Consolidation rate in ulnar shortening osteotomy with the APTUS Wrist plate.

INTRODUCTION: Ulnocarpal impaction syndrome causes pain on the ulnar side of the wrist. Various surgical techniques have been described. Ulnar shortening osteotomy is now a standard treatment. However, it is associated with complications such as non-union of the osteotomy site. The main study objective was to report the rate of radiographic consolidation after ulnar shortening osteotomy with a cutting guide. MATERIAL AND METHODS: This multicenter retrospective study of 30 cases reported clinical and radiographic criteria at a minimum 6 month's follow-up. RESULTS: The non-union rate was 3.4%. One case presented non-union of the osteotomy site. 87% of patients were satisfied or very satisfied with the procedure. Mean VAS pain rating was 2.7 ± 2.4. Mean QuickDASH and PRWE scores were 24.7 ± 19.2 and 28.6 ± 25. Mean strength on Jamar dynamometer was 27.4 ± 8.9 kg. One patient developed complex regional pain syndrome. Five patients required plate removal for hardware-related discomfort. DISCUSSION: Ulna shortening osteotomy with the Aptus Wrist plate provides a standardized approach to the surgical treatment of ulnocarpal impaction syndrome. Compared with other series in the literature, the procedure provided satisfactory consolidation and clinical results.

Lateral elbow ligament reconstruction for posterolateral rotatory instability: 10 years follow-up in 32 patients.

Background: Posterolateral rotatory instability (PLRI) is the most frequent form of both acute and chronic elbow instability. It is due to mechanical incompetence of the lateral collateral ligament. O'Driscoll et al described treatment of this instability by autologous reconstruction of the lateral ulnar collateral ligament. The aim of our study was to evaluate the medium and long-term clinical, functional and radiological results of patients who were surgically treated for PLRI by this technique. We hypothesized that such ligament reconstruction restores a functional joint complex and durably stabilizes the elbow and limits the long-term risk of osteoarthritis. Methods: All patients treated for symptomatic PLRI by ligament reconstruction since January 1995 and who had a minimum follow-up of 36 months were retrospectively included. Results: Thirty-two patients (32 elbows) underwent clinical and radiological evaluation with a mean follow-up of 112 months (range, 36-265 months). The success rate of the procedure was 97% with one patient requiring revision reconstruction. Twenty-four patients (75%) were free from pain. Pain was significantly greater in patients with associated lesions (P = .03) and those with morbid obesity (body mass index ≥40) (P = .03). Twenty-nine (91%) patients had resumed their previous activities. Twenty-eight patients (87%) were satisfied or very satisfied. The mean Mayo Clinic score was 96/100 and the QuickDash 14.7/100. Two patients (6%) with accompanying lesions developed severe osteoarthritis. Conclusion: Elbow ligament reconstruction by the technique of O'Driscoll et al effectively restores stability and limits progression to osteoarthritis in the long term. The only failure in our series was due to several technical errors. Patients who had dislocation with associated lesions or morbid obesity are at risk of poorer functional results.

Total arthrodesis for non-rheumatoid wrists: Outcomes at 5 and 20years of follow-up.

INTRODUCTION: Total wrist arthrodesis (TWA) aims to obtain a painless wrist with a strong grip. Its main disadvantage is compromised mobility and for many authors it remains a rescue intervention. However, after one or more palliative interventions, TWA confers poorer results. The objective of our study was to evaluate the medium-term results of TWA, and their long-term stability. HYPOTHESIS: Our hypothesis was that the results are reliable and persistent for pain and strength, without repercussions to other joints. MATERIAL AND METHODS: This was a single-center consecutive series of TWA performed with a dedicated plate, excluding rheumatoid wrists, evaluated at 5.4 and 21.1years of follow-up. RESULTS: Thirty wrists were assessed at the first review and 17 reassessed at the last follow-up. At the mean follow-up of 5.4years, 93% of patients considered themselves "very satisfied" or "satisfied" with the TWA surgery. No infectious complications occurred. At the mean follow-up of 21.1years, all were "very satisfied" or "satisfied" and 88% of them considered their result stable or improved compared to the first revision. The average VAS had gone from 8.4/10 preoperatively to 1.8/10 at the first evaluation and to 0.3/10 at the last follow-up. Except for a patient with both wrists operated on for whom comparison was not possible, the strength of the operated side was on average 89.7% of that of the contralateral side (from 45% to 150%). The mean Quick DASH score was 30.3 (4.5 to 61.4) and the mean PRWE score was 32.5 (1 to 77). DISCUSSION: TWA using a plate provides excellent results for both pain control and strength restoration. The clinical results remain stable over time, and arthrodesis at more than 20years of follow-up does not seem to have any impact on the other joints of the upper limb. After wrist surgery, the main complaint of patients is the limited range of motion, but the main cause of dissatisfaction is persistent pain. Arthrodesis can be performed first-line in case of questionable indication of partial arthrodesis on a stiff wrist because the results of TWA are better in the absence of a surgical history. LEVEL OF EVIDENCE: IV; retrospective study.

Comparison of results of arthroscopic arthrolysis between traumatic and degenerative elbow stiffness.

INTRODUCTION: Elbow stiffness significantly affects the patient's quality of life. This joint must have at least 30°/130° extension/flexion and 50°/50° pronation/supination to function normally according to Morrey. HYPOTHESIS: The objective of this study was to evaluate functional outcome of arthroscopic arthrolysis by comparing stiffness of post-traumatic and degenerative origin. The hypothesis was that this surgical technique allows functional improvement in any indication but with a faster result in degenerative pathology. MATERIAL AND METHODS: This was a retrospective study including all patients who underwent elbow arthrolysis under arthroscopy, operated on by a single operator, between 2013 and 2020. Thirty-four patients were included, with a mean age of 45years (range, 18-78years). Patients were divided into two groups according to etiology. Group A (post-traumatic) consisted of 18 patients with a mean age of 33years (range, 18-64years) and group B (degenerative) of 16 patients with a mean age of 59years (range, 42-78years). All patients were clinically assessed at a mean 27months. Range of motion, level of satisfaction and Mayo Elbow Performance Score (MEPS) were collected. RESULTS: In the overall series, preoperative range of motion was 81° and significantly improved postoperatively to 122° (p<0.001). The preoperative data of the 2 groups were comparable except for age (p<0.001) and MEPS (p=0.044). Postoperatively, range of motion improved significantly in both groups but with greater gain in group A (p=0.003). MEPS improved significantly in both groups, but the postoperative score was poorer in group B (p=0.001). Recovery of range of motion was faster in group B (2.4months) than in group A (3.7months) (p=0.021). There were 5 complications: 4 secondary decompensations of ulnar tunnel syndrome, and 1 postoperative radial nerve paresis. 94% of patients were satisfied or very satisfied with the result of surgery. CONCLUSION: Arthroscopic arthrolysis is an effective option for post-traumatic and non-traumatic elbow stiffness. Improvement was significant in terms of both function and range of motion, with, however, better results in the post-traumatic group but results achieved more rapidly in the degenerative pathology group. LEVEL OF EVIDENCE: IV, retrospective study.

Terrible triad injury of the elbow: a historical perspective.

PURPOSE: The aims of this study are to summarize (1) the history of terrible triad injury (TTi) treatment and (2) the clinical and biomechanical data that engendered its evolution. METHODS: A literature search was performed using five electronic databases. Results were discussed as a chronologic review of the relevant literature between 1920 and 2022. RESULTS: In 1962, Osborne was the first to describe a link between elbow dislocation, radial head fracture, and lateral collateral ligament complex injury via a novel mechanism: posterolateral rotatory instability (PLRI). Given that untreated elbow instability leads to post-traumatic osteoarthritis (PTOA), there has been increasing interest in elbow biomechanics since the 1980s. Data from studies in that period revolutionized the approach to elbow instability. The authors demonstrated that TTi could occur via a PLRI mechanism with a disruption of the lateral collateral ulnar ligament and a functionally competent anterior medial collateral ligament (aMCL). Since the 1990s, due to the difficulty in identifying its pathoanatomic features, some began to speculate about a sequence of injuries and mechanisms leading to TTi. However, the clinical literature has largely been unable to reproduce in vitro findings describing the pathomechanics of TTi. Some aspects of treatment remain controversial including systematic coronoid and aMCL repair. CONCLUSION: Despite a growing body of biomechanics data, there is no widely accepted surgical protocol for the treatment of TTi. Functional outcomes among patients have greatly improved. Better diagnosis and treatment of infra-clinical instability after a TTi may be an important stepping stone to prevent the onset of moderate/severe PTOA.

Comparison of subjective outcomes of Darrach and Sauvé-Kapandji procedures at a minimum 2 years' follow-up.

INTRODUCTION: In distal radioulnar joint pathology, the literature regularly recommends reserving the Sauvé-Kapandji (SK) procedure to young patients and heavy manual workers, and the Darrach (D) procedure to older patients and rheumatic wrists. However, the SK procedure is more technically demanding and requires more proximal resection of the ulna, with greater risk of instability in the ulnar stump. The aim of the present study was to determine whether the SK procedure really does show superiority. HYPOTHESIS: Subjective results are no better after the SK than the D procedure. MATERIAL AND METHODS: Seventy of the 101 operated cases (70 patients: 40 female, 30 male; mean age at surgery, 50.2 years [range, 16.4-87.2 years]) were assessed, at a minimum 24 months. Group D comprised 44 wrists, and group SK 26. Assessment was conducted by telephone interview for pain, ranges of flexion-extension and pronation-supination, strength, stump stability and satisfaction, and by mail for the QuickDASH questionnaire. Mean follow-up was 8.2 years (range, 25 months to 17 years). RESULTS: The surgical revision rate was significantly higher in SK (p=0.003). Results were comparable between groups for pain, strength, range of motion and satisfaction. Mean QuickDASH score was 45.5 in group D and 26.5 in group SK. Age-matched comparison found no significant differences on endpoints. DISCUSSION: Subjective results after the SK procedure showed no superiority over the D procedure, despite group D patients having twice the rate of heavy manual work and sport activities. This non-difference casts doubt on the need to reserve the D procedure to elderly patients and the SK procedure to young patients and heavy manual workers, especially as the latter is more technically demanding and is associated with a higher rate of surgical revision. LEVEL OF EVIDENCE: IV; retrospective study.

Percutaneous Reconstruction of the Medial Patello-Femoral Ligament Using Dynamic Gracilis Tendon Transfer.

BACKGROUND: Many techniques have been described for reconstructing the medial patello-femoral ligament (MPFL), using a variety of transplants and fixation methods to treat patello-femoral dislocation. The main challenge with static transfers is to position the femoral fixation point at the site that best restores MPFL anisometry. The objective of this cadaveric study was to propose a version of the initially described dynamic gracilis transfer technique that can be performed percutaneously. HYPOTHESIS: Our working hypothesis was that using a minimally invasive approach would provide better cosmesis without altering the biomechanical efficacy of the procedure. METHODS: 20 cadaveric knees were used to evaluate the feasibility and reliability of our percutaneous technique. We analysed femoral pulley location and scar length. RESULTS: After dissection, the position of the femoral pulley allowed superimposition of the transplant along the trajectory of the native MPFL in all 20 knees. Cumulative scar length was 6.5cm (range, 6-7.5cm). DISCUSSION: Percutaneous dynamic gracilis transfer is easy to perform, reproducible, and capable of creating a pulley that anatomically replicates the femoral insertion point of the native MPFL. LEVEL OF EVIDENCE: IV; retrospective study.

Median nerve entrapment syndrome in the elbow and proximal forearm. Anatomic causes and results for a 55-case surgical series at a mean 7years' follow-up.

BACKGROUND: Proximal median nerve (MN) neuropathy represents 1% of upper-limb compressive neuropathies. The literature reports two clinical presentations, depending on the location of the entrapment: pronator teres (PT), and anterior interosseous nerve (AIN) syndrome. HYPOTHESIS: There is no correlation between symptoms and location of proximal compressive structures on the MN trunk or AIN. PATIENTS AND METHODS: Clinical and paraclinical data from 55 surgical MN releases around the elbow and proximal forearm were analyzed retrospectively. Mean age at diagnosis was 56±15years. Preoperative sensory and motor deficit signs were present in 89% of cases. Reduced MN conduction velocity and/or neurogenic anomalies in the MN territory were present in 94% of cases. Intraoperative details of compressive structures were collected. Patients were followed up in consultation to assess progression of symptoms and deficits. RESULTS: Mean follow-up was 84±70months. Objective motor deficit signs persisted in 18 of the 35 patients (18 cases), and objective sensory signs in 19 cases. A compressive anatomical structure was systematically found. There were at least two MN entrapment sites in 13 cases (24%). No isolated AIN entrapment was found. There was a significant correlation between symptom duration and persistence of objective sensory signs (p=0.002). DISCUSSION: There was no correlation between entrapment site and clinical signs on examination. Surgery requires exploring all potential entrapment sites. Improvement may be incomplete in case of late treatment. LEVEL OF EVIDENCE: IV; retrospective study.