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 intramedullary 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 score and range of motion. 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, (eight patients in non-union), with no difference between the two groups. The overall mean active anterior elevation (AAE) was 125 ± 22°, mean external rotation (ER1) was 35 ± 17°, and mean internal rotation (IR) was at L3. The mean Constant score was 58 ± 23 and subjective shoulder evaluation score 73 ± 12%. ranges of motion were better in the lateral than standard position group (AAE 133 ± 17 vs. 122 ± 23, P = .03; ER1 47 ± 13 vs. 30 ± 16, P < .001; IR T12 vs. L5, P = .02). The nail was less often protruding in the lateral than standard position group (1/20 [5%] vs. 20/52 [38.5%], P = .002). The nail was better positioned from the anteroposterior view (nail centered: 16/20 [75%] vs. 26/52 [50%], P = .047) and lateral view (nail centered: 18/20 [90%] vs. 34/52 [65.4%], P = .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.

Arthroscopic shoulder suspensioplasty in painful hemiplegic shoulder subluxation-a case series.

Background: Inferior glenohumeral subluxation (GHS) can cause disabling pain in hemiplegics. Conservative treatments have not been proven to be effective or maintained over time. A few studies have shown the benefits of surgical treatment. The objective of our study was to evaluate the medium-term clinical and radiological results of arthroscopic glenohumeral suspensioplasty surgery by biceps tenodesis in the setting of painful GHS in hemiplegics. Methods: We conducted a retrospective study of patients who underwent arthroscopic glenohumeral suspensioplasty. The assessment, at a minimum of 1 year, included a clinical evaluation (pectoralis major spasticity, pain, range of motion, satisfaction) and a radiographic evaluation (Dursun classification, height of subacromial space). Results: Five patients with a mean age of 51 years (36-72 years) were included at a mean follow-up of 40 months (12-70). Satisfaction was good in 80% of patients. Pain decreased in all patients, but not significantly. Four patients (80%) would repeat the procedure if it were necessary. In all patients, a reduction in GHS over time was observed, with a reduction in subacromial height, except in 1 patient who suffered a tenodesis rupture during a fall. Conclusion: Our results suggest that arthroscopic glenohumeral suspensioplasty by biceps tenodesis may be a therapeutic option in hemiplegic patients with painful GHS.

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.

Arthroscopic Shoulder Biceps Suspensionplasty for Hemiplegic Shoulder Painful Inferior Subluxation.

Inferior glenohumeral subluxation represents one of the causes of disabling pain in patients with hemiplegia after a stroke. In the case of failure of medical treatment by orthosis or electrical stimulation, surgical treatment of suspensionplasty has been described with good results. We describe here an arthroscopic technique of glenohumeral suspensionplasty by tenodesis of the biceps, proposed in the context of a painful glenohumeral subluxation in patients with hemiplegia.

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.

"Champagne Fracture": A Superior Fracture-Dislocation of the Proximal Humerus: A Case Report.

A 79-year-old right-handed woman presented with an indirect trauma to her left shoulder after a fall down the stairs. X-rays and computed tomography showed a four-part glenohumeral fracture-dislocation with a subcutaneous ectopic location of the humeral head in the retroclavicular space. A reverse total shoulder arthroplasty was performed using a deltopectoral approach with direct superior extraction of the humeral head. The result at 2 years was a subjective shoulder value of 80%, an absolute Constant score of 59, and a relative Constant score of 92/100. To the best of our knowledge, this is the first description in the literature of such a lesion of superior glenohumeral fracture-dislocation and its treatment.

What is the patient acceptance when only scapulectomy is possible in case of malignant tumor? A case series.

Background: Scapulectomy is one of the surgical options in the case of malignant lesions in the scapula with an indication of surgical removal. Very few series in the literature have looked at postoperative quality of life and emotional acceptance, particularly in the case of scapulectomy without reconstruction. The objective is to assess the midterm results of scapulectomies in terms of function, quality of life, and acceptance for the patient. Methods: With a mean follow-up of 85 months (range 42 months-180 months), 11 scapulectomies for malignant tumors were performed with a mean age of 50 years: 5 partial scapulectomies, 4 total scapulectomies, and 2 subtotal scapulectomies. There were 6 chondrosarcomas, 2 high-grade osteosarcomas, 1 malignant peripheral nerve sheath tumor, and 1 low-grade atypical epithelioid sarcoma. The radio-clinical analysis was focused on functional results and mental health evaluation. Results: The mean Musculoskeletal Tumor Society score of 11 scapulectomies was 20 ± 5 at 66% of normal, with the Disabilities of the Arm, Shoulder and Hand (DASH) score of 35 ± 26, and the Toronto Extremity Salvage Score of 76%. Patients had controlled pain (mean visual analog scale 1/10). Mobilities of the 11 scapulectomies were correct: average active anterior elevation of 89.5 ± 43 degrees, average abduction of 81 ± 42 degrees, average external rotation of 30 ± 25 degrees, and average internal rotation was at L5. Scapulectomy results in impaired physical and mental health compared with the general population (PCS-12 = -9; MCS-12 = -7). Partial scapulectomy, compared to total scapulectomy, gave better results: Musculoskeletal Tumor Society score (14 ± 1 vs. 24 ± 1 P = .0175), acceptance (45 ± 9 vs. 92 ± 16, P = .0184), mental health (MCS-12: 29 ± 1 vs. 55 ± 4, P = .0175), and Toronto Extremity Salvage Score (84 ± 5 vs. 68 ± 7, P = .0195). Partial and subtotal scapulectomies were better accepted (45 ± 9 vs. 86 ± 23, P = .0323) and tolerated (MCS-12: 29 ± 1 vs. 52 ± 6, P = .0099) by the patient compared to total scapulectomy. Conclusion: Total or partial scapulectomies without scapula reconstruction remain a disabling procedure performed with consequences on the physical and mental health of the patients. Partial or subtotal scapulectomy should be performed whenever possible because it seems to be associated with a better functional prognosis as well as less poor mental health and emotional acceptance of the patients, even though total scapulectomy may be necessary to obtain a complete curative tumor resection, which is the main goal.

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.

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.

Influence of dual-mobility acetabular implants on revision and survivorship of cup and Kerboull-type reinforcement ring constructs in aseptic acetabular loosening.

INTRODUCTION: Dual-mobility (DM) acetabular implants have been used in revision total hip arthroplasty (THA) to prevent postoperative instability, with excellent mid-term survivorship. However, few comparative studies assessed the long-term outcomes of DM implants used in Kerboull-type reinforcement ring constructs for acetabular revision. The present study aimed to compare long-term survivorship, dislocation rates and clinical outcome between DM acetabular implants and conventional single-bearing (SB) implants when cemented in a reinforcement ring. HYPOTHESIS: Dual-mobility implants are associated with equivalent survivorship and lower dislocation rates than SB implants. MATERIAL AND METHODS: A retrospective study included 60 revision THAs for aseptic loosening using a Kerboull-type reinforcement ring, and finally included 2 groups of 23 patients with either DM or SB cemented acetabular implants after matching for age, gender, BMI and preoperative Harris hip score. Mean follow-up was 10 years (range, 6-14 years). Acetabular implant survivorship, dislocation rate and radiographic failure incidence (>5mm migration, progressive radiolucency, graft non-integration, reinforcement ring breakage) were compared between the two groups. Clinical outcomes used the Harris hip score, the Postel-Merle d'Aubigné score and the Parker score. RESULTS: Survivorship free of aseptic acetabular re-revision was 89% at 10 years, with no significant difference between DM and SB (91% and 86%, respectively; p=0.54). Single-bearing implants showed a hazard ratio for dislocation of 6.7 (95% CI, 1.5-29.6; p=0.01) compared to DM implants. There were no significant differences in radiologic failure (10-year survivorship 72% and 64%, respectively; p=0.88) or functional scores. DISCUSSION: The present study confirmed the impact of dual-mobility implants in reducing long-term dislocation risk when used in Kerboull-type reinforcement ring constructs for acetabular aseptic revision, with no increased risk of re-revision compared to conventional single-bearing implants. LEVEL OF EVIDENCE: III, comparative retrospective study.