A prospective study of 100 patients with rotator cuff tendinopathy showed no correlation between subacromial bursitis and the efficacy of ultrasound-guided corticosteroid injection.

OBJECTIVES: The objective of this study was to determine whether the presence of subacromial bursitis in patients with rotator cuff tendinopathy (RCT) was associated with a better outcome after ultrasound (US)-guided subacromial corticosteroid injection. METHODS: A single-center prospective study was performed including patients referred for subacromial injection to manage RCT. At baseline, all patients received an US-guided intra-bursal injection of betamethasone (1 ml). The primary endpoint was reduced pain 3 months (M3) after the procedure: a good responder was defined by a decrease in Visual Analogue Scale pain of more than 30%. Secondary endpoints included functional recovery assessed by the Oxford Shoulder Score (OSS) and clinical success at 6 weeks (W6). We also explored the association between good clinical response and other factors, such as US or X-ray features. RESULTS: One hundred patients were included and 49 presented with subacromial bursitis. At M3, 60% of patients (54/100) were considered good responders. The rate of good responders did not differ between the bursitis and non-bursitis groups (p = 0.6). During follow-up, OSS improved over time whether bursitis was present or not. We did not find any US or X-ray features significantly associated with a favorable clinical outcome. CONCLUSION: The presence of subacromial bursitis did not influence clinical outcomes at 3 months post-subacromial injection in patients suffering from RCT. CLINICAL RELEVANCE STATEMENT: The presence of subacromial bursitis did not influence clinical outcomes at 3 months post-subacromial corticosteroid injection in patients with rotator cuff tendinopathy. For patient management, looking for ultrasonographic signs of bursitis does not appear relevant for the indication of the injection. KEY POINTS: • Ultrasound-guided subacromial corticosteroid injections led to a significant improvement in 60% of patients suffering from rotator cuff tendinopathy. • The presence of subacromial bursitis was not associated with better improvement at 3 months post-injection. • Except for the Minnesota score referring to job satisfaction, we did not find any baseline clinical, X-ray, or ultrasound characteristics associated with a successful outcome.

Development of a new radiographic score for the follow-up of calcific tendinopathy of the rotator cuff.

OBJECTIVES: The aim of this study was to evaluate the psychometric properties of a new x-ray scoring system for calcific tendinopathy of the rotator cuff (CTRC). METHODS: This is a post-hoc analysis of the CALCECHO trial. All patients received an ultrasound-guided puncture and lavage of their calcification. Clinical data and x-rays from baseline and follow-up visits at 7 days (D7), 3 months (M3) and 12 months (M12) were used. The scoring system was based on the reduction in size and density of the calcification compared to the initial x-ray (0 = no change; 1 = decrease of less than 50%; 2 = decrease of between 50 and 90%; 3 = decrease of more than 90%; 4 = complete disappearance). Inter-observer and intra-observer reliability were established between 3 independent investigators (2 experts and one junior) using weighted Kappa calculation. Construct validity was assessed as well as predictive validity and sensitivity to change. RESULTS: Between the two experts, inter-reader reliability was at 0.677, 0.744 and 0.656 at D7, M3 and M12 respectively. Intra-reader reliability was between 0.577 and 0.836 for the two expert readers and between 0.519 and 0.697 for the junior reader. Our score was correlated with shoulder pain and function at M3 and M12 and the score at M3 was predictive of the clinical outcome at M12. Finally, sensitivity to change was 0.8. CONCLUSIONS: Our new score presented good psychometric properties and was correlated with clinical data. It could be useful in the follow-up of patients treated for CTRC.

Difference of Knee Strength Recovery Between Revision and Primary ACL Reconstruction.

Different grafting procedures are available to restore knee stability after revision anterior cruciate ligament (ACL) reconstruction. We compared knee strength recovery between ACL revision surgery and primary reconstruction. One hundred and ten patients with ACL revision surgery were matched with 110 patients with primary reconstruction based on the graft procedure. The isokinetic knee strength had been assessed for the first 9 months post-surgery. Knee laxity, function, and activity score were also evaluated. Limb symmetry index for knee extensor and flexor strength was not different at 4-, 6- and 9-months post-surgery between revision surgery and primary reconstruction. These results depended on ipsilateral or contralateral graft choice. Ipsilateral hamstring tendon (HT) and contralateral bone-patellar-tendon-bone (BPTB) graft procedures were similar for a revision of a BPTB graft failure. Contralateral HT procedure was better than ipsilateral BPTB procedure for a revision of a HT graft failure. The early recovery of isokinetic knee strength after ACL revision surgery regardless of the HT or BPTB procedures, was similar to the recovery after primary ACL reconstruction with the same graft technique. These results apparently depended on a temporary quadriceps arthrogenic muscle inhibition and on a persistent donor site morbidity, concerning the new and the previous grafts, respectively.

Enlightenment on Knee Flexors Strength Loss in Cases of Posterior Knee Pain After Anterior Cruciate Ligament Reconstruction.

CONTEXT: The persistence and the recurrence of posterior medial knee pain (PKP) after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon graft are often overlooked during rehabilitation. DESIGN: Cross-sectional observational study. METHODS: The study aimed (1) to evaluate the prevalence of these types of PKP before 4 months post-ACLR, (2) to measure their consequences on the knee flexors strength, and (3) to evaluate the role of the type of ACLR. From a cohort of patients operated on with hamstring tendon procedures, the persistent and the recurrent PKP were sought at 4 months post-ACLR. The evolution of isokinetic muscle strength recovery in PKP subjects was compared with those of nonpainful subjects. The functional deficit was measured at 6/7 months post-ACLR by a hop test. RESULTS: Three hundred seventeen subjects (25.8 [6.0] y) were included. At 4 months post-ACLR, 2 populations were identified based on the recurrent onset of PKP (PKP+, n = 40) or the absence of knee pain (PKP-, n = 277). The prevalence of PKP was 8.3%. At the fourth month post-ACLR, the PKP+ group had a higher flexor strength deficit compared with the PKP- group (limb symmetry index at 60°/s: 67.2% [12.4%] vs 84.3% [12.6%]; P < .05). At 6/7 months, the loss of strength persisted (limb symmetry index at 60°/s: 82.3% [13.4%] vs 87.7% [12.8%]; P < .05). The hop test deficit was comparable, and no difference was shown according to the type of graft. CONCLUSIONS: Persistent and recurrent PKP during the rehabilitation period were not uncommon and were associated with a worsening of flexors strength loss on the ACLR side.

Artistic Swimming Injuries in Young Elite Athletes: An 11-year Follow-Up.

OBJECTIVE: Artistic swimming is a highly challenging discipline, requiring physical skills and creativity. There are almost no published data on trauma. We aimed to assess the incidence and the nature of injuries in artistic swimmers. DESIGN: An 11-year retrospective single-center cohort study. SETTING: Department of Sport Medicine of a University Hospital. PATIENTS: One hundred and twenty-four elite female artistic swimmers aged 12.9 ± 1.6 years. INTERVENTIONS: The cohort was divided into 3 groups according to the competition categories (from 9 to 12 years old called "future", 12-15 years old called "youth", 15-19 years old called "junior"). MAIN OUTCOME MEASURES: Injury rate per season and per athlete was assessed. RESULTS: The injury rate was 0.95 injuries/season/athlete and 1.05 injuries/1000 hours of practice. The most frequent injuries were rotator cuff tendinopathy (13.6%), acute low back pain (13.6%), and patellofemoral syndrome (11.9%). Swimmers in the youth and junior categories had significantly more injuries than those in the future category (P = 0.009), possibly because of more training hours (P < 0.001). Twelve major injuries occurred, all in the same group of youth swimmers. CONCLUSION: This is the first study investigating trauma during artistic swimming practice. A better knowledge of the main injuries is necessary for the physician to provide optimal care for athletes and to develop prevention. Attention should be particularly paid to the swimmers' shoulders and knees.

Consequences of Patellar Tendinopathy on Isokinetic Knee Strength and Jumps in Professional Volleyball Players.

Patellar tendinopathy (PT) in professional volleyball players can have an impact on their careers. We evaluated the impact of this pathology in this specific population in terms of isokinetic strength and jumping performances. Thirty-six professional male volleyball players (mean age: 24.8 ± 5.2) performed isokinetic knee assessments, single-leg countermovement jumps and one leg hop test. They filled out the Victorian Institute of Sport Assessment-Patella (VISA-P) score. Two groups were assessed: "PT group" (n = 15) and "control group" (n = 21). The VISA-P score was lower in the PT group (p < 0.0001). No difference was found between the isokinetic strength limb symmetry index and the jump performance limb symmetry index. The healthy legs of the control group were compared with the affected (PT+) and the unaffected legs (PT−) of the PT group. Compared with the healthy legs, both PT+ and PT− legs showed decreased values of quadriceps and hamstring strengths. Only PT+ legs scored lower than healthy legs in countermovement jumps and hop tests. No differences were found between PT+ and PT− legs for muscle strengths and jumps. A low correlation existed between quadriceps strength and jumping performances (r > 0.3; p < 0.001). Volleyball players with PT showed a decrease in the isokinetic knee strength. This strength deficit was found both on the symptomatic legs and the asymptomatic ones. Jumps were only significantly altered on the pathological legs. Highlighting that the unaffected limbs were also impaired in addition to the affected limbs may help provide a better adaptation of the rehabilitation management.

Isokinetic knee strength deficit in patients with moderate haemophilia.

INTRODUCTION: Knee joint bleedings are responsible for quadriceps atrophy and strength deficit in patients with severe haemophilia. Little is known about patients with moderate haemophilia (PWMH). AIM: To evaluate isokinetic quadriceps and hamstrings strength in PWMH and to assess correlation with radiological and clinical parameter. METHODS: 18 PWMH aged 37.1 ± 11.4 and 18 healthy age-, weight- and height-matched controls performed a knee isokinetic test at 180°/s to assess quadriceps and hamstrings strength. In the PWMH group, knee Pettersson's score was pursued and Haemophilia Joint Health Score 2.1 (HJHS) was performed to determine unaffected knees (knee HJHS = 0) and affected ones (knee HJHS >0). RESULTS: Affected knees had a decrease of quadriceps strength compared to controls, 1.26 ± 0.47 vs 1.64 ± 0.27 Nm/kg and a decrease of hamstring strength, 0.60 ± 0.29 vs 1.03 ± 0.21 Nm/kg, (P < 0.001). Unaffected knees also had a decrease of quadriceps strength compared to controls, 1.36 ± 0.31 vs 1.64 ± 0.27 Nm/kg and a decrease of hamstring strength, 0.69 ± 0.18 vs 1.03 ± 0.21 Nm/kg, (P < 0.001). The conventional hamstring-to-quadriceps ratio was significantly decreased in affected knees compared to controls, 0.46 ± 0.15 vs 0.64 ± 0.13 (P < 0.001) but also in unaffected knees, 0.53 ± 0.16 vs 0.64 ± 0.13 (P = 0.02).No correlation was found between strength and HJHS or Pettersson's score. CONCLUSION: PWMH have a significant knee strength deficit, both on the quadriceps and the hamstrings, which is responsible for an important muscle imbalance.

A Comparison of Two Models Predicting the Presence of Chronic Exertional Compartment Syndrome.

Clinical history and physical examination are usually not sufficient to diagnose leg chronic exertional compartment syndrome (CECS). Two predictive clinical models have been proposed. The first model by De Bruijn et al. is displayed as a nomogram that predicts the probability of CECS according to a risk score. The second model by Fouasson-Chailloux et al. combines two signs (post-effort muscle hardness on palpation or hernia). To evaluate those models, we performed a prospective study on patients who were referred for possible CECS. 201 patients underwent intra-compartmental pressure at 1-min post-exercise (CECS if ≥ 30 mmHg) - 115 had CECS. For the De Bruijn et al. model, the risk score was 7.5±2.2 in the CECS group and 4.6±1.7 in the non-CECS group (p<0.001) with an area under the ROC curve of 0.85. The model accuracy was 80% with a sensitivity of 82% and a specificity of 78%. Concerning Fouasson-Chailloux et al. model, the accuracy was 86%; the sensitivity and the specificity were 75 and 98%, respectively. The De Bruijn et al. model was a good collective model but less efficient in individual application. In patients having both muscle hardness and hernia, we could clinically make the diagnosis of CECS.

Impact of Patellar Tendinopathy on Isokinetic Knee Strength and Jumps in Professional Basketball Players.

Patellar tendinopathy is characterized by tendon pain which may reduce the level of performance. This study's main aim was to compare isokinetic knee strength and jump performances at the start of the sport season between players with patellar tendinopathy and those without. Secondary aims were to assess the relationship between knee strength and jump function. Sixty-two professional basketball players were enrolled (mean age: 25.0 ± 4.0). All players performed knee isokinetic measurements, single leg countermovement jumps, and one leg hop tests. Correlations between knee strength and jump performances were examined. Twenty-four players declared a patellar tendinopathy and were compared to the 38 players without tendinopathy. The isokinetic quadriceps strength was lower in cases of patellar tendinopathy, and a camel's back curve was observed in 58% of the cases of patellar tendinopathy. However, jump performances were preserved. No link was found between quadriceps and hamstring limb symmetry indexes at 60 and 180°/s with jumps. This preseason screening enabled us to identify the absence of consequences of patellar tendinopathy in professional basketball players. Jump performances were not altered, possibly due to compensatory strategies.

Hamstring Muscle Injury Prediction by Isokinetic Ratios Depends on the Method Used.

OBJECTIVES: Hamstring muscle injury prediction by isokinetic strength ratios is low but could result from the method-depending either on the use of the limbs or of the sportsmen as references. We aimed to establish a predictive model including unilateral and bilateral ratios calculated from the dominant, nondominant, right, and left limb in injured and uninjured professional soccer players. DESIGN: Cohort study. SETTING: Soccer team of the French Professional Premier League. PATIENTS: Ninety-one professional soccer players. INTERVENTIONS: Isokinetic muscle strength was prospectively measured at the beginning of 5 consecutive seasons (2009-2014). MAIN OUTCOME MEASURES: Several bilateral, conventional, and functional ratios were calculated from isokinetic measurements at different angular speeds (60 and 240 degrees/s in concentric mode and 30 degrees/s in eccentric mode). Thirty-one soccer players had a hamstring injury during the seasons and were compared with 60 uninjured players. Four models were tested to predict the occurrence of hamstring injury from isokinetic ratios calculated in accordance with the dominant, nondominant, right, and left limb. RESULTS: No predictive model was found when ratios were calculated from the dominant or the right limb. Two models of prediction were found when ratios were calculated from the nondominant or the left limb. In these 2 models, only the bilateral concentric hamstring-to-hamstring ratio at 60 degrees/s was predictive. The best prediction was found with the left limb. CONCLUSIONS: We identified 2 low predictive models for hamstring muscle injuries depending on the limbs studied. Because of a low prediction, the consensual method used to predict hamstring muscle injury must be defined in future studies.

Jumper's knee mechanical consequences in professional basketball players: the "Camel's Back curve".

PURPOSE: Jumper's knee is characterized by an anterior knee pain during tendon palpation and can be classified in overuse pathologies, secondary to repetitive jumps. The prevalence is high in professional basketball players. It is responsible for an alteration of the motor control inducing a strength deficit of the quadriceps. We aimed to describe an isokinetic curve anomaly, a double-humped curve called "Camel's Back curve", consequence of a jumper's knee history. METHODS: 170 Professional basketball players were enrolled (24.8 ± 4.6 years; 91.8 ± 12.0 kg, 194 ± 9.0 cm). All players performed isokinetic tests of the knee extensors on a concentric mode at the angular speed of 60°/s and 180°/s. RESULTS: 43 players had a jumper's knee history and 35 (81%) had a "Camel's Back curve" at 60°/s. The sensitivity and the specificity of this curve were 81.3% and 100%, respectively. The minimum torque of strength was decreased from 12 to 18% compared to the 2 maximal peaks. Yet, the strength measured every 5° of ROM was significantly different between the players with "Camel's Back curve" and those with normal curve. CONCLUSIONS: "Camel's Back curve" had never been described in that context. It may be secondary to a protective inhibitory mechanism which could alter jumping. The presence of a "Camel's Back curve" would enable clinicians to adapt physical preparation, knee rehabilitation, and trainings to improve players performances.

Simultaneous pain intensity rating and quantification of ischemia throughout exercise and recovery in proximal versus distal arterial claudication.

Data on simultaneous hemodynamic changes and pain rating estimation in arterial claudication while walking are lacking. This study was conducted to determine if a difference in transcutaneous oxygen pressure (tc pO2) exists between proximal and distal localization at pain appearance (PAINapp), maximal pain (PAINmax) and pain relief (PAINrel) in proximal or distal claudication and if a relationship exists between tc pO2 changes and pain intensity. We analyzed the pain rating (Visual Analog Scale (VAS)) to lower limb ischemia, measured with the decrease from rest of oxygen pressure (DROP) tc pO2 index during constant-load treadmill tests in patients with calf ( n = 41) or buttock ( n = 19) claudication. Calves versus buttocks results were analyzed with ANOVA tests. The R2 correlation coefficient between individual VAS versus DROP was calculated. Ischemia intensity versus pain rating changes were correlated. Significant ischemia was required for pain appearance, but pain disappeared despite the persistence of ischemia. We observed no statistical difference for DROP at PAINapp, PAINmax or PAINrel between proximal or distal claudication. A significant correlation between pain rating versus DROP was found: from PAINapp to PAINmax, R2 = 0.750 (calves) and 0.829 (buttocks), and from PAINmax to PAINrel, R2 = 0.608 (calves) and 0.560 (buttocks); p<0.05. Pain appeared after a significant decrease of hemodynamic parameters but disappeared while parameters were not normalized. No difference in pain rating was found in proximal versus distal claudication.

The correlation of the "Walking Estimated-Limitation Calculated by History" (WELCH) questionnaire with treadmill maximal walking time is not impaired by age, in patients with claudication.

PURPOSE: The "Walking Estimated-Limitation Calculated by History" (WELCH) questionnaire is a short four-item questionnaire that estimates the walking capacity of a patient in comparison with relatives, friends or people the same age. As such, it should be relatively insensitive to age, yet this has never been tested. METHODS: A prospective study was performed among 525 patients presenting vascular-type claudication. Patients were grouped into quintiles of age-from quintile 1 for the youngest patients to quintile 5 for the oldest ones. Patients completed a self-administered questionnaire and then had their maximal walking time (MWT) measured on a treadmill. We estimated the coefficient of correlation, the slope and the intercept of the relationship between the WELCH score and the MWT, then the accuracy of a WELCH score under 25 to predict the ability to walk for 5 min on a treadmill. RESULTS: The slopes of the relationships and the correlation coefficients were not significantly different in each quintile, but a significant shift in the intercept of regressing lines was found with age. Nevertheless, the accuracy in predicting treadmill results from the WELCH score with a cut-off point of 25 was, respectively, 68.6, 72.4, 80.0, 72.4 and 73.3 % in quintiles 1, 2, 3, 4 and 5 (p = 0.45). CONCLUSIONS: The relationship of MWT on a treadmill and the WELCH score is slightly influenced by age, but a score superior to 25 seems to be of equal discriminatory performance in different quintiles of age to predict the ability to walk for 5 min on a treadmill. This makes this cut-off limit of interest for routine use, regardless of age.

Comparison of two devices for measuring exercise transcutaneous oxygen pressures in patients with claudication.

BACKGROUND: We aimed at estimating the agreement between the Medicap" (photo-optical) and Radiometer• (electrochemical) sensors during exercise transcutaneous oxygen pressure ( tcp02) tests. Our hypothesis was that although absolute starting values (tcp02rest: mean over 2 minutes) might)e different, tcpOTchanges over time and the minimal value of the decrease from rest of oxygen pressure (DROPmin) results at exercise shall be concordant between the two systems. taneously, one of each system on the chest, on each buttock and on each calf. RESULTS: Seventeen Medicap" probes disconnected during the tests. tcp02rest and DROPmin values were higher with Medicap• than with Radiometer•, by 13.7 ± 17.1mmHg and 3.4 ± 11.7 mmHg, respectively. Despite the differences in absolute starting values, changes over time were similar between the two systems. The concordance between the two systems was approximately 70% for classification of test results from DROPmin. CONCLUSIONS: Photo-optical sensors are promising alternatives to electro-chemical sensors for exercise oximetry, provided that miniaturization and weight reduction of the new sensors are possible. PATIENTS AND METHODS: Forty seven patients with arterial claudication ( 65 ± 7 years) performed a treadmill test with 5 probes each of the electro-chemical and photo-optical devices simul-

Anatomic feasibility study of a sartorius myocutaneous flap with a distally based pedicle and proximal skin paddle.

INTRODUCTION: We conducted an anatomic feasibility study of a sartorius myocutaneous flap with a distally based pedicle and proximal skin paddle to cover soft tissue defects of the knee region. HYPOTHESIS: A recent anatomic study by Mojalla showed that the sartorius muscle had 2 distinct pedicles, making it possible to isolate this muscle on its distal pedicle and harvest it with a skin paddle. MATERIALS AND METHODS: This anatomic study was conducted on 10 lower limbs. The 2 criteria assessed were (1) the viability of our proximal skin paddle and (2) the arc of rotation and coverage obtained with this myocutaneous flap. RESULTS: We identified 7 proximal skin paddles after the injection of India ink into the distal pedicle of the sartorius muscle. In all cases, the arc of rotation of the flap allowed coverage of the knee region. The mean distance between the inferior edge of the skin paddle and the proximal border of the patella (DBAP) was measured at 13cm, and the mean distance between the superior edge of the flap paddle and the anterior superior iliac spine (DASIS) at 16cm. The average skin paddle size was 14 by 7cm. DISCUSSION: Our anatomic study demonstrated the feasibility of our sartorius flap with a distally based pedicle and proximal skin paddle. This technique may be a viable alternative when using gastrocnemius flaps is not feasible, or the surgeon lacks the microsurgical skills to perform free flaps. LEVEL OF EVIDENCE: IV; descriptive anatomic study.

Proximal toe wrap-around: a coverage technique for circumferential skin defects of the fingers.

Circumferential skin defects of the fingers are a technical challenge. Although rare, their management should respect tissue organization and functional abilities. We report two cases of circumferential skin defect. Management used individually tailored "wrap-around" flaps taken from the hallux. The sample concerned the proximal cutaneous sheath of the first toe and the neurovascular pedicle of the first inter-metatarsal space. Nail and toe pad were spared. Both cases had complex circumferential skin defect of the finger, involving the neuro-vascular pedicle. Postoperative results were favorable, without functional limitation. The wrap-around technique provided skin coverage and also neurovascular pedicle reconstruction. Donor site damage was limited, with no functional consequences. This technique is a valuable option for management of circumferential skin defect of the finger.

Prolonged Physiotherapy after Anterior Cruciate Ligament Reconstruction Does Not Improve Muscular Strength and Function.

Background: After the rupture of the anterior cruciate ligament (ACL), surgery is proposed in the case of knee instability or for athletes who want to return to a pivotal and/or contact sport. The current trend is to extend physiotherapy sessions until a patient's return to sport. We aimed to assess the interest in prolonging the physiotherapy sessions up to 4 postoperative months to restore muscle knee strength and function. Methods: From a historical cohort, 470 patients (24.3 ± 8.7 years) were included; 312 (66%) were males. They all had undergone a primary ACL reconstruction with a hamstring procedure. The number of physiotherapy sessions was established at 4 postoperative months. The main study parameters to assess the benefit of prolonged physiotherapy were the isokinetic limb symmetry index (LSI) for the quadriceps and the hamstrings as well as the Lysholm score. Results: At 4 postoperative months, 148 patients (31.4%) still had physiotherapy sessions. This group had performed 49 ± 14 physiotherapy sessions at the time of evaluation compared to 33 ± 9 sessions performed by the group that stopped physiotherapy at 3 months post-ACL reconstruction. The isokinetic knee LSI and the Lysholm score were not different between the two groups. Continued physiotherapy sessions were associated with female gender, previous high sport level, meniscal repair, lateral tenodesis and outpatient rehabilitation at the beginning of the rehabilitation management, while knee pain complications were not associated. Conclusions: No significant correlation was found between the number of physiotherapy sessions and the knee strength LSI or the Lysholm score. Prolonging patient physiotherapy sessions after 3 months post-ACL reconstruction seems ineffective in improving knee strength recovery and function.

Nerve entrapment complicating neurogenic thoracic outlet syndrome surgery: A 10-year retrospective study.

Neurogenic thoracic outlet syndrome results from compression of the brachial plexus. The symptoms are mainly pain, upper-limb weakness and paresthesia. Management always starts with a rehabilitation program, but failure of rehabilitation may necessitate surgery. In practice, we observed that several patients developed secondary distal nerve entrapment in the months following surgery, with no preoperative compression. We aimed to assess the occurrence of distal nerve entrapment after surgery for neurogenic thoracic outlet syndrome in a retrospective cohort study. Seventy-four patients were included; 82% females; mean age, 39.4 ± 9.4 years. There were 36.5% with high intensity and 63.5% with low to moderate intensity work. Eighteen (24.3%) developed secondary upper-limb entrapment at 10.6 ± 5.8 months after surgery. Sixteen had a single entrapment and 2 had two different entrapments. In 10 cases (50%) the ulnar nerve was involved at the elbow, in 7 (35.0%) the radial nerve at the radial tunnel, and in 3 (15.0%) the median nerve. No differences were found between patients with and without secondary nerve entrapment in gender (p = 0.51), mean age (p = 0.44), symptom duration (p = 0.92) or work intensity (p = 0.26). Further studies are needed to confirm these results and to shed light on the underlying mechanisms.

Anatomic feasibility study of osteocutaneous free flap from the proximal ulna.

OBJECTIVE: The present anatomic study aimed to assess the feasibility of an osteocutaneous free flap harvested from the proximal ulna for reconstruction after complex hand trauma. METHOD: Nineteen upper limb specimens free of scarring in the elbow region were injected in the brachial artery. After S-shaped incision centered on the medial epicondyle, a systematic approach to the epitrochlear-olecranal groove exposed the superior ulnar collateral artery and ulnar nerve. Bone and skin perforators were screened for during dissection and their emergence with respect to the medial epicondyle was assessed. Pedicle length was also assessed. The skin paddle was harvested in the distal part of the S incision and the operative site was closed by local skin plasticity. RESULTS: Bone and skin perforators from the superior ulnar collateral artery were found in all 19 specimens. Mean pedicle length from the artery was greater than 9cm in all cases. The skin perforator emerged at a mean 19mm distally from the medial epicondyle, and the bone perforator at a mean 40mm. DISCUSSION: An osteocutaneous free flap can be harvested from the proximal ulna and medial side of the elbow. As bone and skin perforators were found in all 19 cases, this flap can be used routinely. Harvesting, however, systematically involves ulnar nerve release and anterior transposition. This osteocutaneous free flap harvested from the proximal ulna offers an alternative for osteocutaneous defects in the hand, with harvesting from the same limb. CONCLUSION: In this anatomic series, an osteocutaneous free flap could in all cases be harvested from the posterior ulnar recurrent artery via a medial elbow approach. Safety and efficacy remain to be demonstrated in in vivo reconstruction. LEVEL OF EVIDENCE: III.