Stress shielding following radial head arthroplasty: the impact of preoperative bone quality.

INTRODUCTION: We sought to assess if the medullary diameter to cortical width ratio (MD:CW), canal flair index (CFI), and canal fill (CF) of the proximal radius were associated with the presence of Stress shielding (SS) after a MoPyC radial head arthroplasty (RHA). MATERIAL & METHOD: We conducted a retrospective, international, multicenter (4 centers) study. A total of 100 radial head arthroplasties in 64 women and 36 men with a mean age of 58.40 years ±14.90 (range, 25.00; 91.00) were included. Radiographic measurements, including MD:CW, CFI, CF, and postoperative SS were captured at a mean follow-up of 3.9 years ±2.8 (range, 0.5-11). RESULTS: Stress shielding was identified in 60 patients. Mean preoperative MD:CW, CFI, and CF were 0.55 ±0.09, 1.05 ±0.18 and 0.79±0.11, respectively. The presence of SS was significantly associated with MD:CW (aOR=13.66; p=0.001), and expansion of the stem (aOR=3.78; p=0.001). The amount of the SS was significantly correlated with expansion of the stem (aß 4.58; p<0.001). CONCLUSIONS: Our study found that MD:CW was an independent risk factor of SS after Mopyc RHA. Patients with longer and larger diameter (auto-expansion) Mopyc stems were also at significantly increased risk of SS. Further studies involving multiple implants designs are needed to confirm the preliminary observations presented in the current study.

[Hand accident prevention]. / Prévention des accidents de la main.

HAND ACCIDENT PREVENTION. Advances in surgical techniques and a better organization with SOS mains structures have improved the management of hand injuries. However, there are still too many accidents, which can lead to functional and aesthetic after-effects, as well as their socio-professional consequences. The prevention of hand injuries is therefore mandatory. It is organized with three levels: primary prevention, that aims to prevent the occurrence of the accident itself; secondary prevention, to guide and provide the best emergency care for the patient; and tertiary prevention, to avoid deprofessionalization and provide support for any physical and psychological after-effects.

PREVENTION DES ACCIDENTS DE LA MAIN. Les progrès des techniques chirurgicales et l'organisation en services SOS mains ont contribué à améliorer la prise en charge des accidents de la main. Ceux-ci restent cependant nombreux et peuvent entraîner des séquelles fonctionnelles, esthétiques et avoir des conséquences socioprofessionnelles. La prévention des accidents de la main est donc fondamentale. Elle s'organise en trois volets : la prévention primaire pour éviter la survenue de l'accident, la prévention secondaire pour orienter et prendre en charge au mieux le patient, et la prévention tertiaire afin d'éviter une déprofessionnalisation et accompagner les séquelles physiques et psychologiques éventuelles.

The initial treatment of complex proximal humerus fracture affects the outcome of revision with reverse shoulder arthroplasty.

PURPOSE: The purpose of the study is to report the results of reverse shoulder arthroplasty (RSA) after three types of initial treatment performed for complex proximal humeral fracture (PHF): conservative, reduction and internal fixation (RIF), or hemiarthroplasty. METHODS: This is a retrospective study of 63 patients separated into three groups with a minimum follow-up of two years. Group I included 25 patients with an initial conservative fracture treatment, group II included 25 patients treated by RIF, and group III included 13 patients initially treated by hemiarthroplasty. Patients were assessed using the absolute Constant-Murley score, functional parameters, complications rate, and radiological follow-up. RESULTS: One patient died and five were lost to follow-up. All functional outcomes improved significantly post-operatively for the three groups (p < 0.005). The mean Constant-Murley score increased from 13.7 to 54.1 (group I); 16.6 to 48.5 (group II); and 22.6 to 48.2 (group III) (p < 0.001). The gain of Constant-Murley and SST scores was better for group I (p = 0.049 and 0.028, respectively), while post-operative pain was better in group III (p = 0.033). The complication rate was 38% in group III, 30% in group II, and 14.3% in group I. CONCLUSIONS: Reverse shoulder arthroplasty represents a good surgical option in complex proximal humeral fracture sequelae. Whatever the initial treatment, function and motion of the shoulder are improved. The final result is better if the initial treatment was conservative. The group initially treated with hemiarthroplasty had the most complications.

Bony defects in chronic anterior posttraumatic dislocation of the shoulder: Is there a correlation between humeral and glenoidal lesions?

BACKGROUND: The prevalence of combined humeral and glenoid defects varies between 79 and 84 % in case of chronic posttraumatic anterior shoulder instability. The main goal of this study was to evaluate the relationship between humeral and glenoid defects based on quantitative radiological criteria. METHODS: A retrospective study was performed between 2000 and 2011 including patients who underwent primary surgical shoulder stabilization for chronic posttraumatic anterior shoulder instability, with bone defects in both the glenoid and humerus and a healthy contralateral shoulder. The following measurements were taken: D/R ratio (Hill-Sachs lesion depth/humeral head radius) on an AP X-ray in internal rotation and the D1/D2 ratio [diameter of the involved glenoid articular surfaces (D1)/the healthy one (D2)] on a comparative Bernageau glenoid profile view. Measurements were taken by two observers. Correlations were determined by the Spearman correlation coefficients (r), Bland and Altman diagrams, and intra-class correlation coefficients (ICC). A sample size calculation was done. RESULTS: Thirty patients were included, 25 men/5 women, mean age 29.8 ± 11.2 years. The mean D/R was 23 ± 12 % for observer 1 and 23 ± 10 % for observer 2. The mean D1/D2 was 95 ± 4 % for observer 1 and 94 ± 6 % for observer 2. No significant correlation was found between humeral and glenoid bone defects by observer 1 (r = 0.23, p = 0.22) or observer 2 (r = 0.05, p = 0.78). Agreement of the observers for the D/R ratio was excellent (ICC = 0.89 ± 0.04, p < 0.00001) and good for the D1/D2 ratio (ICC = 0.54 ± 0.14, p = 0.006). CONCLUSION: Humeral and glenoid bone defects were not correlated. Inter-observer reliability was excellent for the D/R ratio and good for the D1/D2 ratio. LEVEL OF EVIDENCE: Nonconsecutive Patients, Diagnostic Study, Level III.

Universal Dorsal Approach of the Wrist.

The ideal dorsal wrist approach has to provide the best exposure while preserving sensitive dorsal nerve branches, dorsal veins, and skin integrity. Longitudinal incision is mostly used in the wrist surgery. Few anatomic or clinical studies have described transverse dorsal approach following Langer's lines. We present a universal transversal skin incision, the design of which meets the requirements of a dorsal wrist approach. It is adjustable with the radial and ulnar extension and respects Langer's lines, nerves, and veins. We conducted both an anatomic, clinical, and a retrospective study. For the anatomic part, we performed a cadaveric study on the wrist. For the clinical part of the study, we analyzed clinical results for 10 consecutive patients who underwent a universal dorsal wrist approach for various surgical procedures by the same surgeon. For the last part, we reviewed the patients operated during the past 5 years with this approach for different procedures in the wrist.

Transfer of the clavicular or sternocostal portion of the pectoralis major muscle for irreparable tears of the subscapularis. Technique and clinical results.

PURPOSE: The transfer of the pectoralis major in cases of irreparable rupture of the subscapularis has been described through different techniques. The aim of this prospective study was to compare the clinical results of transferring the clavicular or the sternal head of the pectoralis major tendon underneath the conjoint tendon. METHODS: Fifteen patients underwent the procedure, including eight clavicular head of the pectoralis major tendon transfers and seven sternal head transfers. The mean age at the time of surgery was 57 years (range, 37-66). Each patient had pre-operative MRI and CT scan. The criteria for an irreparable subscapularis tear were retraction at the level of the glenoid and fatty infiltration of the muscle graded III or IV. Pre-operative and postoperative functions were assessed by the Constant score. Patients were finally asked if they were very satisfied, satisfied or unhappy with the functional outcome. RESULTS: The average follow-up was 24 months (range, 12-50). The mean absolute Constant score of the entire series increased significantly from 36 preoperatively to 69 at the latest follow up (p < 0.01); it improved significantly and similarly in both types of tendon harvested. Nine patients were very satisfied, three were satisfied and three were dissatisfied with the clinical outcome. CONCLUSION: A clavicular or a sternocostal head transfer of the pectoralis major under the coracoid process reduced pain, and improved the strength and function of the shoulder.