Posterolateral stabilization of the elbow by autologous ligament reconstruction to limit long-term development of osteoarthritis.

BACKGROUND: Posterolateral instability is the most frequent form of both acute and chronic elbow instability. Joint incongruity due to posterolateral unlocking leads to shear and compression stress of the internal aspect of the humeroulnar joint. We carried out long-term analysis of patients with posterolateral elbow instability in order to determine whether, in addition to improving their symptoms, reconstruction of the lateral collateral ligament complex may play a protective role against the development of post-traumatic osteoarthritis. We hypothesized that ligament reconstruction according to the technique of O'Driscoll stabilizes the elbow and also limits the development of osteoarthritis in the long term. METHODS: Patients with symptomatic posterolateral instability of the elbow and who underwent ligament reconstruction according to the technique of O'Driscoll from January 1995 to December 2010 were identified and retrospectively included for 2 follow-up evaluations at a mean of 5 and 14 years. RESULTS: Fourteen elbows in 14 patients were included. All had a negative lateral pivot shift test and none reported a new episode of instability. Two patients (14%) had osteoarthritis. The 2 radiographic evaluations showed no progression of osteoarthritis. Osteoarthritis developed in 33% of patients with intra-articular fracture. In simple dislocations, pre-existing osteoarthritic lesions were stabilized and there were no new cases of osteoarthritis. CONCLUSION: Elbow ligament reconstruction according to the technique of O'Driscoll gives effective posterolateral stabilization and appears to protect against progression to osteoarthritic degeneration in the long term. In the absence of associated lesions, it prevents the development of osteoarthritis or the worsening of pre-existing osteoarthritis.

Complications of osteosynthesis for long-finger metacarpal and phalanx fracture.

Fractures of the metacarpals and phalanges represent a significant proportion of hand fractures. Although non-operative treatment is generally effective, some fractures require surgery. Historically, osteosynthesis using K-wires was widely used, but screw plates and then cannulated intramedullary screws have emerged as therapeutic alternatives. We assessed the complications associated with the different osteosynthesis techniques: stiffness, infection, bone consolidation and hardware-related problems. Each osteosynthesis technique has advantages and disadvantages, and choice depends on several factors. An individualized approach according to patient and fracture is essential to optimize clinical results.

Metal hypersensitivity in trapeziometacarpal arthroplasty: A systematic pattern of progression.

Metal hypersensitivity is a rare and often underestimated complication, as shown by the small number of published studies, particularly concerning the upper limbs and the hand. However, the increase in the annual number of trapeziometacarpal arthroplasties underlines the importance of better understanding of this problem. We performed a study based on data from the revision of trapeziometacarpal prostheses to assess the incidence of this complication and to define a sequence of radiological changes to detect metal hypersensitivity. This single-center retrospective study included 37 patients operated on between January 2014 and November 2023 for revision of trapeziometacarpal prosthesis. Ten (27%) had no clearly identified cause of failure. For these 10 patients, we analyzed clinical data and postoperative X-rays. In the 11 revision arthroplasties, 2 patients had no symptoms or radiographic signs suggestive of allergy. Six patients had a-posteriori diagnosis established by allergy testing, which also identified 2 additional patients, for a total of 8 patients (21% of the initial cohort). In these cases, there was systematic metaphyseal osteolysis of the first metacarpal between 15 days and 1 month after implantation. Clinically, most patients had an asymptomatic period of 2 weeks to 1 month before onset of symptoms and osteolysis, often accompanied by local inflammation. This study found a reproducible pattern of progression, characterized by the appearance of radiographic signs of osteolysis in the first month, followed by clinical deterioration. Although this course is strongly suggestive of a metal hypersensitivity, it is crucial not to exclude the possibility of an infectious cause, which should always be considered.

Long-term results of the Malingue technique in the surgical treatment of Dupuytren's disease.

OBJECTIVES: The choice of surgical technique for aponeurectomy in Dupuytren's disease is controversial due to varying outcomes and complication rates. The Malingue plasty has shown mathematical and mechanical advantages, but long-term efficacy and results compared to other techniques have never been reported. This study aimed to evaluate the long-term functional, esthetic and recurrence outcomes of Malingue plasty in Dupuytren's disease. MATERIAL AND METHODS: The study included patients who underwent aponeurectomy with Malingue plasty performed by a highly experienced surgeon between January 2014 and December 2016, with a minimum follow-up of 5 years. Preoperative records were analyzed. At follow-up, extension lag was analyzed in each joint (metacarpophalangeal, proximal interphalangeal and distal interphalangeal) in each operated finger, as well as signs of recurrence or extension of the disease. Function and esthetics were assessed using the QuickDASH (Disabilities of the Arm, Shoulder and Hand) questionnaire and the Michigan Hand Outcomes Questionnaire. RESULTS: Out of 107 eligible patients, 55 were included in the study after exclusions and loss to follow-up. Three patients required revision surgery for recurrence during follow-up. All preoperative deformities of the proximal interphalangeal and metacarpophalangeal joints were corrected postoperatively, and no intraoperative or postoperative complications occurred. Mean extension deficit at follow-up was 18.1 °. Only the little finger showed significant loss of correction (p = 0.02). Mean QuickDASH score was 13.2 and the overall Michigan Hand Outcomes Questionnaire score was 91.8%. Recurrence affected 50% of patients according to the Leclercq criteria and 27.5% according to the Felici criteria. CONCLUSION: Although Malingue plasty did not improve the recurrence rate in Dupuytren's disease compared with other techniques, its advantages in terms of functional improvement and complications make it an interesting surgical option.

Recurrence of ulnar tunnel syndrome: Long-term clinical and functional results of surgical management using revision neurolysis and subcutaneous anterior transposition.

OBJECTIVE: Recurrence after primary ulnar tunnel syndrome surgery is observed in 1.4%-25% of patients. However, the outcome of revision surgery is uncertain and limited. This study aimed to assess the clinical and functional outcomes of neurolysis combined with anterior subcutaneous transposition in cases of recurrence. PATIENTS AND METHODS: This retrospective single-center study included patients who were operated on for iterative ulnar tunnel syndrome at the elbow between January 1996 and December 2020, with a minimum follow-up of 24 months. Demographic data, pre- and post-operative clinical evaluations, surgical details, and satisfaction levels were collected. RESULTS: Twenty-eight patients were reviewed. Mean follow-up was 11.7 years (range, 2.1-26.4 years). The secondary procedure led to significant improvement in mean Quick-DASH score, from 25.3 (range, 11-50) to 20.0 (range, 11-49) (p = 0.023), with a satisfaction rate of 78.5%. Symptoms of pain (p = 0.033), amyotrophy (p = 0.013), hypoesthesia (p < 0.01), and paresthesia (p < 0.001) also showed significant improvement. There were 7 cases of failure (25.0%). CONCLUSION: The combination of neurolysis and anterior subcutaneous transposition was a reliable technique, improving clinical outcome in recurrent ulnar tunnel syndrome after previous surgery. LEVEL OF EVIDENCE: IV - retrospective study.

Surgical treatment of trigger finger: a comparative study of A1 pulley opening versus ulnar superficialis slip resection.

Trigger finger is a common condition. Surgery most frequently involves opening the A0 and A1 pulleys. However, this shows limited effectiveness in correcting proximal interphalangeal joint fixed flexion deformity. The present study aimed to compare clinical outcomes between two surgical techniques for trigger finger treatment. This retrospective study included 127 patients, 72 of whom underwent resection of the ulnar slip of the flexor superficialis, and 55 underwent opening of the pulleys. Study data comprised patient characteristics, range of motion, proximal interphalangeal fixed flexion deformity measurement, Quick-DASH and PRWE scores, and overall satisfaction. There were no significant differences between the two groups in terms of Quick-DASH or PRWE scores. Fixed flexion deformity correction was slightly but not significantly better with resection of the ulnar slip of the flexor superficialis (100%) compared to opening of the pulleys (88%). LEVEL OF EVIDENCE: : Level IV.

Egg membrane as a training model for microsurgery.

Teaching microsurgery is limited by the availability of appropriate training models. In-vivo models, such as rats, remain the gold standard, but ethical and economic limitations restrict their use for initial training. This study investigated the feasibility of using egg membrane as an inert model, an accessible and economical alternative for introduction to microsurgery. The specifications for inert models include ease of access, low cost, high reproducibility and realistic reproduction of relevant characteristics. Fourteen microsurgery students assessed egg membrane as an inert training model on a 10-item questionnaire evaluating the specifications for use in microsurgery teaching. Easy access to the material and the ease with which it could be set up were evaluated positively. Dissection of the membrane added an educational dimension, distinguishing this model from other inert alternatives. On the other hand, the flexibility of the egg membrane and its resistance to the passage of the needle or the tightening of the thread were generally considered to be different from the in-vivo arterial wall. In conclusion, egg membrane as an inert model offers a practical, economical alternative in microsurgery training despite a lack of fidelity in reproducing the most relevant characteristics of the arterial wall. This model is more suited to the initial phase of learning microsurgery: in particular, working under a microscope, eye/hand coordination, tremor management and digital dexterity.

Validation of a simplified evaluation grid applied to the microsurgery on inert material via smartphone.

OBJECTIVES: Microsurgery is usually performed in experimental research models and clinical surgery. It requires meticulous technical skills and continuous training. Inert materials such as Shirataki noodles are readily available and low-cost consumables regularly used for practice. The objective of this study was to evaluate the repeatability and reproducibility of a simplified evaluation grid of suture on inert material (Shirataki Konnyaku noodle) under smartphone magnification. MATERIAL AND METHODS: Ten students performed end-to-end suture on inert material with magnification via their smartphone. Each suture was filmed, and the videos were randomized. Each student was evaluated on each video three times over three consecutive days, using a simplified evaluation grid. Intra- and inter-observer agreement was evaluated on Concordance Correlation Coefficients. Values were assessed on Pearson's correlation coefficient. RESULTS: Intra-observer correlation was weak for 2 items (0.288 and 0.246) and moderate for the other 2 (0.419 and 0.529). Inter-observer correlation was weak for 3 items (0.344, 0.358, and 0.276) and close to zero for the other (0.034). CONCLUSION: This simplified evaluation grid for microsurgery training on inert material via smartphone was poorly repeatable and reproducible. Loss of certain items in the grid due to the use of inert material probably impaired relevance.

Prevalence of transthyretin amyloidosis in patients undergoing carpal tunnel surgery: a prospective cohort study and risk factor analysis.

Transthyretin amyloidosis is a frequent cause of heart failure, resulting from an accumulation of abnormal proteins in the myocardium. Recent research has highlighted the importance of early diagnosis to enhance the effectiveness of specific treatments. Extra-cardiac symptoms may precede several years before cardiac complications, with carpal tunnel syndrome often considered a red flag. The aim of this prospective, observational cohort study was to determine the incidence rate of positive synovial biopsies for transthyretin amyloidosis in patients aged 60-80 years undergoing carpal tunnel decompression, and to identify risk factors. The diagnosis of transthyretin amyloidosis was confirmed through the analysis of synovial tissue biopsies using Congo Red and immunohistochemical staining. The study included 254 patients, with an 18.5% prevalence of transthyretin amyloidosis. Risk factors for positive test results were identified as male sex, trigger finger, hearing disorders and valve disease. A predictive analysis using logistic regression yielded a probability model for individuals belonging to the positive group.Level of evidence III.

Self-Assessment Versus Peer-Assessment in Microsurgery Learning: A Comparative Retrospective Study in a Surgery Residents Cohort.

INTRODUCTION: In surgical learning, self-assessment allows the physician to identify and improve his strong and weak points. However, its scientific validity has yet to be demonstrated. The aim of this study was to analyze if there is a link between self-assessment accuracy and improvement in surgical skills. We make the hypothesis that an accurate self-assessment allows a greater improvement MATERIAL AND METHOD: We set up a retrospective cohort study at the tertiary University Hospital of Angers. Between 2019 and 2021, twenty-eight surgery residents took part into a microsurgery program and were included in the study. For two weeks, they performed anastomosis training on inert material and living anesthetized rats under microscope. Each resident was evaluated during the workshop by senior surgeons on 10 items: movement stability and fluidity, instrument manipulation, needles, dissection, clamp setting, vessel manipulation, suture, checking before clamp removal, checking after clamp removal, watertighness. Self-assessment was performed by the residents with the same grid, at the end of the workshop. Residents' and senior's evaluations were double-blind. We retrospectively analyzed the concordance between senior objective assessment and self-assessment, and the effect of an accurate self-assessment on technical improvement. RESULTS: Data for twenty-five residents were analyzed, 14 were female (56%). The mean age was 29 years. Surgical specialties were orthopedics (44%), maxillofacial surgery (45.4%), neurosurgery (12%), gynecology (4%) and vascular surgery (4%). According to Cohen's kappa coefficient, 14 residents (56%) underestimated themselves, 7 (28%) were concordant with peer-assessment and 4 (16%) overestimated themselves. The concordance between self and peer assessment during sessions was positive for the most objective items, and negative for the most subjective items. Technical skills improvement in term of peer-assessment averages was positive for each item in each group, without statistical differences between groups. CONCLUSION: We found that the ability to self-assess in a fast-track microsurgery module for surgery residents varied according to analyzed gestures. We demonstrated an improvement in term of self-assessment for objective items, and a decrease for subjective items. However, we didn't find any relation between improvement curve and the accuracy of self-assessment.

Comparison of results of arthroscopic arthrolysis between traumatic and degenerative elbow stiffness.

INTRODUCTION: Elbow stiffness significantly affects the patient's quality of life. This joint must have at least 30°/130° extension/flexion and 50°/50° pronation/supination to function normally according to Morrey. HYPOTHESIS: The objective of this study was to evaluate functional outcome of arthroscopic arthrolysis by comparing stiffness of post-traumatic and degenerative origin. The hypothesis was that this surgical technique allows functional improvement in any indication but with a faster result in degenerative pathology. MATERIAL AND METHODS: This was a retrospective study including all patients who underwent elbow arthrolysis under arthroscopy, operated on by a single operator, between 2013 and 2020. Thirty-four patients were included, with a mean age of 45years (range, 18-78years). Patients were divided into two groups according to etiology. Group A (post-traumatic) consisted of 18 patients with a mean age of 33years (range, 18-64years) and group B (degenerative) of 16 patients with a mean age of 59years (range, 42-78years). All patients were clinically assessed at a mean 27months. Range of motion, level of satisfaction and Mayo Elbow Performance Score (MEPS) were collected. RESULTS: In the overall series, preoperative range of motion was 81° and significantly improved postoperatively to 122° (p<0.001). The preoperative data of the 2 groups were comparable except for age (p<0.001) and MEPS (p=0.044). Postoperatively, range of motion improved significantly in both groups but with greater gain in group A (p=0.003). MEPS improved significantly in both groups, but the postoperative score was poorer in group B (p=0.001). Recovery of range of motion was faster in group B (2.4months) than in group A (3.7months) (p=0.021). There were 5 complications: 4 secondary decompensations of ulnar tunnel syndrome, and 1 postoperative radial nerve paresis. 94% of patients were satisfied or very satisfied with the result of surgery. CONCLUSION: Arthroscopic arthrolysis is an effective option for post-traumatic and non-traumatic elbow stiffness. Improvement was significant in terms of both function and range of motion, with, however, better results in the post-traumatic group but results achieved more rapidly in the degenerative pathology group. LEVEL OF EVIDENCE: IV, retrospective study.

Acute pain after digital crushing and nicotine intoxication. Cigarettes are always a false friend. A prospective study.

BACKGROUND: Nicotine addiction is a public health problem. Our hypothesis was that the degree of nicotine dependence is positively correlated with the perceived intensity of acute pain. MATERIALS AND METHODS: A single-center prospective comparative observational study was conducted from 2019 to 2021. Patients included presented distal phalanx extra-articular trauma of less than 24hours' progression. We compared a group of smokers with a group of non-smokers. A Digital Pain Scale (DPS) was assessed at time of trauma, at first consultation, and once a day until the fifth day post-trauma. A Fagerström test was performed. The primary endpoints were the correlation between dependence and DPS and the correlation between the amount of tobacco consumed and DPS. The secondary endpoints were analgesic consumption according to Fagerström, DPS and tobacco consumption. RESULTS: Sixty-seven patients were included: 26 smokers, 41 non-smokers. No significant correlation was found between dependence level or amount of tobacco used and DPS. Consumption of level II analgesics was significantly 2-fold higher in the smoking group on the second, third and fifth day: respectively, 2.15 tablets versus 1.22 (p=0.02), 1.27 versus 0.49 (p=0.01), and 0.69 versus 0.20 (p=0.04). CONCLUSION: Patients who smoke are exposed to more frequent and more intense pain and consume more palliative painkillers. LEVEL OF EVIDENCE: IIB; exposed vs. non-exposed cohort.

Arthroscopic release of the pectoralis minor tendon as an adjunct to acromioplasty in the treatment of subacromial syndrome associated with scapular dyskinesia.

INTRODUCTION: One of the causes of scapular dyskinesia is the retraction of the pectoralis minor muscle. It can be the cause of shoulder pain associated with increased anterior tilt and internal rotation of the shoulder. HYPOTHESIS: Arthroscopic release of the pectoralis minor tendon is effective for shoulder pain, linked to a correction of dyskinesia, resulting in the early disappearance of scapulalgia. PATIENTS AND METHODS: This was a retrospective, monocentric, single-surgeon study on a continuous series of patients with symptomatic shoulder pain, related to subacromial impingement associated with scapular dyskinesia. The series underwent arthroscopic tenotomies of the pectoralis minor between January 2015 and September 2018. Fifty-eight releases were performed to 57 patients (22 males, 35 females), with a mean age of 51.4 years (29-66 years). In all cases, they presented pain on palpation of the upper bundle of the trapezius muscle, and on palpation of the coracoid insertion of the pectoralis minor. RESULTS: Preoperatively, there were 30 cases of stage 1 scapular dyskinesia and 28 cases of stage 2, with a scapular index measured at 53.84 (41.66-65.78), while the constant score was 41.46 (19-59). Upper trapezius pain was present in 87.7% of cases. The 57 patients were clinically assessed, with a mean follow-up of 8.9 months (6-24 months). Post-operatively, 15 cases (25.8%) of scapulalgia persisted at 2 months of follow-up, while upper trapezius pain was present in only 22.4%. Scapular dyskinesia was no longer present at 2 months in patients without scapulalgia. The scapular index was measured at 60.42 (52.38-70.96), and the constant score at last follow-up was 76.36 (42-92). CONCLUSION: Tenotomy of the pectoralis minor improves painful symptomatology and scapular dyskinesia, in cases of subacromial syndrome with retraction of the pectoralis minor muscle. LEVEL OF EVIDENCE: IV, retrospective study.

Septic arthritis of the fingers: is short-term oral antibiotic therapy appropriate?

The management of septic arthritis of the hand is poorly described and there is no consensus. It is based on how septic arthritis of the large joints is managed, despite certain specificities related to the hand, typically involving inpatient management and intravenous antibiotic therapy. The primary objective of this work was to evaluate our postoperative protocol for the management of septic arthritis of the hand with short-term antibiotic therapy. The secondary objective was to determine the risk factors for treatment failure. We conducted a retrospective, descriptive, single-center study and analyzed the medical records of patients managed for septic arthritis of the fingers over a 1-year period from January 2018 to December 2018. We collected patient demographics and all pre-, intra-, and postoperative data. A total of 128 patients were included. The median age was 52.4 years (41-66). An exogenous source of contamination was reported in 98% of cases (animal bite, plant thorn, wound, cyst trituration, etc.). The most frequently isolated microorganism was Staphylococcus aureus (45%), followed by Streptococcus spp. (22%) and Pasteurella spp. (18%). The vast majority of patients (79%) were treated with oral amoxicillin/clavulanic acid. This treatment was continued in 91% of patients after microbiological results were obtained for a median treatment duration of 8 days (7-15). Nine percent of patients failed treatment. The risk factors identified were crush wounds (p = 0.04), initial radiological abnormalities (chondrolysis and/or osteolysis) (p = 0.016) and infection with Pasteurella spp. (p = 0.015). Our study suggests that simplified antibiotic therapy is feasible for the management of septic arthritis of the hand with short duration, broad spectrum oral antibiotics in the absence of identified risk factors.

Arpe total joint arthroplasty for trapeziometacarpal osteoarthritis: 80 thumbs in 63 patients with a minimum of 10 years follow-up.

In this retrospective study, we report a series of 80 Arpe prostheses for trapeziometacarpal osteoarthritis in 63 patients. Twenty-seven prostheses (20 patients) were lost to follow-up. Twenty-one were revised, eight of them during the first year after operation. The calculated cumulated implant survival rate was 85% at 10 years but could be lower due to the lack of information on the patients lost to follow-up. The number of complications due to technical errors was high; but after we had done 30 cases, the number of early revisions decreased markedly. At follow-up, 23 of 32 thumbs were totally free of pain, and the patients were satisfied with 31 thumbs. We conclude that the implant survival declines progressively in the long run, with a survival rate of 80% after 15 years of follow-up and a further decline thereafter. We also found that this surgery was difficult to master. We advise selecting this implant for thumb trapeziometacarpal osteoarthritis with caution. Level of evidence: IV.

Fast-track teaching in microsurgery.

INTRODUCTION: In France, microsurgery is taught in University diploma courses, for a mean 100hours (range, 45-120hours) extending over several months. This training, spread over the year, encounters problems of maintaining high-quality supervision and enduring acquisition of skills. These difficulties risk leading to withdrawal of certain courses, already suffering from funding issues and administrative requirements for animal welfare. MATERIAL AND METHOD: We report our experience with a 2-week module comprising nine 4-hour sessions (total, 36hours), with continuous supervision of 5 students in each of 2 groups (10 students), enabling personalized learning. At the end of each session, an assessment questionnaire was filled out by teachers and students. RESULTS: Students' scores increased from a mean 23.9/30 points (range, 20 - 30) at session 3 to 26.9 points (range, 23 - 30) at session 9 (p=0.012). At the end of session 3, students were grouped as good, average or beginners, based on the first assessments: i.e., with differences in level between groups at session 3. At the end of session 9, all 3 groups showed statistically comparable levels. Comparison between student and teacher questionnaire responses showed a significant discrepancy in 7 of the 10 cases in week 1, and no significant discrepancy in 7 of the 10 cases by the end of week 2. DISCUSSION: The efficacy of condensed learning is based on immediate repetition of exercises, following Ebbinghaus: without repetition, memory decays exponentially, whereas if the information is rapidly repeated, the curve flattens and memory is consolidated. The present rapid improvement in the acquisition of the principles of microsurgery stimulated the enthusiasm of both students and teachers for what is reputed to be a demanding type of training. The study showed that acquisition, assessed in terms of vascular suture reliability, was achieved by the end of a 36-hour module, regardless of the student's baseline level.