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.

Subscapularis impairment on magnetic resonance imaging is correlated with functional limitations in neonatal brachial plexus palsy.

PURPOSE: The relationship between functional shoulder deficits in children with neonatal brachial plexus palsy (NBPP) and magnetic resonance imaging (MRI) shoulder abnormalities was evaluated. METHODS: Shoulder function was assessed in 16 children (mean age: 5.8 years; range: 3-12 years) with NBPP based on shoulder rotator muscle strength, as measured using an isokinetic dynamometer and the modified Mallet score. The thickness and fatty infiltration of the subscapularis and infraspinatus muscles, and the morphology of the glenoid on MRI, were also determined. RESULTS: The highest subscapularis fatty infiltration subgroup of NBPP patients promoted the highest alteration muscle thickness and modified Mallet score. CONCLUSIONS: In NBPP children, subscapularis impairments play a major role in the functional limitations. This study of pediatric NBPP patients highlighted the value of adding an examination of the muscles to routine MRI assessment of bone parameters in the shoulders of NBPP children. TRIAL REGISTRATION: NCT03440658.

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.

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.

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.

International Recommendations to Manage Poststroke Equinovarus Foot Deformity Validated by a Panel of Experts Using Delphi.

OBJECTIVE: To establish international recommendations for the management of spastic equinovarus foot deformity. DESIGN: Delphi method. SETTING: International study. PARTICIPANTS: A total of 24 international experts (N=24) in neuro-orthopedic deformities, from different specialties (Physical and Rehabilitation Medicine physicians, neurologists, geriatricians, orthopedic surgeons, neurosurgeons, plastic surgeons). INTERVENTIONS: Experts answered 3 rounds of questions related to important aspects of diagnosis, assessment, and treatment of spastic equinovarus foot deformity. MAIN OUTCOME MEASURES: A consensus was established when at least 80% of experts agreed on a statement RESULTS: A total of 52 items reached consensus. Experts recommend assessing effect of the deformity on functional activities before treatment. Before treatment, it is crucial to differentiate spastic muscle overactivity from soft tissue contractures, identify which muscles are involved in the deformity, and evaluate the activity of antagonist muscles. Motor nerve blocks, 2-dimensional video analysis, and radiologic examinations are often required to complement a clinical examination. The treatment of equinovarus foot depends on the correctability of the deformity and the patient's ability to stand or walk. The preoperative assessment should include an interdisciplinary consultation that must finalize a formal agreement between physicians and the patient, which will define personalized attainable goals before surgery. CONCLUSION: The establishment of guidelines on managing equinovarus foot will help physicians and surgeons, specialists, and nonspecialists to diagnoses and assess the deformity and direct patients to a network of experts to optimize patient functional recovery and improve their autonomy.

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.

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.

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.

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.

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.

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.

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.