Partial arthroscopic trapeziectomy and stabilisation by ligamentoplasty: Outcomes in patients younger than 60years.

BACKGROUND: Thumb carpometacarpal joint (TCMJ) osteoarthritis is the fourth leading cause of referral to elective hand surgery. None of the available techniques has proved superior over the others. Some techniques carry unacceptable risks for younger patients, such as loss of strength and shortening of the thumb column after total trapeziectomy, or wear and loosening after total arthroplasty. Our objective was to assess outcomes after partial arthroscopic trapeziectomy (PAT) combined with suspensionplasty using the abductor pollicis longus (APL) tendon in patients younger than 60years of age. HYPOTHESIS: PAT combined with suspensionplasty using the APL tendon in patients younger than 60years would restore strength in the medium-term without further surgery. MATERIAL AND METHODS: We retrospectively included consecutive patients operated between 2007 and 2017, in a single centre, and aged less than 60years. All patients had isolated TCMJ osteoarthritis stage 1 to 3 according to Eaton and Glickel classification that remained symptomatic despite optimal conservative treatment. We collected pain intensity, range of motion, strength, the Nelson Hospital Score (NHS), and the Patient-Rated Wrist Evaluation (PRWE) score. Radiographs were reviewed. RESULTS: We included 27 patients, of whom 6 had surgery on both thumbs, yielding 33 thumbs for the analysis. Mean follow-up was 64.7months (range: 10.6-136.5months). Pain intensity, grip strength, and key-pinch strength were significantly improved (p<0.001), with no difference between men and women. No differences were found for the Kapandji score (p=0.2) or TCMJ hyperextension (p=0.06). At last follow-up, the mean NHS was 83.2±19.4 and the mean PRWE was 15.4±17.9. Mean sick leave duration was 5.4weeks (range: 1-24weeks). Only 2 patients, both in manual jobs, were unable to return to work. The radiographs at last follow-up showed the development of moderate TCMJ narrowing in 14 patients and evidence of scapho-trapezio-trapezoid (STT) osteoarthritis in 10 patients. No patient experienced complex regional pain syndrome or injury to the sensory branch of the radial nerve. A single patient required further surgery for persistent pain. DISCUSSION: Patients younger than 60years who are treated with this minimally invasive technique are likely to experience sustained improvements in both strength and pain intensity. Total trapeziectomy and pyrocarbon implant has also been evaluated in younger patients, who experienced pain relief and strength gains but had lower levels of satisfaction and developed complications inherent in the implants. The short time off work and low morbidity make our technique a procedure of choice in younger patients. To build on this study, a comparison of PAT and arthroplasty would be of interest. LEVEL OF EVIDENCE: IV.

Feasibility of arthroscopic decompression of the axillary nerve in the quadrilateral space: Cadaver study.

INTRODUCTION: Axillary nerve compression is a rare, but disabling condition. The three main causes are quadrilateral space syndrome among young athletes, compression due to an inferior glenohumeral osteophyte in early osteoarthritis and isolated teres minor atrophy secondary to triceps hypertrophy. The diagnosis is clinical, but may be reinforced by an electromyogram or corticosteroid injection. The usual surgical treatment is open nerve decompression using a posterior approach. Arthroscopy is a less invasive approach that should be useful in theory. HYPOTHESIS: Arthroscopic decompression of the axillary nerve is safe and less invasive than open techniques. MATERIAL AND METHODS: Arthroscopic nerve decompression was performed as described by PJ Millet and TR Gaskill on 10 shoulders from 6 frozen cadavers. An open posterior approach was then made to verify the effectiveness of the nerve decompression. RESULTS: The axillary nerve and its branches, the circumflex artery and the triceps were always sufficiently released in the space below the joint capsule. When the joints were subsequently opened by a posterior approach, complete nerve decompression was confirmed in all cases with no iatrogenic lesions. DISCUSSION: The good results of this study are encouraging, but should be supplemented with a comparative study in patients of open versus arthroscopic axillary nerve release. CONCLUSION: We think this arthroscopic technique is a good option for treating axillary nerve compressions. The complication risk is expected to be low. LEVEL OF EVIDENCE: IV.

Prospective comparative analysis of arthroscopic debridement for primary and post-traumatic elbow osteoarthritis.

INTRODUCTION: The main aim of the present study was to compare the preoperative profiles and the efficacy of arthroscopic debridement for elbow osteoarthritis between patients with primary versus post-traumatic osteoarthritis. The study hypothesis was that the two groups would show no difference on either criterion. METHOD: In the framework of a symposium of the French Arthroscopy Society (SFA), a prospective comparative multicenter study included 87 patients with 6 months' follow-up of arthroscopic debridement for elbow osteoarthritis: 53 primary (G1) and 34 secondary (G2). Pre- and post-operative clinical assessment in both groups compared Andrews-Carson specific functional score for elbow osteoarthritis (main endpoint), and the QuickDash (QD), Patient-Related Elbow Evaluation (PREE) and Mayo Elbow Performance Score (MEPS) functional scores, pain on VAS, range of motion (RoM) and strength. RESULTS: Arthroscopic debridement significantly improved all functional scores at 6 months, notably including the specific Andrews-Carson score, which showed gain in both groups: 68.5±28.7 (range, -5 to 110) in G1 and 62.6±25.4 (18 to 110) in G2 (P=0.35). Pain decreased significantly in both groups, by 5.1±2.6 points (range, 10 to 1) in G1 and 4.4±2.7 points (range, 8.5 to 1) in G2 (P=0.28). RoM in flexion-extension improved comparably in both groups, by 42.9±22.1 (-15 to 105) in G1 and 49.3±24.5 (10 to 90) in G2 (P=0.22). Strength in flexion improved comparably, by 7.6±4.7kg (-2 to 17.5) in G1 and 6.1±4.8kg (-1 to 13) in G2 (P=0.23). DISCUSSION/CONCLUSION: The study hypothesis was confirmed: there were no differences according to primary versus secondary osteoarthritis in preoperative profile or results. Elbow osteoarthritis entails mechanical impingement. Arthroscopic debridement gave good results independently of primary or post-traumatic etiology. LEVEL OF EVIDENCE: III, prospective comparative observational multicenter cohort study.

Can preoperative imaging predict the outcomes after arthroscopic release for elbow arthritis?

INTRODUCTION: The primary symptoms of elbow osteoarthritis are the progressive development of stiffness along with pain at the end range of motion due to osteophyte impingement. Surgical treatment involves resecting these "bone stops". In the literature, these osteophytic lesions are more common than cartilage lesions, which suggests they may occur beforehand. The aim of our study was to confirm osteophytes are more common than cartilage lesions, and also to establish a link between these lesions and the functional outcomes. METHODS: This was a prospective multicenter (8 hospitals) study conducted in the context of a symposium of the Francophone Arthroscopy Society (SFA). Eighty-seven patients with elbow osteoarthritis treated by arthroscopic release were included. The clinical outcomes (range of motion in flexion, extension and pronation-supination; strength; pain at rest and during activity; satisfaction; Andrews and Carson score; QuickDASH, Patient-Rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS), Self-Evaluation Elbow (SEE) were determined before the procedure and at the 6-month follow-up visit. A standard radiographic assessment was done before the surgery and at the last follow-up visit. A CT arthrogram was done before the procedure. The presence of joint narrowing, osteophytes, filling of fossa along with secondary osteochondroma was evaluated in terms of their location, severity, size and/or number. The presence of radial head subluxation was recorded. The Bröberg & Morrey and Rettig & Hastings classification systems were applied. All the postoperative clinical data along with their change (difference between preoperative and postoperative values) were compared to the imaging findings. RESULTS: Osteophytes were found in 95% of our patients. They were located at the olecranon in 85% of cases and at the coronoid process in 81%. Filled fossae found in 94% of cases. The olecranon, coronoid and radial fossa were filled in 83%, 80% and 60% of elbows, respectively. On the initial X-rays, joint narrowing was found in 68% of elbows. CT arthrogram identified narrowing in 70% of cases. Narrowing was present in the humeroradial joint in 60% of cases and in the humeroulnar joint in 23% of cases. The presence of joint narrowing on CT arthrogram was a negative prognostic factor for pain during activity (p<0.05) along with the Quick DASH (p<0.01) and PREE (p<0.05). Involvement of the humeroradial joint impacted pain at rest (p<0.01). Narrowing of the humeroulnar joint was associated with worse outcomes in terms of pain at rest (p<0.05) and during activity (p<0.05), QuickDASH (p<0.005), MEPS (p<0.05), PREE (p<0.05) and the SEE (p<0.05). The presence of loose bodies before the procedure was associated with better outcomes in terms of pain at rest (p<0.05), QuickDASH (p<0.001), MEPS (p<0.001), Andrews & Carson score (p<0.05) and PREE (p<0.005). The osteoarthritis stage in the Bröberg & Morrey or the Rettig & Hastings classification systems did not impact the various clinical parameters or functional outcome scores. DISCUSSION/CONCLUSION: In the imaging work-up, signs of impingement (osteophytes and filling of fossa) are more common than signs of joint narrowing. The presence of humeroulnar and/or humeroradial impingement when there are no cartilage lesions visible may correspond to a pre-arthritic stage. The outcomes of arthroscopic release are better in elbows with isolated impingement than in those with cartilage lesions, especially at the humeroulnar joint. Excision of secondary osteochondromas is also an excellent surgical indication. Current classification systems cannot be used to determine the prognosis before arthroscopic release of elbow osteoarthritis cases. LEVEL OF EVIDENCE: III, Prospective multicenter observational cohort study.

Arthroscopic treatment of elbow osteoarthritis.

Elbow osteoarthritis chiefly affects heavy manual labourers and athletes and may be primary or post-traumatic. Arthroscopic debridement for primary elbow osteoarthritis reliably produces pain relief, motion range gains, and good functional outcomes. Total elbow arthroplasty, in contrast, is considered a salvage option in this patient population, as activities must be restricted to protect the implant. Here, we describe the operative technique used for arthroscopic elbow release in 87 patients with symptomatic elbow osteoarthritis included prospectively at 6 centres in a study that was conducted for a French Arthroscopy Society symposium and whose findings are reported elsewhere. The technique involves exploration of the anterior and posterior compartments with resection of motion-limiting osteophytes; clearing of the fossae; foreign body extraction; and treatment of the posterior and anterior capsule and of the lateral inclines. The indications of ulnar nerve release, radial head excision, release of the posterior band of the medial collateral ligament (MCL), and/or fenestration as described by Outerbridge-Kashiwagi are discussed. After 6 months, 93.5% of patients were satisfied with the procedure. No serious neurological complications were recorded. Wound healing was impaired in 4 patients, of whom 3 responded to local care; the remaining patient required open debridement for surgical-site infection. Complex regional pain syndrome developed in 3 patients. Ulnar nerve transposition was required secondarily in 1 patient and another patient had persistent dysesthesia after ulnar nerve release. This minimally invasive technique provides good short-term outcomes in primary elbow osteoarthritis and is associated with a low complication rate.

Arthroscopic debridement for osteoarthritis of the elbow: Results and analysis of predictive factors.

INTRODUCTION: Osteoarthritis is the second most frequent cause of elbow stiffness, after trauma sequelae. Surgical treatment mainly consists of debridement. The main aim of the present study was to assess the efficacy of arthroscopic treatment of osteoarthritis of the elbow on Andrews-Carson score. Secondary objectives comprised assessment of the impact of associated procedures and of epidemiological factors on functional results. METHOD: A prospective multicenter study involving 8 centers, in a symposium held by the French Society of Arthroscopy (SFA), included patients treated by arthroscopy for primary or secondary osteoarthritis of the elbow between January 2017 and March 2018, with a minimum 6 months' follow-up. Clinical assessment was based on change in Andrews-Carson functional score (AC), specific to osteoarthritis of the elbow, and on other functional scores: QuickDash (QD), Patient-Rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS) and Self-Evaluation Elbow (SEE). Progression in pain on visual analog scale (VAS) and range of motion (RoM) was also assessed. Initial imaging work-up comprised standard X-ray and CT arthrography; paraclinical follow-up was based on X-ray. The impact of the following procedures associated to arthroscopic debridement was analyzed: radial head resection, ulnar nerve release, humeral fenestration, lateral ramp release, and medial collateral ligament posterior bundle release. The functional impact of epidemiological factors (age, handedness, manual occupation, smoking, body-mass index, and work accident/occupational disease status) and radiographic factors (foreign bodies, joint impingement, osteophytes, and fossa filling) was also assessed. RESULTS: The series comprised 87 patients: 75 male (86.2%); mean age, 49 years (range, 18-73 years). Arthroscopic debridement significantly improved all functional scores at a minimum 6 months, and notably the specific AC score: 113.6±25.4 (40-180) versus 178.7±20.2 (110-200) (P<0.0001). Pain diminished significantly: 6.4±2.1 (0-10) versus 1.7±1.8 (0-8) (P<0.0001). RoM increased significantly: flexion/extension, 93.44±20.5° (5-130°) versus 124.2±13.8° (90-160°) (P<0.0001); pronation/supination, 147.6±25.6° (60-180°) versus 162.5±20.6° (100-180°) (P<0.0001). Strength (kg) increased in flexion (8.8±4.0 (4 to 20) versus 15.3±5.1 (3 to 32) (P<0.0008) and in grip [33.1±12.3 (10 to 58) versus 42.1±14.0 (2 to 68) (P<0.0001)]. Epidemiologically, males showed better recovery than females for both pain and strength. There was a significant positive impact of manual work on functional recovery, pain and also strength. There was a significant negative impact of work-accident/occupational disease on pain and strength. Regarding associated procedures, lateral ramp debridement improved AC score, with a gain of 75.4±25.3 points (-5 to 110) vs. 49.6±23.5 (10 to 100) (P<0.0001), and pain on VAS, with a fall of -5.6±2.1 points (-10 to -1) vs. -3.6±3.0 (-8.5 to 1) (P=0.0013). Ulnar nerve release, radial head resection and humeral fenestration had no positive impact. Preoperative foreign body was a factor for good prognosis. Cartilage wear, especially in the humeroulnar compartment, was associated with poorer functional results. DISCUSSION/CONCLUSION: Arthroscopic treatment of osteoarthritis of the elbow significantly improved clinical results at 6 months, with significant improvements in functional scores, pain, strength and range of motion. Gender, type of work and work-accident/occupational disease status influenced clinical results. Lateral ramp release is an often overlooked technical factor improving functional results. Radiologically, the best candidates are those presenting with a foreign body and no humeroulnar impingement. LEVEL OF EVIDENCE: III, Prospective observational multicenter cohort study.

Failed rotator cuff repair.

After rotator cuff repair, few patients require revision surgery, and failure to heal does not always translate into clinical failure, although healing is associated with better outcomes. Failure of rotator cuff repair is perceived differently by the patient, by the surgeon, and in terms of social and occupational abilities. The work-up of failed cuff repair differs little from the standard work-up of cuff tears. Information must be obtained about the circumstances of the first repair procedure, a possible diagnostic inadequacy and/or technical error, and early or delayed trauma such as an aggressive rehabilitation programme. Most cuff retears do not require surgery, given their good clinical tolerance and stable outcomes over time. Repeat cuff repair, when indicated by pain and/or functional impairment, can improve pain and function. The quality of the tissues and time from initial to repeat surgery will influence the outcomes. The ideal candidate for repeat repair is a male, younger than 70 years of age, who is not seeking compensation, shows more than 90̊ of forwards elevation, and in whom the first repair consisted only in tendon suturing or reattachment. In addition to patient-related factors, the local conditions are of paramount importance in the decision to perform repeat surgery, notably repeat suturing. The most favourable scenario is a small retear with good-quality muscles and tendons and no osteoarthritis. When these criteria are not all present, several options deserve consideration as potentially capable of relieving the pain and, to a lesser extent, the functional impairments. They include the implantation of material (autograft, allograft, or substitute), a muscle transfer procedure, or reverse shoulder arthroplasty. However, the outcomes are poorer than when these options are used as the primary procedure. Prevention is the best treatment of cuff repair failure and involves careful patient selection and a routine analysis of the treatments that may be required by concomitant lesions. Biceps tenotomy should be considered on a case-by-case basis. Smoking cessation should be strongly encouraged and any metabolic disorders associated with repair failure should be brought under control.

Bone mineral density of the coracoid process decreases with age.

PURPOSE: Surgical options in the treatment of recurrent anterior shoulder instability are numerous. The Latarjet procedure is one of the most common procedures performed. It has been previously demonstrated that bone mineral density decreases with age. This reduction thus increases the risk of osteoporosis and osteoporosis-related iatrogenic, traumatic or pathological fractures. The objective of this study was to quantify the bone mineral density of the coracoid process in different age groups. The hypothesis was that mineral bone density of the coracoid process decreases with age. METHODS: Using the hospital's electronic database, 60 patients who underwent a shoulder CT scan were randomly selected retrospectively. Four groups of 15 were formed with mean ages of 20, 30, 40 and 50 years. Bone density, length, width and thickness of the coracoid process 10 mm from the tip were measured four times by two different evaluators. Bone density was expressed in Hounsfield units (HU). RESULTS: The mean bone mineral density of the coracoid process significantly decreased with age (p < 0.0001). A lower but insignificant difference of bone mineral density was observed in females. A good inter- and intra-observer reliability was found for bone mineral density measurement of the coracoid process (0.67 and 0.7, respectively). CONCLUSIONS: The bone mineral density of the coracoid process diminishes with age, thus confirming our hypothesis. There is a good inter- and intra-observer reliability of our CT scan-based coracoid process bone mineral density measurement rendering it reproducible in daily clinical practice. LEVEL OF EVIDENCE: IV.

Arthroscopic treatment of comminuted distal clavicle fractures (latarjet fractures) using 2 double-button devices.

Complex distal clavicle fractures associated with a rupture of the coracoclavicular ligaments (Latarjet fractures) can result in delayed union or nonunion. There is no standard treatment for a clavicle fracture. This report introduces an arthroscopic technique for treating distal clavicle fractures associated with ruptured coracoclavicular ligament using 2 double-button devices. By use of posterior and anterior standard arthroscopic portals, the base of the coracoid process is exposed through the rotator interval. A 4-mm hole is drilled through the clavicle and the coracoid process with a specific ancillary drill guide. The first button is pushed through both holes down the coracoid process. The device is tightened, and the second button is fixed on top of the clavicle, allowing reduction and fixation of the proximal part of the fracture. Then, the undersurface of the lateral clavicle is dissected through standard posterior and lateral subacromial approaches. The inferior clavicle fragment is reduced and fixed to the clavicle body by a double button fixed down and at the top of the clavicle. With this technique, the arthroscopic treatment of distal clavicle fracture has been extended to comminuted fractures.