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.

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.

Standard views do not suffice in assessing distal scaphoid articular cannulated screw penetration.

BACKGROUND: Articular screw penetration is one of the most common hardware-related problems after scaphoid fracture fixation, occurring in up to two-thirds of patients, in particular into the scaphotrapezotrapezoidal (STT) joint. The aim of this study was to investigate whether this clinically important issue could be detected using standard anteroposterior (AP) and lateral, as well as additional nonstandard fluoroscopic views using direct open visualization with magnifying loupes as reference standard. MATERIALS AND METHODS: Ten fresh cadaver wrists were used for this imaging study. A 2.2 mm cannulated compression screws with a length of 24 mm was placed in the scaphoid and incrementally left to protrude at the STT joint up to 2 mm. Eight fluoroscopic views of the wrist were then obtained by rotating the forearm using goniometric measurements, keeping the image beam parallel to the floor: (1) anteroposterior with the wrist in neutral rotation, (2) anteroposterior with the wrist in ulnar deviation, (3) supinated oblique 60° from neutral (60° supinated oblique), (4) supinated oblique 45° from neutral (45° supinated oblique), (5) a true lateral, (6) a true lateral with the wrist in radial deviation, (7) pronated oblique 45° from neutral (45° pronated oblique), and (8) a pronated oblique 60° from neutral (60° pronated oblique). RESULTS: Standard anteroposterior and lateral fluoroscopy views (radiographically calibrated) of a percutaneous cannulated screw fixation of a scaphoid fracture were insufficient to detect distal articular penetration, missing half the amount of screw penetrations in the current study. The 45° pronated oblique view was found as the most sensitive in detecting STT penetration (p < 0.0001). CONCLUSIONS: Standard anteroposterior and lateral fluoroscopy views of a percutaneous cannulated screw fixation of a scaphoid waist fracture are insufficient to detect STT screw penetration. According to the current study, standard views would have missed half the amount of screw penetrations, which seems to reflect the high incidence of this problem in current practice. The most sensitive view was the 45° pronated oblique view, which detected STT screw penetration in all cases. Level of Evidence Not applicable.

Results of radial head prostheses implanted during Essex-Lopresti syndrome in multicentric study.

AIMS: The aim was to evaluate the results of radial head prostheses (RHP) in Essex-Lopresti injury (ELI) and to compare results after RHP between acute and chronic ELI. PATIENTS AND METHODS: Thirty-one patients treated with RHP for ELI were selected from a multicenter retrospective series of 310 RHP, with follow-up greater than two years. Two groups were acute ELI group (n=19, average diagnosis = 5+/-9 days) and chronic ELI group (n=12, average diagnosis 8.4+/-7.1 months). RHP was associated in some cases with K-wires: during acute ELI to stabilize the distal radio-ulnar joint (n=4) or during chronic ELI with ulnar osteotomy or palliative surgery (n=4). Clinical and radiologic evaluation was performed including analysis of the complications and revisions rates, pain level, range of motion, and MEPS (Mayo Elbow Performance Score) and DASH score (Disabilities of the Arm, Shoulder and Hand). RESULTS: At last follow-up (71+/-38 months), survival of RHP in the acute ELI group was 84% (16/19) and 92% (11/12) in the chronic ELI group without statistically significant difference. Flexion (acute=131degrees+/-13.4 vs chronic=22+/-12.8, p=0.041) and supination (ELI=71+/-16.8 vs chronic=58+/-17.4; p=0.045) were better in acute ELI group. The DASH score was also better in the acute group (15+/-9.1 versus 24+/-15.2, p=0.048). There was more advanced stage of humero-radial osteoarthritis in the chronic ELI group (0.7+/-0.5 versus 1.4+/-0.6, p=0.041). CONCLUSION: RHP in acute ELIs provide better clinical results, although RHPs are part of the therapeutic arsenal to treat chronic ELI.

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.

Nerve stress during reverse total shoulder arthroplasty: a cadaveric study.

BACKGROUND: Neurologic lesions are relatively common after total shoulder arthroplasty. These injuries are mostly due to traction. We aimed to identify the arm manipulations and steps during reverse total shoulder arthroplasty (RTSA) that affect nerve stress. METHODS: Stress was measured in 10 shoulders of 5 cadavers by use of a tensiometer on each nerve from the brachial plexus, with shoulders in different arm positions and during different surgical steps of RTSA. RESULTS: When we studied shoulder position without prostheses, relative to the neutral position, internal rotation increased stress on the radial and axillary nerves and external rotation increased stress on the musculocutaneous, median, and ulnar nerves. Extension was correlated with increase in stress on all nerves. Abduction was correlated with increase in stress for the radial nerve. We identified 2 high-risk steps during RTSA: humeral exposition, particularly when the shoulder was in a position of more extension, and glenoid exposition. The thickness of polyethylene humeral cups used was associated with increased nerve stress in all but the ulnar nerve. CONCLUSION: During humeral preparation, the surgeon must be careful to limit shoulder extension. Care must be taken during exposure of the glenoid. Extreme rotation and oversized implants should be avoided to minimize stretch-induced neuropathies.

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.

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.

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.

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.

[Necrotizing fasciitis related to injections of morphine (Skénan(®)) in a HIV-infected patient]. / Fasciites nécrosantes liées à des injections de morphine (Skénan(®)), chez un patient infecté par le VIH.

We report here a case of necrotizing fasciitis occurred because of intravenous misuse of morphine sulfate (Skénan (®)). Several factors are pertinent: the type of infection, rare but severe, the double localization of the necrotizing fasciitis, complicated by sepsis, the patient profile (HIV-infected) and the injected substance (opiate).

Digital mucous cyst.

Mucous cyst is a benign but recurrent lesion. It is located on the dorsal surface of the digital extremity between the distal interphalangeal joint and the base of the nail. The nail is often affected by the cyst because of its topographical proximity. Nail plate deformity may even be the first obvious abnormality indicating the presence of a small mucous cyst or subungual cyst. Mucous cyst is associated with osteoarthritis of the joint, osteophytes probably being the main contributing factor. Surgical treatment by joint debridement and cyst removal is the most effective way of preventing recurrence.

Palmar Dislocation Fracture of the Hamate: A Case Report and Review of Literature.

Objective Hamate dislocations are rare lesions of the carpus, which make their diagnosis difficult or even missed, and their management non-standardized. Case Description We report the case of a 34-year-old victim of a high kinetic traffic accident. The initial evaluation revealed multiple fractures of both upper limbs, including a palmar fracture dislocation fracture of the hamate, without any vascular or nerve complications. Open surgical treatment via a dorsal approach allowed reduction and fixation of the hamate by temporary multiple pinning. At 12-month follow-up the patient had pain free motion of the wrist with a DASH score of 3. Radiographs showed evidence of proximal pole hamate sclerosis and carpo-metacarpal narrowing. Literature Review Owing to its rarity, literature on this topic is extremity limited. Various mechanisms have been described to explain these injuries, including dorsal pressure on the carpus associated with traction of the annular carpal ligament on its hamate insertion. Symptoms can be minimal and only three cases of nerve complications have been reported. Long-term outcomes following these injuries usually result in decrease in wrist motion and grip strength. Clinical Relevance The rarity of dislocations with or without hamate fracture favors the absence or the delay of diagnosis, which must lead to a precise radiographic analysis and to the implementation of a CT scan in case of high kinetics carpal trauma, even if it is poorly symptomatic. Level of Evidence Level 5, case study.

Metacarpophalangeal hyperextension in trapeziometacarpal osteoarthritis: Relationship to first metacarpal head shape, and clinical impact.

PURPOSE: The aim of this study was to determine whether the shape of the first metacarpal head influences metacarpophalangeal hyperextension, and to evaluate the influence of metacarpophalangeal hyperextension on hand pain and function in patients with trapeziometacarpal osteoarthritis. METHODS: 362 patients with painful basal thumb osteoarthritis were evaluated over a 2-year period. Pain rating on a visual analog scale, trapeziometacarpal and metacarpophalangeal motion, and grip and pinch strength were evaluated. The shape of the metacarpal head was assessed on strict lateral radiographs using the "A/r" ratio. RESULTS: Round metacarpal heads had significantly greater and more frequent metacarpophalangeal hyperextension than flat heads (28° vs. 8°, and 78% vs. 29%). Metacarpophalangeal hyperextension adversely impacted trapeziometacarpal motion in antepulsion (27° vs. 32°), abduction (25° vs. 30°) and pinch strength (3.6 vs. 4.6 KgF). CONCLUSION: Our findings indicate that the shape of the metacarpal head influences metacarpophalangeal hyperextension in trapeziometacarpal osteoarthritis. Metacarpophalangeal hyperextension adversely impacted pinch strength and trapeziometacarpal motion. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

Morbidity associated with pre-hospital upper-limb tourniquet in civilian trauma: a case series.

INTRODUCTION: The widespread pre-hospital use of tourniquets, particularly in the upper limb, raises questions about associated morbidity, which has been little studied and may have serious consequences for functional prognosis. METHODS: A review of 9 patients was carried out, analyzing pre-hospital tourniquet use in terms of complications affecting recovery. RESULTS: There were serious complications: musculocutaneous nerve palsy in 1 patient, and compartment syndrome, rhabdomyolysis and ischemia-reperfusion syndrome in another. A role of prolonged pre-hospital tourniquet application in postoperative infection was also suspected in 2 patients. DISCUSSION: The risk-benefit ratio and indications for using a tourniquet on the upper limb in the pre-hospital setting need to be reconsidered.

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.

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.

Restoration of elbow extension and construction of a "key grip" in people with tetraplegia. Comparative study of a surgical plan in one or two stages.

AIM: We report the comparative results of functional upper extremity surgery plans in patients with tetraplegia, including restoration of elbow extension and construction of a key grip in a "one-stage" or "two-stage" operation. MATERIALS AND METHODS: A series of 36 patients with tetraplegia, with a total of 45 operated upper limbs, was analyzed retrospectively with a mean follow-up of 23 months (13-39 months). We evaluated the analytical strength of elbow extension using the MRC (Medical Research Council) score, the strength of the key grip (kg/F) as well as the autonomy of the patients using functional scores; Lamb (/100) and QIF (Quadriplegia Index of Function) (/100). RESULTS: Sixteen upper limbs were included in the "one-stage" group and 29 in the "two-stage" group. The groups were comparable preoperatively. Elbow extension strength was 3.6/5 in the one-stage group versus 3.7/5, p=0.74. Grip strength was 1.8kg/F in the one-stage group versus 1.3kg/F, p=0.22. Regarding the functional scores, there was no statistically significant difference between the two groups for the Lamb score (p=0.46) and the QIF (p=0.42). There was no statistically significant difference in terms of the frequency of complications for the elbow (p=0.49) and for the hand (p=0.17). The total duration of the one-stage surgery plan averaged 7.5 months compared to 24.7 months for the two-stage plan, p<0.01. The mean follow-up for the one-stage group was 21 months versus 24 months for the two-stage group. CONCLUSION: The results of both plans are similar and indicate that the "one-stage" plan is a reliable option. This all-in-one surgical option reduces postoperative follow-up and dropout rates for patients during the plan timeframe. LEVEL OF EVIDENCE: IV; retrospective clinical series.

After failed radial head arthroplasty, what are the options? Risk factors and results of revisions in a multicenter study.

Introduction: Few multicenter studies have analyzed the outcome of revision surgery of radial head arthroplasties (RHA) in the medium term follow up. The objective is twofold: to determine the factors associated with revision of RHAs and to analyze the results of revision with 2 surgical techniques: isolated removal of the RHA or revision with a new RHA (R-RHA). Hypothesis: There are associated factors of RHA revision and RHA revision results in satisfactory clinical and functional outcomes. Methods: Twenty-eight patients were included in this multicenter retrospective study, with all surgical indications for initial RHA being traumatic/post-traumatic. The mean age was 47 ± 13 years with a mean follow-up of 70 ± 48 months. This series included two groups: the isolated RHA removal group (n = 17) and the revision RHA with new radial head prosthesis (R-RHA) group (n = 11). Evaluation was clinical and radiological with univariate and multivariate analysis. Results: Two factors associated with RHA revision were identified: a pre-existing capitellar lesion (p = 0.047) and a RHA placed for a secondary indication (<0.001). Revision for all 28 patients resulted in improved pain (pre-op Visual Analog Scale 4.7 ± 3 vs. post-op 1.57 ± 2.2, p < 0.001), mobilities (pre-op flexion 118 ± 20 vs. post-op 130 ± 13, p = 0.03; pre-op extension -30 ± 21 vs post-op -20 ± 15, p = 0.025; pre-op pronation 59 ± 12 vs post-op 72 ± 17, p = 0.04; pre-op supination 48 ± 2 vs post-op 65 ± 22, p = 0.027) and functional scores. Mobility and pain control were, for stable elbows, satisfactory in the isolated removal group. When the initial or revision indication was instability, the DASH (Disabilities of the Arm, Shoulder and Hand = 10 ± 5) and MEPS (Mayo Elbow Performance score = 85 ± 16) scores were satisfactory in the R-RHA group. Discussion: In the case of a radial head fracture, RHA is a satisfactory first-line solution without pre-existing capitellar injury, its results being much weaker in the case of ORIF failure and fracture sequelae. In case of RHA revision, isolated removal or R-RHA adapted according to the pre-operative radio-clinical exam. Level of evidence: IV.

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.