Patient satisfaction after distal upper limb surgery under WALANT versus axillary block: A propensity-matched comparative cohort study.

Distal upper limb surgery is performed under WALANT (Wide Awake Local Anesthesia No Tourniquet) in many outpatient centers because the benefits are numerous: simple, low-cost technique, with fast turnover and short length of stay. In view of a paucity of data concerning patient satisfaction, this non-randomized cohort study was designed to compare EVAN-LR anesthesia satisfaction questionnaire results (information, pain, expectation, attention, discomfort: 0-100 points) between patients receiving WALANT or axillary nerve block (AxB). After IRB approval, patients (>18 years, stable ASA 1-3) scheduled for outpatient distal upper limb surgery were prospectively enrolled in the two groups. At discharge, patients in both groups received standard information on postoperative recovery and care, with a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The primary endpoint was EVAN-LR score before discharge. Secondary endpoints were pain relief and side-effects over a 7-day period. Results were recorded as median and 25-75% interquartile range. Propensity-score-matched analysis was performed. Over the study period, from October 2019 to November 2020, 183 patients were included; 48 WALANT patients were propensity-score matched to 48 AxB patients. Pre-procedural APAIS anxiety score was lower in the WALANT than the AxB group: 9 (IQR, 6-12) vs 12 (IQR, 8-14) (p = 0.01). EVAN-LR scores were similar between the WALANT (78 [72-82]) and the AxB group (73 [67-80]). Incidences of paresthesia and of pain (NRS pain score, opioid rescue) were similar. WALANT patients had shorter length of stay: 135 (110-175) min vs 170 (110-250) min (p = 0.01). The present study demonstrated that WALANT was associated with a high level of patient satisfaction. For clinical relevance and quality of care, WALANT should be proposed in first line for distal limb surgery.

Trapeziometacarpal (TMC) arthroplasty under Wide Awake Local Anesthesia with No Tourniquet (WALANT) versus Local Anesthesia with peripheral nerve blocks (LAPNV): Perioperative pain and early functional results in 30 patients.

We hypothesized that WALANT would provide similar perioperative analgesic comfort compared to local anesthesia with peripheral nerve blocks (LAPNV). We analyzed whether the patient's active participation during surgery would improve its early functional results. We did a retrospective, single study in an outpatient surgery unit, comparing two types of surgery: trapeziometacarpal arthroplasty (TMCA) under LAPNV and TMCA under WALANT. Fifteen patients were included per group. Pain levels were determined during anesthesia induction, intraoperatively, postoperatively, at rest and during activity at the last follow-up visit. The overall satisfaction with the surgery and time to resume daily activities and work were documented. The statistical analysis was performed on SAS software with an ANOVA. The significance threshold was set at 0.05. The groups were comparable on age, sex, dominant side, and operated side. No patients were lost to follow-up. The mean follow-up was 4 months (2.3-11). The QuickDASH score was 4.93 for TMCA under WALANT vs. 13.47 for TMCA under LAPNV (p = 0.01). There was no loosening, dislocation, or major complication. Our study showed that TMCA performed with WALANT yields similar results to the same procedure with LAPNV for perioperative pain relief without additional complications. Functional scores seem to be slightly improved with WALANT compared to LAPNV, but these results should be confirmed with longer follow up.

Volar locking plate fixation of distal radius fractures: Isokinetic assessment of the influence of an ulnar styloid process fracture on pronation-supination strength.

Although distal radius fractures (DRF) are frequent, the management of associated ulnar styloid process (USP) lesions is still controversial. According to recent studies, a fracture of the USP does not appear to affect functional outcomes after treatment of a DRF with plate fixation. We sought to compare the impact of a USP fracture on pronation and supination strength in isometric and isokinetic tests. We included patients with a DRF who underwent volar locking plate fixation. We divided our population into three groups: one group consisted of patients who had a fracture of the USP base, one group composed of patients without USP fracture or with a distal ulnar fracture only, and a control group composed of subjects with normal wrists. Inclusion criteria included an age of 18 to 50 years and a minimum follow-up of 10 months post-surgery. The main exclusion criteria were complex intraarticular fractures and postoperative complications. The assessment was based on clinical examination and recording of forearm rotation strength during pronation and supination in isokinetic and isometric tests. The ratio between the operated and contralateral sides was compared for each patient. Thirty-six participants were included (mean age 31.1±4.5 years). The mean postoperative follow-up was 17.9±6.9 months. Participants with a USP fracture differed from other participants in their peak torque on the isokinetic test at 45°/s for pronation and supination, but not on isokinetic tests at 120°/s or in isometric tests. Isokinetic tests revealed a decrease in pronation-supination strength during sustained effort for patients with associated basal USP fractures. These findings may have clinical implications for management of the USP but need to be specified with further study. LEVEL OF EVIDENCE: prognostic study level III.

Correction to: Patient dose reference levels in surgery: a multicenter study.

The original version of this article, published on 01 August 2018, unfortunately contained two mistakes.

Patient dose reference levels in surgery: a multicenter study.

OBJECTIVE: To assess diagnostic reference levels (DRLs) in surgery for the most frequent procedures as required by the European Directive 2013/59/Euratom. METHODS: A survey was conducted in six centers. Eight orthopedic, urology and gastrointestinal surgical procedures were analyzed. Kerma area product (KAP) and fluoroscopy time (FT) were recorded for 50 patients (except for elbow: 30 patients) per procedure and per center from September 2016 to September 2017. DRLs were calculated as the 3rd quartiles of the distributions. For shoulder surgery, DRLs were defined according to the complexity of the procedure. For hand/wrist and foot/ankle surgery, DRLs were defined according to the technology (conventional C-arm vs. mini-C-arm). RESULTS: Results of 1870 procedures were retrieved. DRLs were calculated for the two dosimetric indicators and the eight procedures. DRLs were 2130 mGy.cm2 and 1.4 min for proximal femoral intramedullary nail, 1185 mGy.cm2 and 0.9 min for laparoscopic cholecystectomy and 2195 mGy.cm2 and 1.0 min for double-J (pigtail) ureteral catheter insertion. For shoulder surgery, KAP and FT were significantly higher (p < 0.05) for intramedullary procedures compared to extramedullary procedures. For hand/wrist and foot/ankle surgery, the KAPs were significantly higher (p < 0.05) with conventional C-arm compared to mini-C-arm, but FTs were not significantly different (p: not significant). CONCLUSION: This study reports DRLs in surgery based on a multicentric survey. KEY POINTS: • Delivered dose in surgery depends on procedure, practice and patient. • Diagnostic reference levels (DRLs) are proposed for eight surgical procedures. • DRLs are useful to benchmark practices and optimize protocols.

Bilateral simultaneous endoscopic carpal tunnel release: Mean time to resume activities of daily living and return to work.

The purpose of this study was to determine the time needed to return to personal and professional activities after bilateral simultaneous endoscopic carpal tunnel release. During a retrospective, single-center study, we included a cohort of 30 patients (60 wrists). Patients were evaluated clinically (pain, paresthesia) and functionally (QuickDASH score) pre- and postoperatively. At the last follow-up, patients completed a questionnaire regarding the time needed to resume personal activities using the ADL scale (feeding, personal hygiene and dressing) and return to work. We also evaluated procedure satisfaction and willingness to undergo the surgery again. The average patient age was 60.5 years (range 39-86). At the last follow-up, average time to resume personal activities was 2.2 days (0-14) for feeding, 4.4 days (0-15) for personal hygiene and 3.9 days (0-14) for dressing. Average time to return to recreational activities was 11.7 days (1-60). Average time to return to work was 36.6 days (15-60). Overall, 97% of patients were satisfied or very satisfied with the outcome. All patients would have the bilateral simultaneous surgery again. Bilateral simultaneous endoscopic carpal tunnel release is rarely performed. For mild conditions, contralateral symptom improvement is common after unilateral surgery. Bilateral simultaneous endoscopic carpal tunnel release appears to be disabling right after surgery, but clinical and functional scores are similar after the third postoperative day. These data can be used for patient education and decision making when considering surgery bilateral carpal tunnel syndrome. Bilateral simultaneous endoscopic carpal tunnel release is a feasible and safe procedure. LEVEL OF EVIDENCE: Level IV, case series.

Distal radioulnar joint instability.

Distal radioulnar joint (DRUJ) instability is a rare but disabling problem. Surgical treatment remains a challenge. The advent of arthroscopic techniques has helped to rebuild the triangular fibrocartilaginous complex (TFCC), especially its deep part. However, isolated TFCC damage is not responsible for instability. Its repair is sometimes not sufficient to restore DRUJ stability, or the chronicity of the injury prevents its direct repair. Open surgical procedures still have a role in these cases. They require a detailed knowledge of the various stabilizers of the DRUJ. Passive and active stabilizers other than the TFCC include the bones, joint capsule, oblique distal bundle of the interosseous membrane and the extensor carpi ulnaris. The objective of this review was to analyze current anatomical and biomechanical data on DRUJ stability. Different arthroscopic and open repair techniques for these structures will be reviewed. Lastly, a decision tree will be presented that can be used to better plan the management of this complex entity, because most of these injuries often occur in combination in RUD instability cases.

[Surgical exposures for distal radius fractures]. / Les voies d'abord des fractures du radius distal : une mise au point.

This is a review of the various approaches that can be used for open reduction and internal fixation (ORIF) of distal radius fractures. The main dissection steps are exposed and the specific indications for each approach are described. The anterior approach is discussed extensively as it is now the gold standard for ORIF of distal radius fractures. The lateral and posterior approaches are also described as they are sometimes needed for complex fractures.

Clinical results of endoscopic treatment without repair for partial thickness gluteal tears.

INTRODUCTION: Various surgical treatments have been proposed for greater trochanteric pain syndrome (GTPS) related to gluteal tendinopathy with partial thickness tears. The clinical results of endoscopic debridement without repair of these gluteal tears are not well known. The objectives of this study were to determine if this procedure leads to: (1) reduction of pain, (2) functional improvement, (3) patient satisfaction (on scale of 0 to 10). HYPOTHESIS: Endoscopic treatment without tendon repair provides short-term pain relief in patients with GTPS due to partial thickness gluteal tears. MATERIAL AND METHODS: Seventeen patients (16 women, 1 man) with GTPS due to partial thickness gluteal tears that was present for at least 6 months and was refractory to conservative treatment were included in the analysis. The average age at the time of the procedure was 53.5years (17-71). Pain was evaluated with a visual analogue scale (VAS). Functional outcomes were defined using the Harris Hip Score and the UCLA activity score. Satisfaction was evaluated using a VAS and Odom's criteria. RESULTS: The average follow-up was 37.6months (12-48). The average preoperative and follow-up values were respectively: (1) Pain: 7.2±1.1 (5-9) versus 3.3±1.9 (1-7) (P<0.001), (2) Harris score: 53.5±8.4 (36-68) versus 79.8±14.7 (45-96) (P<0.001). Seven patients (41.2%) were able to resume sports activities. The average satisfaction score for the surgery was 6.2±2.4 (0-9) at follow-up. Five patients had a poor outcome at the review: four still had pain and one had recurrence of the lateral snapping hip. CONCLUSION: Endoscopic treatment without repair of partial thickness gluteal tears is a treatment option with modest clinical results for GTPS patients refractory to conservative treatment. LEVEL OF EVIDENCE: IV, retrospective study.

[Nerve transfer in isolated deltoid palsy: branch of the long head of the triceps to the axillary nerve]. / Neurotisation du nerf du chef long du muscle triceps sur le nerf axillaire, dans les paralysies isolées du deltoïde.

AIM: Nerve transfer of the nerve branch to long head of triceps onto the axillary nerve has joined the therapeutic armamentarium for isolated deltoid paralysis cases. We report our experience in the case of a non-excisable neuroma of the axillary nerve at its origin from the posterior cord. METHODS: Eight patients of average age 28 (15-38) were included in a retrospective study with one operating surgeon. Clinical assessment included analytical testing of the deltoid muscle, pain score (VAS) and a functional assessment. Minimum follow-up was 24 months. RESULTS: Preoperative delay was 10.8 months. In seven cases, recovery was M4 for the posterior deltoid, M3 for the middle deltoid and M2 for the anterior deltoid. The elbow was stable, strong and painless (VAS=2). Cocontraction was found. No morbidity was found at the donor site. The last case was a failure. DISCUSSION: In absence of spontaneous recovery, the surgical treatment of deltoid palsy restores a stable strong shoulder and prevents overloading of the rotator cuff. This nerve transfer initially used in brachial plexus surgery gives results comparable to those using grafts, which is the standard treatment of reference avoiding approach of the plexus. The inconvenience is the persistence of cocontractions and a fatigue phenomenon. CONCLUSION: The nerve transfer of the nerve to the long head of triceps to the axillary nerve is the technique of choice for re-innervation of the deltoid.

[Treatment of rheumatoid swan neck deformity by tenodesis of proximal interphalangeal joint with a half flexor digitorum superficialis tendon. About 23 fingers at 61 months follow-up]. / Traitement des déformations des doigts longs en col-de-cygne dans les affections rhumatismales par ténodèse de l'articulation interphalangienne proximale à l'aide d'un hémi-tendon fléchisseur superficiel. À propos de 23 doigts à 61 mois de recul.

OBJECTIVES: Surgical treatment of finger swan neck deformities is versatile. We aimed to assess the outcome of PIP tenodesis on unfixed deformities, in patients suffering from rheumatoid arthritis. METHODS: Twenty-three PIP tenodeses were performed on eight patients, using half of a superficialis flexor digitorum tendon sutured to A2 pulley through a volar approach. Postoperative splinting, in 20° of PIP flexion, was maintained for 4 weeks. The patients were assessed retrospectively, at a mean period of 61 months. RESULTS: The PIP flexion gained 26°. On the other hand, a 4°-flexion contraction was induced. The mean postoperative flexion reached 65°. The PIP hyperextension was corrected by 33°. In one same patient, the correction was insufficient for the four fingers. The DIP lack of extension was totally corrected in 70% of the cases and partially in 30%. Each patient had functional improvement. Nineteen good and excellent, and four fair results were reported. No major complication was observed. CONCLUSION: This tenodesis seems to be reliable and to give good long-term results. It is our intervention of choice for rheumatoid flexible swan-neck deformity.

Idiopathic avascular necrosis of the scaphoid: 10 new cases and a review of the literature. Indications for Preiser's disease.

INTRODUCTION: Avascular necrosis of the scaphoid (Preiser's disease) is a rare entity for which there are no treatment guidelines to date. The aim of this study was to delineate the optimal treatment at different stages of this disease, based on an analysis of the cases treated in our department. MATERIALS AND METHODS: Ten wrists (nine patients) were retrospectively reviewed after a mean 92 months of follow-up. The initial diagnosis was stage II avascular necrosis in four cases, stage III in four cases and stage IV in two cases. These patients were treated by conservative treatment (non surgical) in three cases, vascularized bone graft in two and palliative treatments (proximal row carpectomy or partial fusion) in five. Radiological examination, sometimes completed by MRI, and functional assessment of range of motion, grip strength and Mayo Wrist Score were performed. RESULTS: Completely different results were obtained in the two stage II cases treated by conservative treatment, while functional results improved in the two cases treated by vascularized bone graft with regression of necrosis on MRI. Pain improved following palliative treatment in 4/5 stage III and IV wrists. Functional results were satisfactory with conservative treatment in one stage IV case for 13 years but worsened at the final follow-up assessment. DISCUSSION: A review of the literature, including 126 cases in 29 articles clarified the role of conservative treatment, vascularized bone grafts and proximal row carpectomy in the treatment of avascular necrosis of the scaphoid. Conservative treatment is ineffective in the early stages and nearly always results in disease progression. In contrast vascularized bone grafts can stop or even reverse damage at stage II. Palliative treatment is indicated when facing irreversible lesions. LEVEL OF EVIDENCE: Level IV - Retrospective study.

[Long-term results of surgical treatment of scaphoid non union: influence of the correction of dorsal intercalated segment instability]. / Résultats à long terme du traitement chirurgical des pseudarthroses du scaphoïde : influence de la correction du DISI.

OBJECTIVES: The publications dealing with scaphoid non-union emphasize importance of correction of the Dorsal Intercalated Segment Instability (DISI) to achieve good functional results and to prevent osteoarthritis. The purpose of this study was to assess, over 10 years follow-up, the functional outcomes of 25 patients with scaphoid non-union surgery. X-ray and DISI deformity were assessed. METHODS: Between 1994 and 1998, 53 patients underwent surgery for scaphoid non-union. Over 10 years follow-up, functional evaluation based on pain, QuickDASH and Mayo Wrist Score was performed, and a physical examination including mobility, strength and pain on the region of the scaphoid. Outcomes on X-rays were assessed by searching osteoarthritis damages and by measuring carpal height index and intracarpal angles. RESULTS: Eight patients had pain on the scaphotrapeziotrapezoidal joint without degenerative lesions on radiography. Compared to other patients, they had worse functional results, decrease of scapholunate angle, decrease of the DISI and increase of carpal height. CONCLUSIONS: The correction of the DISI is not always associated with good functional results. Although there were no osteoarthritic changes on the radiography, residual pain may be related to affection of the scapho-trapezo-trapezoidal joint. Surgical treatment with osteotomy of the scaphoid seems to be dangerous because of the moderate impact on function for these patients.

Factors governing the healing of Staphylococcus aureus infections following hip and knee prosthesis implantation: a retrospective study of 95 patients.

INTRODUCTION: The prognostic factors for total hip arthroplasty (THA) and total knee arthroplasty (TKA) Staphylococcus aureus prosthetic joint infections are poorly known, notably because of the heterogeneous management in terms of both antibiotic administration and adopted surgical strategy. Uniform treatment regimens would make it easier to define the outcome of these S. aureus infections. PATIENTS AND METHODS: Between 2001 and 2006, 95 patients with a S. aureus joint infection after THA or TKA were treated, strictly following a standardized protocol according to the recommendations of Zimmerli et al. The patients' mean age was 65.7 years, 71 with THA and 28 with TKA (four patients had two infected joints). These 95 patients presented 120 infectious episodes, all of whom had surgical treatment: 53 lavages (44.1%), 17 one-stage prosthesis revisions (14.2%), 29 two-stage prosthesis revisions (24.2%), and 21 prostheses removed (17.5%). On the intraoperative samples taken, methicillin-sensitive S. aureus (MSSA) was isolated in 88 patients (73.3%) and methicillin-resistant S. aureus (MRSA) in 18 patients (15%); finally 14 patients were included because of the positive results of preoperative samples taken. Twenty-seven infections (22.5%) were multibacterial, including at least S. aureus and 93 were single S. aureus bacteria. Success was defined at a minimum 12 months of follow-up by the association of the following parameters: normal erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) results, noninflammatory scar with no fistula, no surgical revision, and no antibiotic treatment. RESULTS: At a mean follow-up of 38±24.9 months, 81 of the 120 infectious episodes were resolved (67.5%) and 77 of the 95 patients were healed (81%). Six parameters significantly influenced the healing of the infection: initial cementless fixation, THA, preoperative knowledge of the bacterium, immediate postoperative antibiotic therapy adapted to the microbiological data, changing the prosthesis, and monobacterial infection. Only the latter two were independent, with an odds ratio of 5 (1.6-14.9) and 2.9 (1.1-7.7) respectively. However, resistance to methicillin did not appear to be a factor of failure. DISCUSSION: Management of prosthetic S. aureus infections according to a uniform protocol in a specialized medical center healed the infection in 81% of the patients. Treatment improvement requires knowledge of the bacterium, adaptation of immediate probabilistic antibiotic therapy, and preference for changing the prosthesis over simple lavage.

[Rollover hands: classification of injuries and therapeutic strategy]. / «Mains de portière¼: classification lésionnelle et stratégie thérapeutique.

UNLABELLED: The term Rollover hands (ROHs) corresponds to a loss of compound tissue from the back of the hand. Our aim was to specify the injuries associated with this type of accident and codify the therapeutic strategy. PATIENTS AND METHOD: Twenty-one ROHs were reviewed with an average follow-up of 38 months. Skin coverage included 15 pedicle flaps (two posterior interosseous, 13 pedicled groin flaps), and three free flaps (two external brachial or one parascapular). RESULTS: We identified: seven stage IA injuries where the extensor apparatus could be directly sutured; Seven stage IB injuries requiring a tendon graft; Stage II, like stage 1B but with bone and joint lesions or damage to the wrist extensors as well, and Stage III for which over 50% of the intrinsic muscles had been destroyed. All patients recovered their grasp. The mean active extension deficit for each finger was -20.9° for the whole digital chain and a 194.4° TAM. Palmo-digital grip strength was 51.3% on the controlateral side, and the mean DASH score was 16.1. DISCUSSION: Our study demonstrates the prognostic value of the proposed classification and importance of restoring high-quality skin covering. Reconstruction of the extensor apparatus must be envisaged once the condition of the bone and joints has become stable. Vascularised tendon grafts may be indicated when early mobilisation allowing restoration of a glliding surface around the tendon is impossible, or for loss of substance of over 5 cm. Damage to the intrinsic muscles is a very poor prognostic factor.

[Fracture of the distal radius associated with an articular comminutive fracture of the distal ulna: treatment in emergency by osteosynthesis of the radius by volar locking plate for the radius and a resection of the distal end of the ulna: report of one case]. / Fracture à bascule postérieure du radius distal associée à une fracture comminutive articulaire de l'ulna distal: traitement en urgence par ostéosynthèse du radius par plaque verrouillée antérieure et résection de l'extrémité distale de l'ulna: à propos d'un cas.

The authors present a case of a distal radius fracture associated with a comminutive fracture of the ulna head, treated by volar locking plate for the radius fracture and ulnar head resection. We obtain an early good objective and subjective functional result, whereas this type of fracture is classically associated with bad results in the series published with other treatments. This result needs to be confirmed by a more exhaustive series.

Acute grade III and IV acromioclavicular dislocations: outcomes and pitfalls of reconstruction procedures using a synthetic ligament.

INTRODUCTION: Acromioclavicular dislocation (ACD) is frequent, at 8% of all shoulder traumas. Management in grade III lesions remains controversial. The present study assessed objective and subjective results at medium-term follow-up (mean, 60 months; range, 12-120 mo) in 27 patients managed by Ligastic(®) ligament reconstruction for acute dislocation. PATIENTS AND METHODS: This is a multicenter, multi-surgeon retrospective study. Between 1998 and 2006, 59 patients were operated on for grade III or IV ACD, in one teaching hospital (Lille, France) and one general hospital (Tourcoing, France). Follow-up was performed by an independent (non-operator) observer. The 27 acute cases followed up underwent comparative bilateral radioclinical shoulder examination. Initial X-ray assessment found 14 grade-III (52%) and 13 grade-IV (48%) dislocations using Patte's classification. RESULTS: Mean Constant score was significantly lower on the operated side (82.44 vs 90.04; p<0.05). Specific strength analysis, on the other hand, showed no significant difference with the contralateral shoulder. Coracoclavicular distance was significantly greater on the operated side (p<0.05), with and without traction. Periprosthetic osteolysis was found in 24% of cases, and seemed to worsen over follow-up. There were no cases of fracture on osteolysis. There were no cases of sepsis or of implant intolerance. Four patients, however, required surgical revision. CONCLUSION: In light of literature findings and our own experience, surgery is not to be recommended in grade-III ACD, and the authors have given up use of this device in this group due to the rate of associated osteolysis. LEVEL OF EVIDENCE: Level IV.

Swanson-type silastic arthroplasties of the PIP joint for rheumatoid arthritis. Results of 19 implants at 5.3 years of follow-up.

This retrospective study reports the results from 19 PIP Silastic spacers in 11 female patients suffering from inflammatory diseases at a mean of 2.2 and 5.3 years after surgery. The improvement in range of movement decreased with time, evolving from a gain of 18̊ at 2.2 years to only a 4-gain at subsequent follow-up. The fracture rate was high (30%). Objective analysis by physicians reported poor or mild improvements in 75% of cases. Subjective analysis (assessing aesthetics, function and pain) by patients, showed an average score of 5.6/10. At final follow-up, eight out of nine patients did not regret having had surgery. As patients actually hope for pain relief and improved function and quality of life, rather than anatomical recovery, this explains the high acceptability and interest in this rudimentary surgical procedure.

[Avascular necrosis of the capitate: a case report and a review of the literature]. / Ostéonécrose aseptique du grand os et traitement : à propos d'un cas et d'une revue de la littérature.

We report the rare case of a patient with an avascular necrosis of the proximal part of the capitate, with a review of the literature. The patient was treated by a resurfacing prosthesis of the proximal part of the capitate. At 22 month of follow up, the patient had a good functional result. Resurfacing prosthesis is a good therapeutic option in case of proximal capitate avascular necrosis when there is no more place for conservative surgery.