Midterm outcomes of a short-cemented bipolar radial head arthroplasty, in a cohort of 56 cases with minimum 2-years follow-up.

BACKGROUND: Radial head prostheses are used in comminuted radial head fractures for elbow stabilisation when reduction and internal fixation is not possible. Several implant designs exist, but no large series exist about a short-cemented and bipolar implant. HYPOTHESIS: The hypothesis was that this prosthesis design shows good clinical, functional, and radiological results, with acceptable rate of complications. STUDY DESIGN: This retrospective study included the prostheses with bipolar design and short-cemented stem (Evolutive™), with a minimum 2-years follow-up. MATERIALS AND METHODS: All prosthesis implanted in our Traumatology Center were included, with minimum 2-years follow-up. The evaluation consisted of a clinical and functional evaluation, associated with an independent radiographic assessment. All complications were listed, as long as rate and reasons for implant removal. RESULTS: Fifty-six implants were studied with a mean follow-up of 64.9months (24 to 119). Fifty-three cases were acute injuries with 16% isolated radial head fractures and 76% complex elbow injury such as ulno-humeral, radio-ulnar or longitudinal forearm instability. Fifty (89%) implants were still in place at last follow-up. The main reason for implant removal was during arthrolysis procedure. Ranges of motion were: 126° in flexion, 9° of extension loss, 76° of pronation and 79° of supination. Mean Mayo Elbow Performance Index was 84.1 with 72% of excellent or good results, and the median quick-DASH was rated 18.2. Radiographic evaluation found 12% significant ulno-humeral arthtitis, 64% capitellar osteopenia and 12% loosening. We recorded 5% of implant-related complications. DISCUSSION: The short-cemented stem bipolar radial head prosthesis presents clinical and functional results similar to other radial head prosthesis with low incidence of elbow arthritis, when treating both isolated radial head fracture or complexes elbow injury. This implant should therefore be valid for treating comminuted radial head fractures in all types of traumatological injuries. LEVEL OF EVIDENCE: IV; Retrospective cohort study.

Can you maintain a competitive golf swing after total shoulder arthroplasty?

PURPOSE: Return to sports after joint arthroplasty is mainly evaluated for lower limbs procedures. When a return to a specific sport is mentioned, no technical approach nor level consideration are specified. We suggested that patients who undergo total shoulder arthroplasty will be able to maintain playing golf at same high level. METHODS: We performed a retrospective study on active golf players who have undergone shoulder arthroplasty. Inclusion criteria were: (1) over 50 years old (2) handicap < 54 (3) playing golf before the procedure (4) minimum follow-up of 1 year. Patients were divided into two groups: ASA group and RSA Group. A clinical assessment was performed using the following scores: Constant, ASES and QuickDash. RESULTS: Sixty-one patients were retrospectively included in the cohort. Mean age was 69.1 years old. Mean follow-up was 79 months. Preoperative golf frequency and handicap were similar between the two groups. Surgery resulted in significant pain relief in both groups. No difference was shown between the two groups in clinical assessment. Satisfaction rate was 95%. Return to golf time was done progressively from the twentieth week for putting until the twenty-seventh week for playing on the course. Handicap analysis did not show any difference between the level before surgery and the current level in ASA group (23.7 vs. 22.9,p = 0.33) and RSA group (24.2 vs. 23.3,p = 0.63). CONCLUSION: Our study suggested that both patients with ASA or RSA can maintain an active lifestyle with moderate to high frequencies of participation after surgery, particularly in golf. Surgeons can reassure their patients about their recovery and show confidence with regard to their ability to return to a similar golf practice also after RSA. Prospective study with larger cohort is required to confirm the results. LEVEL OF EVIDENCE: Level IV, cases study.

Daily Life Impact of Brachial Plexus Reconstruction in Adults: 10 Years Follow-Up.

PURPOSE: Reconstructive surgery of brachial plexus injury in adults remains a challenge. Short- and midterm follow-up results have been described in terms of impairments, such as muscle strength grading. However, psychologic management has been shown to be a major contributor in long-term results. A new, specific brachial plexus injury scale, including functional and psychologic components, was described. Objectives of this study were: (1) to assess functional long-term brachial plexus reconstruction outcomes; and (2) to validate the Mancuso scale at 10 years of follow-up. METHODS: Twenty patients with at least 10 years of follow-up were included in the study. Four patients had C5-C6 palsy and 16 had a C5-T1 injury. Shoulder abduction and elbow flexion were assessed with Medical Research Council grades. Shoulder function was evaluated with a Constant score. The 36-item short-form survey (SF36) was used to assess quality of life, and the quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) was used for patient reports of disability. The Mancuso scale was assessed and correlated to the different scores used. RESULTS: At the last follow-up, the Medical Research Council grade was at least grade 3 in 10 cases (50%) of shoulder abduction and in 12 cases (60%) of elbow flexion. The Constant score was 31.4 (SD, 15.1). The SF36 score was 67.5 (SD, 4.25) and the QuickDASH was 50 (SD, 15.9). We found a correlation between the symptom score (Mancuso score) and the different quality-of-life scores (QuickDASH: coefficient, 0.491; SF36: coefficient, -0.565; limitations score: coefficient, 0.445). CONCLUSIONS: This study reported results from the Mancuso scale at a minimum of 10 years of follow-up of reconstructive surgery for brachial plexus injury in adults. Correlations between this composite scale and the SF36 and QuickDASH scores suggest construct validity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Hand wounds: An analysis of topography and related damage to underlying structures.

INTRODUCTION: Hand wounds account for 35 to 51% of hand traumas. Damage to underlying anatomical structures depends on the location of the wound. The objective of this study is to describe the topographic distribution of hand wounds allowing for subsequent evaluation of the link between affected surface area and underlying lesion. METHODS: We retrospectively reviewed the medical records of 1058 patients with a total of 1319 wounds over a period of 2 years. Wound location was described according to the cutaneous projection of IFSSH zones for flexors and extensors. Any associated deep lesions were evaluated. Topographical distribution was modeled graphically using a heat-map. We compared the proportion of underlying lesions between each cutaneous zone. Sub-group analysis for lesions' rate regarding zone groups were performed. RESULTS: 58.9% of wounds were located on the palmar surface and 41.1% on the dorsal surface. 71% of wounds affected only the digits. The index finger was the most affected. The most damaged region was zone 2 for palmar wounds and zone 3 for dorsal wounds. 45.5% of wounds resulted in injury to a significant underlying anatomical structure. This frequency was 36.4% and 58.5% for palmar and dorsal wounds respectively. More than 50% of wounds in palmar zone 5 and dorsal zones 1, 3, 5, 6 and 7 presented at least one lesion. A lesion of major structure was more frequently found in palmar zone 5 (p <0.001). Dorsally, no zone predominated. Subgroup analysis for dorsal wounds revealed that wounds overlying joints had more major lesions including more tendons injuries and more articular violations with zone 3 presenting a rate of 68%. CONCLUSION: We provided the first graphical representation for the topographical distribution of hand wounds. Dorsal wounds have a higher association with injury to underlying structures. These results generally support surgical exploration of all hand wounds regardless of their location. LEVEL OF EVIDENCE: IV Study type: Epidemiological study.

Clinical results after surgical resection of benign solitary schwannomas: A review of 150 cases.

INTRODUCTION: Peripheral nerve schwannomas are the most common nerve tumors. While they are efficiently treated with surgery, the risk of neurological complications, especially sensory deficits, remains debated. HYPOTHESIS: We postulate that rates of post-operative sensory deficits in peripheral schwannoma surgery are low and are not increased in schwannomas of the hand, in which preservation of discriminative tact is of prime functional importance. MATERIALS AND METHODS: A retrospective multicenter study was carried out on 150 patients with an isolated peripheral schwannoma operated between 2002 and 2018, including 11 patients with schwannomas of the hand. All cases were reviewed preoperatively and postoperatively with a detailed exam of the neurological status. RESULTS: Most schwannomas were located in the lower limbs (58%). The two main affected trunks were the posterior tibial nerve in the lower limb and the median nerve in the upper limb. The average preoperative tumor volume measured on MRI was 2.93 cm3 [0.11 cm3-25 cm3]. The most common preoperative symptoms were paresthesia (77.1%) and pseudo-Tinel sign (55.7%). Less frequently, pain (50.3%) and hypoesthesia (18.1%) were observed. On the other hand, preoperative neurological motor manifestations remained exceptional (3.3%). The rates of new post-operative motor deficits, paresthesias, and sensory deficits were 4.6%, 10.9% and 8% respectively and were not increased in schwannomas of the collateral nerves of the hand. CONCLUSION: Surgical resection is a safe procedure for peripheral nerve schwannoma treatment with satisfying functional results and an acceptable risk of nerve injury, especially for sensory function. LEVEL OF PROOF: D; Multicenter retrospective study.

Atypical Presentation of Juvenile Hyaline Fibromatosis of Hands.

Juvenile hyaline fibromatosis is a rare disorder characterized by an extracellular accumulation of hyaline deposit. In the extremities, lesions may remain quiescent or gradually increase in size, eventually resulting in skin ulceration. There is no curative treatment. Surgery may allow some recovery of function, but recurrence is possible. We report a case of juvenile hyaline fibromatosis in both hands of a 25-year-old man who required multiple surgical procedures to address problems with function, pain, and appearance.

Rare Case of Dynamic Thoracic Outlet Syndrome Resolved by an Isolated Subclavius Posticus Muscle Resection: A Case Report.

CASE: We reported a dynamic neurogenic left thoracic outlet syndrome (TOS) with a permanent abduction of the fifth left finger. Preoperative magnetic resonance imaging (MRI) assessed the presence of subclavius posticus muscle (SPM). Because of a nonoperative treatment failure, we performed a brachial plexus neurolysis and SPM resection. Immediate postoperative assessment showed an immediate disappearance of the Wartenberg sign. CONCLUSION: SPM constitutes an underestimated cause of TOS. A careful MRI reading is necessary to make correct diagnosis. Nonoperative treatment includes physiotherapy and can be proposed in first instance. When nonoperative treatment fails, brachial plexus exploration with release of the SPM may result in resolution of symptoms.

Complete Fasciotomy Using a Radial Approach for Acute Forearm Compartment Syndrome: A New Technique.

Acute forearm compartment syndrome is damaging but rare. Early treatment reduces mid and long-term sequelae. The palmar compartment is most frequently involved but the dorsal compartment and mobile wad are also at risk. Multiple fasciotomies approaches have been described but are associated with long-term complications. In particular, wound management is important. Mini-invasive techniques are not available for acute forearm compartment syndrome. Acute leg release via a single approach has been developed and proven effective. Likewise, we present a lateral S-shaped approach for fasciotomies of the 3 forearm compartments in the case of acute forearm compartment syndrome.

WITHDRAWN: Midterm outcomes of a short cemented bipolar radial head arthroplasty, in a cohort of 56 cases with minimum 2-years follow-up.

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High-resolution sonographic study of the communicating branch of Berrettini: an anatomical feasibility study.

Sensory changes are common manifestations of nerve complications of carpal tunnel surgery. Division or contusion of a superficial communicating branch between the median nerve and the ulnar nerve, the communicating branch of Berrettini, can explain these symptoms. The aim of this study was to describe the potential value of high-resolution sonography to examine this branch. We conducted a study on eight fresh cadaver hands. An ultrasound assessment of the communicating branch of Berrettini, accompanied by an injection of methylene blue, was performed by a senior radiologist. Subsequent dissections confirmed that the eight guided ultrasound injections allowed the methylene blue to be placed around the origin and termination of the communicating branch of Berrettini. This study extends the limits of ultrasound both in the postoperative diagnosis of potential nerve complications and its possible use in ultrasound-guided carpal tunnel release.

Natural history of peripheral nerve schwannomas.

BACKGROUND: Little information about the natural history of peripheral nerve schwannomas exists in the literature. The aim of this study was to determine the natural history of those tumors both in sporadic and schwannomatosis cases to determine their growth rates and patterns. METHODS: In 44 patients from 3 surgical centers, hospital charts, follow-up records, and imaging studies were reviewed. Of these patients, 7 had sporadic schwannomatosis. Histological diagnosis was obtained in 37 patients (84%). Tumor growth rates were determined by calculating the absolute and relative growth rates. RESULTS: On the 47 tumors analyzed, the median tumor size at diagnosis was 1.8 cm3, and the majority of tumors were located in the lower limb (62%). The absolute growth rate ranged from - 1.13 to 23.17 cm3/year (mean, 1.69 cm3/year). Relative annual growth rates ranged from - 9 to 166%/year (mean, 33.9%/year). There was no clear correlation between initial tumor size, age at diagnosis, and tumor growth rate. Six patients (13%) harbored "fast-growing" tumors (absolute growth rate > 2 cm3/year and relative growth rate > 35%/year) while 19% of tumors demonstrate no growth or negative growth. In schwannomatosis patients, each tumor displayed a distinct growth pattern. CONCLUSION: This study confirms the slow-growing nature of most, but not all, peripheral nerve schwannomas. Additional studies are mandatory to explore the environmental factors influencing growth in sporadic cases and the precise growth patterns in schwannomatosis cases to detect the rare cases of malignant transformation and pave the way to the evaluation of future clinical trials.

Impact of the COronaVIrus Disease 2019 lockdown on hand and upper limb emergencies: experience of a referred university trauma hand centre in Paris, France.

PURPOSE: The lockdown imposed in France to cope with the COronaVIrus Disease 2019 (COVID-19) outbreak has led to major changes in the lifestyle of French citizens. The aim of our study was to study its impact on activity related to emergencies in hand and upper limb trauma in comparison to the same reference period in 2019. MATERIAL AND METHODS: All consecutive patients consulting for upper limb injury requiring urgent care at Georges-Pompidou European Hospital (HEGP), France, during the lockdown period (case group) and the equivalent period in 2019 (control group) were included. In each group, the type of accident, the anatomical location of the injury, and the treatment were reported and compared. RESULTS: Two hundred seventy-five patients were included in the case group in comparison to 784 patients in the control group. We observed a two-third decrease in the rate of upper limb emergencies (- 64.9%) in particular a drastic drop in the rate of road, work, and leisure accidents (10.4% vs 14.3%, p = 0.1151; 10.0% vs 22.6%, p < 0.0001; 13.1% vs 30.8%, p < 0.0001, respectively), and a clear increase in domestic accidents (66.5% vs 32.3%, p < 0.0001). The aetiologies were more dominated by lacerations of soft tissues (48.4%, vs 38.3%, p = 0.0034) and infections (8.7% vs 5.1%, p = 0.0299) with an increase in the indications for surgical management (51.2% vs 36.9%, p < 0.0001). Conversely, we observed fewer consultations for joint injuries (20.7% vs 30.7%, p = 0.0015) and fractures (22.2% vs 25.9%, p = 0.2210). CONCLUSION: The lockdown imposed in France has changes the etiologies and the management of hand and upper limb emergencies.

Double-Nerve Transfer to the Axillary Nerve in Traumatic Upper Trunk Brachial Plexus Injuries Using an Axillary Approach: Anatomical Description and Preliminary Case Series.

BACKGROUND: Restoration of shoulder external rotation remains challenging in patients with C5/C6 brachial plexus injuries (BPI). OBJECTIVE: To describe a double-nerve transfer to the axillary nerve (AN), targeting both its anterior and posterior motor branches, through an axillary route. METHODS: A total of 10 fresh-frozen cadaveric brachial plexuses were dissected. Using an axillary approach, the infraclavicular brachial plexus terminal branches were exposed, including the axillary, ulnar, and radial nerves. Under microscopic magnification, the triceps long head motor branch (TLHMB), anteromedial fascicles of the ulnar nerve (UF), the anterior motor branch of the axillary nerve (AAMB), and the teres minor motor branch (TMMB) were dissected and transected to simulate 2 nerve transfers, THLMB-AAMB and UF-TMMB. Several anatomical criteria were assessed, including the overlaps between fascicles when placed side-by-side. Six patients with C5/C6 BPI were then operated on using this technique. RESULTS: TLHMB-AAMB and UF-TMMB transfers could be simulated in all specimens, with mean overlaps of 37.1 mm and 6.5 mm, respectively. After a mean follow-up of 23 mo, all patients had recovered grade-3 strength or more in the deltoid and teres minor muscles. Mean active shoulder flexion, abduction, and external rotation with the arm 90° abducted were of 128°, 117°, and 51°, respectively. No postoperative motor deficit was found in the UF territory. CONCLUSION: A double-nerve transfer, based on radial and ulnar fascicles, appears to be an adequate option to reanimate both motor branches of the AN, providing satisfactory shoulder active elevations and external rotation in C5/C6 BPI patients.

Total Elbow Arthroplasty in an Older Patient with a Forearm Amputation: A Case Report in a Spastic Elbow.

INTRODUCTION: Total elbow arthroplasty is a common procedure in older patients after comminuted distal humerus fractures. However, in patients with a forearm amputation, this treatment indication is less obvious. CASE REPORT: We report the case of an older spastic patient with bilateral forearm amputation for whom we performed a total elbow arthroplasty for a complex left distal humerus fracture. At 1 year follow-up, our patient was satisfied with the outcome as she had recovered her previous range motion and autonomy. There was no sign of implant loosening or migration on radiographs. CONCLUSIONS: Given that this treatment has the same benefits as in the typical target population and that any complications that may occur could be less devastating in a patient with forearm amputation. We think that elbow arthroplasty should be offered, in case of complex articular fracture, to all older patients with forearm amputation who has functional demands.

Atypical Localization of Calcific Shoulder Tendinopathy: Humeral Insertion of the Pectoralis Major.

INTRODUCTION: Calcific tendinopathy of the pectoralis major at its humeral insertion is extremely rare. Few cases have been reported in the literature. We reported a unique case of calcification of the pectoralis major insertion site and conducted a review of the existing literature to propose standardized management. CASE PRESENTATION: We reported a case of a 63-year-old lady, right-handed, non-smoker, homemaker without any history of trauma or symptoms suggestive of para-neoplasia syndrome. For 1 month, the patient presented severe, disabling pain of the left shoulder which occurred spontaneously, usually in the morning and after effort. The patient had painful passive terminal adduction and internal rotation. There was no neurovascular deficiency. Magnetic resonance imaging and computed tomography (CT) scan helped diagnose the calcific tendinopathy at the pectoralis major humeral insertion. Non-surgical management was performed, combining physiotherapy and painkillers. Two months' control, CT scan reported complete calcification resorption. The biologic assessment revealed hyperparathyroidism. CONCLUSION: This rare and atypical localization can mislead the surgeon. A biological assessment to research a systemic etiology is mandatory and standardized. A biopsy is not required, radiological examinations are sufficient. Surgical treatment may be proposed in specific cases to shorten the necessary rehabilitation time.

Direct transfer of C7 pectoral fascicles to the suprascapular nerve in C5/C6 brachial plexus palsies: an anatomical study.

We investigated a technique to reconstruct the suprascapular nerve in patients with C5/C6 brachial plexus palsies, using pectoral fascicles from the ipsilateral C7 root. Using a supraclavicular approach in eight cadavers, the suprascapular nerve was placed side by side with an anterior quadrant fascicle from the C7 root. Several criteria were assessed, including the fascicle length, the overlap between the two nerves and their respective diameters. The mean length of the C7 fascicles was 19.3 mm, with a mean overlap of 4.7 mm. The suprascapular nerve and the C7 fascicles had mean diameters of 2.2 mm and 2.1 mm, respectively. Pectoral fascicles from C7 seem to be an option for reconstruction of the suprascapular nerve in C5/C6 palsies. Clinical studies will be required to establish the potential limitations of this transfer, especially in cases with complex lesions of the suprascapular nerve.

Distal sensory disorders in Dupuytren's disease.

PURPOSE: Dupuytren's disease is a common and disabling condition. Its pathophysiology is not well understood. Some patients complain of postoperative loss of fingertip sensitivity that could be due either to the surgery or to the disease itself. Our hypothesis is that distal sensory disorders are a component of Dupuytren's disease. METHODS: We performed a prospective, single-center study to compare two populations: controls and patients with Dupuytren's disease. Subjects were excluded if they were under 18 years of age or had any disease or treatment that could alter finger sensitivity or test comprehension. Sensitivity was determined using Weber's static two-point discrimination test. Each ray of the tested hand in the Dupuytren's patients was classified as healthy or diseased; the diseased rays were graded using the Tubiana stages and the type of involvement (pure digital, pure palmar, palmar-digital). RESULTS: The study enrolled 56 patients in two comparable groups of 28 patients and 28 controls. A statistically significant difference was found between the affected hands of Dupuytren's patients and the hands of the controls. There was also a significant difference in the mean sensitivity of affected and normal rays in the Dupuytren's patients. CONCLUSION: Preoperative distal sensory disorders are a component of Dupuytren's disease that could be related to neuropathy and/or mechanical nerve compression. LEVEL OF EVIDENCE: IV, case-control study, diagnostic study.

All-Endoscopic Resection of an Infraclavicular Brachial Plexus Schwannoma: Surgical Technique.

Due to recent progress in shoulder arthroscopy, all-endoscopic brachial plexus (BP) dissection has progressively become a standardized procedure. Based on previously described techniques, we present an additional neurological procedure that may be performed all-endoscopically, that is, the excision of an infraclavicular BP schwannoma. Starting from a standard shoulder arthroscopy with posterior and lateral portals, additional anterior and medial portals are progressively opened outside the joint under endoscopic control to access the BP. At first, dissection of the subcoracoid space allows the identification of the posterior and lateral cords, along with the axillary artery. Then, by performing a pectoralis minor tenotomy, the medial cord and axillary vein are exposed, giving access to the whole infraclavicular plexus. Intraneural dissection is performed using arthroscopic tools such as a long beaver blade, a grasper, and a smooth dissector to progressively extract the encapsulated tumor from the nerve without any damage. Using a standardized technique, endoscopy may be an advantageous tool in selected cases of BP benign peripheral nerve sheath tumors.