve transfers in restoring elbow flexion following upper brachial plexus injury (C5-C6+/-C7)

PURPOSE

Restoring active elbow flexion is essential in the surgical management of C5-C6 +/- C7 brachial plexus palsies. This study compares the clinical results of 2 techniques to restore elbow flexion: the partial ulnar nerve transfer and the intercostal nerve transfer.

METHODS

Partial ulnar nerve transfer was performed in 23 patients, and intercostal nerve transfer was performed in 17 patients. For both techniques, the transfer to the musculocutaneous nerve was made at the same anatomical point. Age and preoperative delay were comparable between groups of patients.

RESULTS

Biceps reinnervation time was significantly earlier (p = .001) in the ulnar nerve technique (mean, 5.1 mo) than the intercostal nerve technique (mean 9.9 mo). Ten of 17 patients recovered useful elbow flexion force (British Medical Research Council grade >M3) in the intercostal nerve transfer group, compared with 20 of 23 patients in the ulnar nerve transfer group. No patient who had surgery more than 6 months after the injury recovered useful elbow flexion force in the intercostal nerve transfer. Elbow flexion strength was better in patients less than 30 years old in the intercostal nerve group. No complications were observed in either group.

CONCLUSIONS

This study shows that transferring fascicles of the ulnar nerve yields better results than intercostals nerve transfer for restoring elbow flexion. Moreover, preoperative delay and age are important preoperative prognostic factors for the intercostal nerves transfers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Calcified glomus tumor of the shoulder. A case report

The authors report a case of calcified glomus tumor of the shoulder in a 54-year-old woman. The nonspecific clinical findings and the noncharacteristic imaging results made diagnosis of this tumor impossible before surgery. The diagnosis was confirmed by a biopsy. The outcome after surgical resection was excellent.

Short- or long-term effects of adult myoblast transfer on properties of reinnervated skeletal muscles

Skeletal muscle demonstrates a force deficit after repair of injured peripheral nerves. Data from the literature indicate that myoblast transfer enhances recovery of muscle function. Thus, we tested the hypothesis that transfer of adult myoblasts improves the properties of reinnervated rabbit tibialis anterior (TA) muscles in both the short term (4 months) and long term (14 months). Two months after transection and immediate suture of the common peroneal nerve, TA muscles were made to degenerate by cardiotoxin injection and then transplanted with adult myoblasts cultured for 13 days. Under these conditions, muscles studied at 4 months were heavier, contained larger fibers, and developed a significantly higher maximal force than muscles that had only been denervated-reinnervated. In the long term, although muscles made to degenerate were heavier and developed a significantly higher maximal force than denervated-reinnervated muscles, myoblast transfer failed to improve these parameters. However, the overall characteristics of long-term operated muscles tended clearly to approach those of the controls. Taken together, these results may have significant implications in certain orthopedic contexts, particularly after immediate or delayed muscle reinnervation.

Transplantation of primary satellite cells improves properties of reinnervated skeletal muscles

Skeletal muscle demonstrates a force deficit after repair of injured peripheral nerves. We tested the hypothesis that transplantation of satellite cells into reinnervated rabbit tibialis anterior (TA) muscles improves their properties. Adult rabbits underwent transection and immediate suture of the common peroneal nerve. In order to provide an environment favorable for cell transplantation, TA were then made to degenerate by cardiotoxin injection, either immediately or after a 2-month delay, which is sufficient for muscle reinnervation. In both cases, the injured TA were transplanted with cultured satellite cells 5 days after induction of muscle degeneration. When cells were transferred immediately after nerve repair, drastic morphological and functional muscle alterations were observed. However, when the muscles were allowed to become reinnervated before cell transplantation, muscles were heavier and developed a significantly higher maximal force compared to denervated-reinnervated muscles. Thus, application of the cell therapy protocol improved properties of denervated muscles only when they were allowed to become innervated. These results, which represent the application of cell therapy to improve force recovery of reinnervated muscles, will be of significant interest in certain clinical contexts, particularly after immediate or delayed muscle reinnervation.