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INTRODUCTION: The Sauvé-Kapandji (SKp) procedure is a frequently used surgery for the management of post-traumatic sequelae of the distal radio-ulnar joint (DRU). Series evaluating long-term outcomes and the risk of complications are rare. The main objective was to describe the long-term clinical and radiographic results after SKp performed in a post-traumatic context. The secondary objectives were to identify postoperative complications, surgical revisions, and their risk factors for occurrence. Our hypothesis was that although SKp confers good clinical results, identifiable risk factors for complications exist. PATIENTS AND METHODS: This monocentric retrospective study included all patients for whom an SKp was performed in a post-traumatic context from 2008 to 2018. Pain, satisfaction, range of motion and pre- and postoperative radiographic measurements were recorded. All complications were sought and described, as well as surgical revisions. Several variables were analysed to identify risk factors for revision surgery after SKp: age, sex, initial traumatic mechanism, initial non-surgical or surgical treatment and type of surgery, time until revision surgery with SKp after the initial trauma. RESULTS: Thirty-seven patients were included. At a median follow-up of 9.5 years (min 7.3-max 11.5), 22 patients (60%) had a VAS of 0. Range of motion was significantly improved for all the patients (p<0.001). Seventeen (46%) patients had a complication, including 5 (13.4%) cases of ossification, 4 (10.8%) cases of discomfort related to the hardware and 4 (10.8%) painful instability at the proximal ulnar stump. Thirteen (35%) patients required revision surgery. Two risk factors for revision surgery after SKp were found: time period between initial treatment and SKp of less than 7.2 months and an age of less than 53.5 years; the combination of the two factors having a sensitivity of 97.5 and a specificity of 56.7. CONCLUSION: SKp in a post-traumatic context significantly improved range of motion and allowed pain control at long follow-up. Revision surgery seemed more frequent in patients under 53.5 years of age and when SKp was performed less than 7.2 months after the initial trauma. LEVEL OF EVIDENCE: IV, retrospective study.
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Osteoartritis , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Reoperación , Estudios de Seguimiento , Osteoartritis/diagnóstico por imagen , Osteoartritis/etiología , Osteoartritis/cirugía , Dolor/cirugía , Factores de Riesgo , Articulación de la Muñeca/diagnóstico por imagen , Articulación de la Muñeca/cirugía , Rango del Movimiento Articular , Cúbito/cirugíaRESUMEN
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.
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Pie Equinovaro , Humanos , Espasticidad Muscular , Extremidad Inferior , Caminata , Pie , Técnica DelphiRESUMEN
Neuro-orthopedic surgery is an alternative to the conservative treatment of spastic equinovarus foot (SEF) in adults. The objective of the present narrative review was to summarize current practice with regard to patient assessment, the choice of treatment, the various neuro-orthopedic procedures, and the latter's outcomes. We searched literature databases (MEDLINE, EMBASE, Cochrane) for original articles or opinion papers on surgical treatment of spastic equinovarus foot in adults. Neuro-orthopedic approaches require a careful analysis of the patient's and/or his/her caregiver needs and thus relevant treatment goals. Surgical planning requires detailed knowledge of impairments involved in the spastic equinovarus foot deformity based on a careful clinical examination and additional information from diagnostic nerve blocks and/or a quantitative gait analysis. Procedures mainly target nerves (neurotomy) and tendons (lengthening, transfer, tenotomy). These procedures reduce impairments (spasticity, range of motion, and foot position), improve gait and walking function, but their impact on participation and personalized treatment goals remains to be demonstrated. Neuro-orthopedic surgery is an effective treatment option for spastic equinovarus foot in adults. However, practice is still very heterogeneous and there is no consensus on the medical strategies to be applied before, during and after surgery (particularly the type of anesthesia, the need for immobilization, rehabilitation procedures).
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Pie Equinovaro , Procedimientos Ortopédicos , Adulto , Pie Equinovaro/cirugía , Femenino , Pie/cirugía , Marcha , Humanos , Masculino , Espasticidad Muscular/cirugía , Procedimientos Ortopédicos/métodosRESUMEN
INTRODUCTION: Among the various procedures for degenerative carpal lesions, four-corner fusion relieves pain while conserving motion and strength. There are various fixation options, not presently standardised. HYPOTHESIS: Internal fixation by screws or dorsal locking plate provides good 5-year clinical results in four-corner fusion. MATERIAL AND METHOD: A single-centre retrospective study included 18 four-corner fusions at a minimum 5 years' follow-up: 8 plate and 10 screw fixations. Endpoints comprised pain, wrist range of motion, grip strength, QuickDASH and PRWE scores, and immobilisation time. Radiographic analysis was performed and complications inventoried. RESULTS: Pain VAS score fell to 1/10 in both groups. Flexion-extension was 56° with screws and 55° with plates. QuickDASH was 20.5 and 4.6 respectively, and PRWE 11 and 9. Grip strength was 16kg in both groups. The consolidation rate was 85.7% with screws and 57.1% with plates. Eighty percent of patients with screw fixation progressed toward radiolunate osteoarthritis. Four patients required revision surgery: 3 in the screw group and 1 in the plate group. DISCUSSION: There was clear clinical and functional improvement in both groups at a minimum 5 years. Consolidation was better with screw fixation, but with risk of radiolunate osteoarthritis. LEVEL OF EVIDENCE: IV, retrospective study.
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Artrodesis , Fuerza de la Mano , Placas Óseas , Tornillos Óseos , Estudios de Seguimiento , Humanos , Rango del Movimiento Articular , Estudios RetrospectivosAsunto(s)
Osteoartritis , Radiología , Desarticulación , Estudios de Seguimiento , Humanos , RadiografíaRESUMEN
Introduction: Spasticity is the main complication of many upper motor neuron disorders. Many studies describe neuro-orthopedic surgeries for the correction of joint and limb deformities due to spasticity, though less in the upper extremity. The bulk of care provided to patients with spasticity is provided by rehabilitation clinicians, however, few of the surgical outcomes have been summarized or appraised in the rehabilitation literature. Objective: To review the literature for neuro-orthopedic surgical techniques in the upper limb and evaluate the level of evidence for their efficacy in adult patients with spasticity. Method: Electronic databases of MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews were searched for English, French as well as Farsi languages human studies from 1980 to July 2, 2020. After removing duplicated articles, 2,855 studies were screened and 80 were found to be included based on the criteria. The studies were then divided into two groups, with 40 in each trial and non-trial. The results of the 40 trial articles were summarized in three groups: shoulder, elbow and forearm, and wrist and finger, and each group was subdivided based on the types of intervention. Results: The level of evidence was evaluated by Sackett's approach. There were no randomized control trial studies found. About, 4 studies for shoulder, 8 studies for elbow and forearm, 26 studies for wrist and finger (including 4 for the thumb in palm deformity), and 2 systematic reviews were found. Around, two out of 40 trial articles were published in the rehabilitation journals, one systematic review in Cochrane, and the remaining 38 were published in the surgical journals. Conclusion: Most surgical procedures are complex, consisting of several techniques based on the problems and goals of the patient. This complexity interferes with the evaluation of every single procedure. Heterogenicity of the participants and the absence of clinical trial studies are other factors of not having a single conclusion. This review reveals that almost all the studies suggested good results after the surgery in carefully selected cases with goals of reducing spasticity and improvement in function, pain, hygiene, and appearance. A more unified approach and criteria are needed to facilitate a collaborative, evidence-based, patient referral, and surgical selection pathway.
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Toxinas Botulínicas , Carrera de Maratón , Fármacos Neuromusculares , Paresia , Toxinas Botulínicas/uso terapéutico , Marcha , Humanos , Inyecciones Intramusculares , Espasticidad Muscular/tratamiento farmacológico , Fármacos Neuromusculares/uso terapéutico , Paresia/tratamiento farmacológico , Paresia/etiología , Músculo CuádricepsRESUMEN
INTRODUCTION: The aim of this study was to analyze the radiological changes and determine the clinical and functional outcomes of proximal row carpectomy (PRC) over the long term. HYPOTHESIS: Radiological changes after PRC occur in every patient while the clinical and functional outcomes remain stable over time. METHODS: This was a retrospective single-center study of patients who underwent PRC between January 2004 and December 2014. A clinical assessment (range of motion, grip strength), functional assessment (Mayo Wrist score and QuickDASH) and radiographic assessment (radiocapitate osteoarthritis, radiocapitate congruency) was done in every patient at the longest follow-up. RESULTS: Thirty-one patients were reviewed with a mean follow-up of 97.9 months. The indications for PRC were SLAC (n=10), SNAC (n=5), Kienböck disease (n=9) and other conditions (n=7). The radiocapitate index, which is the radius of curvature of the tip of the capitate divided by the mean radius of curvature of the lunate fossa, went from 0.68 immediately postoperative to 0.74 at the final assessment (p=0.035). The mean flexion/extension arc was 93°. The mean grip strength was 25 kg. The mean QuickDASH was 29 and the mean Mayo Wrist score was 69. Fifteen patients had radiocapitate osteoarthritis. Seven patients (22%) required revision surgery for wrist fusion after a mean of 18.6 months. CONCLUSION: Radiological adaptation in the radiocapitate joint after PRC was found in this study. PRC is a reliable solution and yields stable outcomes over time for treating radiocarpal osteoarthritis, except in young adults and manual laborers who had a notable early revision rate. LEVEL OF EVIDENCE: IV - retrospective study.
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Huesos del Carpo , Huesos del Carpo/diagnóstico por imagen , Huesos del Carpo/cirugía , Estudios de Seguimiento , Humanos , Rango del Movimiento Articular , Estudios Retrospectivos , Articulación de la Muñeca/diagnóstico por imagen , Articulación de la Muñeca/cirugía , Adulto JovenRESUMEN
INTRODUCTION: Trapeziectomy is a technique of choice for osteoarthritis of the trapeziometacarpal joint, but few studies have assessed long-term radiological and clinical outcome in total trapeziectomy, mean follow-up being rather between 2 and 6 years in most cases. The main aim of the present study was to assess loss of trapezial space height at a minimum 10 years' follow-up. Secondary endpoints comprised functional outcome at the same follow-up. HYPOTHESIS: There is systematic loss of trapezial space height, with discrepancy between radiological and clinical results, beyond 10 years' follow-up. MATERIAL AND METHODS: Sixteen patients were retrospectively reassessed at a mean 13.8 years' follow-up (range, 10-17.8 years), for 21 total trapeziectomies. Criteria for the main endpoint comprised trapezial space height (TSH) and trapezial space ratio (TSR=TSH/thumb P1 phalanx length). Secondary endpoint criteria comprised pain, Kapandji opposition and retropulsion scores, active abduction, dynamometric parameters (key-pinch, tip-pinch and grip strength compared to the contralateral side), QuickDASH and satisfaction. RESULTS: Mean TSH and TSR were respectively 3.7mm (range, 0.5-6.1) and 0.14 (0.02-0.25) at last follow-up. Ranges of motion were conserved, with mean Kapandji score of 9.3 (6-10), Kapandji retropulsion score of 2.8 (1-4) and active abduction of 43° (30-45°). Strength measurements were comparable to contralateral values except for key-pinch, which was significantly weaker on the operated side (4.8kg (1.5-8.5kg) versus 5.5kg (1.5-8kg); p=0.041). Mean QuickDASH was 23.5 (0-68.2), and overall satisfaction on VAS was 9.5/10 (6-10). Statistical testing confirmed the absence of correlation between radiological and clinical criteria. DISCUSSION: Despite systematic trapezial space height loss, functional results were satisfactory and stable at a mean follow-up of 13.8 years. There was no correlation between radiological and clinical criteria in the long term. LEVEL OF EVIDENCE: IV, single-center retrospective study.
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Articulaciones Carpometacarpianas , Osteoartritis , Hueso Trapecio , Articulaciones Carpometacarpianas/diagnóstico por imagen , Articulaciones Carpometacarpianas/cirugía , Estudios de Seguimiento , Humanos , Osteoartritis/diagnóstico por imagen , Osteoartritis/cirugía , Rango del Movimiento Articular , Estudios Retrospectivos , Pulgar , Hueso Trapecio/diagnóstico por imagen , Hueso Trapecio/cirugíaRESUMEN
Complete femoral nerve palsies are uncommon but devastating injuries when they are caused by large nerve defects. Direct repair is usually not possible and nerve grafting renders uncertain outcomes. Recent studies proposed different peripheral nerve transfers as treatment strategies for large femoral nerve defects. We report a clinical application of a nerve transfer to reinnervate the quadriceps muscle with two motor branches of the obturator nerve in a 48 years-old man that was diagnosed with a femoral nerve palsy after resection of a retroperitoneal schwannoma. The branches supplying the gracilis and adductor longus muscles were transferred to the motor branch of the femoral nerve to the quadriceps muscle at 6 months postinjury. At 34 months of follow-up, knee extension was quoted M4. The presented nerve transfer may be feasible, technically simple, and renders good functional outcomes.
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Neuropatía Femoral/cirugía , Transferencia de Nervios , Nervio Obturador/cirugía , Humanos , Masculino , Persona de Mediana EdadRESUMEN
INTRODUCTION: Radiocarpal dislocation (RCD) is defined as total loss of contact between the carpal and radial joint surfaces. The condition is rare, with few published series. The aim of the present study was to assess functional results of RCD surgery, notably without ligament reconstruction. HYPOTHESIS: Functional outcome of RCD surgery is satisfactory for everyday use of the wrist. MATERIALS AND METHODS: A retrospective study was performed for the period January 2012 to July 2017. Inclusion criteria comprised: RCD on preoperative X-ray, in adult patients, with a minimum 6months' follow-up; exclusion criteria comprised: unclosed growth plate, and distal radial epiphyseal fracture with large displacement. RCD type was assessed on Dumontier's classification. Functional results were assessed as postoperative range of wrist motion, grip strength (Jamar®), and QuickDASH and Green-O'Brien (modified by Cooney) functional scores. RESULTS: Fourteen patients were followed up at a mean 31months (range, 7-60months). Three showed type I RCD and 11 type II. All were treated surgically; no ligament sutures were performed. Mean flexion was 63° (range, 20-90°), extension 51° (25-90°), pronation 79° (60-90), supination 80° (50-90), and grip strength 27.9kg (8-40). Mean QuickDASH and modified Green-O'Brien scores were respectively 25.6 (4.54-40.9) and 74 (35-100). DISCUSSION: The present functional results were satisfactory and comparable to those of the literature, despite no use of radiocarpal ligament suture in type-1 RCD. LEVEL OF EVIDENCE: IV.
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Luxaciones Articulares/cirugía , Procedimientos Ortopédicos/métodos , Traumatismos de la Muñeca/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Luxaciones Articulares/fisiopatología , Masculino , Persona de Mediana Edad , Rango del Movimiento Articular , Estudios Retrospectivos , Resultado del Tratamiento , Traumatismos de la Muñeca/fisiopatología , Articulación de la Muñeca/fisiopatologíaAsunto(s)
Fracturas de Tobillo/terapia , Callo Óseo/diagnóstico por imagen , Reducción Cerrada/efectos adversos , Atrapamiento del Tendón/diagnóstico por imagen , Atrapamiento del Tendón/etiología , Adulto , Fracturas de Tobillo/complicaciones , Artralgia/etiología , Callo Óseo/cirugía , Moldes Quirúrgicos , Curación de Fractura , Humanos , Imagen por Resonancia Magnética , Masculino , Atrapamiento del Tendón/cirugía , Tenosinovitis/diagnóstico por imagen , Tenosinovitis/etiología , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Tibialis posterior transfer (TPT) is the treatment most widely used to palliate foot drop due to dorsiflexor palsy. TPT has been extensively studied in patients with peripheral neurological causes of foot drop. In contrast, data are scarce on central foot drop, in which TPT is often blamed for causing flattening of the arches. The primary objective of this study was to assess the impact on foot alignment of TPT in patients with central foot drop. The secondary objective was to determine whether TPT combined with other surgical procedures improved gait. HYPOTHESIS: TTP can induce flattening of the medial arch of the foot. PATIENTS AND METHODS: We retrospectively identified 13 patients managed with TPT (1 foot per patient). Mean follow-up was 65 months (range, 12-108 months). The causes were stroke (n=5), head injury (n=3), spinal cord injury (n=2), cervical spondylotic myelopathy (n=1), cerebral palsy (n=1), and a brain tumour (n=1). The clinical assessment focused chiefly on forefoot alignment and footprint parameters. The following variables were collected from weight-bearing radiographs: Djian-Annonier angle, Méary-Toméno angle, lateral arch angle, and calcaneal pitch angle in the sagittal plane; talo-metatarsal angle in the transverse plane; and rearfoot valgus angle in the coronal plane. RESULTS: Of the 13 feet, 6 had normal footprint parameters and 7 pes cavus. There were no cases of flatfoot. Pronation deformities and supination deformities were each found in 2 patients. Comparing the radiographic parameters between the two feet in each patient identified differences only for the lateral arch angle and calcaneal pitch angle, which indicated pes cavus on the operated side (operated side: 142.7° [range, 136°-156°], p=0.041; and 24° [range, 14°-33°], p=0.028, respectively). DISCUSSION: In contrast to the working hypothesis, we found no evidence of progression to valgus flatfoot after TPT transfer performed to treat central foot drop. LEVEL OF EVIDENCE: IV, retrospective study with no control group.