Study of the position of six volar locking plates for distal radius fracture relative to the watershed line.

INTRODUCTION: Volar plate malpositioning in the treatment of distal radial fracture can lead to tendinitis or even tendon tear, especially when the plate position is very distal. We studied the impact of design on plate position in the distal radius. The primary aim was to compare the position of six volar wrist plates relative to the watershed line using the Soong classification. The secondary objectives were to assess the epidemiology of volar locking plate fixation within the administrative Département of Finistère (northwestern France) and to study whether the type of fracture played a role in plate position. HYPOTHESIS: The plate design itself influences positioning relative to the watershed line on the Soong classification. MATERIALS AND METHODS: A total of 2723 volar locking plate fixation cases were analyzed and categorized according to the Soong classification. Plates used were divided into six groups based on design: Zimmer Biomet®, Newclip Technics®, Stryker®, Synthes®, Medartis® and Medartis® Footprint. The number of Soong 0 + 1 plates (i.e., plates graded 0 and 1 taken together) was determined for each design, then compared using the Marascuilo procedure with a significance level of α = 0.05. RESULTS: On the Marascuilo procedure, we found significant differences in the number of Soong grade 0 + 1 plates. The Zimmer Biomet and Newclip Technics® plates were significantly more often proximal to the watershed line than the Synthes and Medartis Footprint plates. Plate position with the Medartis® design was significantly more proximal to the watershed line than for its companion design, the Medartis® Footprint plate. The rate of volar locking plate fixation of distal radial fractures over the past 10 years increased in Finistère. Also, the type of fracture affected the choice of plate when different designs were available within a hospital center (Medartis® Footprint plate used in 2R3A fractures). CONCLUSION: Our study highlights a significant difference in volar locking plate position relative to the watershed line between the various models available. Plate design is a deciding factor when treating distal radial fracture, to avoid impingement when implant removal is not routinely planned.

Post-traumatic total wrist arthrodesis: Satisfaction study of 42 cases at a mean 97months' follow-up.

INTRODUCTION: Total wrist arthrodesis is effective in reducing pain in osteoarthritic wrist, but at the cost of range of motion. The aim of the present study was to assess patient satisfaction after post-traumatic total wrist arthrodesis, complications and risk factors. HYPOTHESIS: Post-traumatic total wrist arthrodesis provides a high rate of satisfaction. PATIENTS AND METHODS: A single-center retrospective observational satisfaction survey was carried out for the period 2005-2020 by telephone interview. RESULTS: Forty-two post-traumatic dorsal plate total wrist arthrodeses were included. Mean follow-up was 97 months. Total arthrodesis achieved a mean 75% reduction in pain, with good functional results (QuickDASH: 23±9.1 [11-42]) and satisfaction (83% of patients very satisfied or satisfied). Seventy-two percent of patients continued in their previous work. The complications rate was 48%. Twenty patients had complications, including 14 (33%) requiring surgical revision. Thirteen patients (31%) had hardware removed due to plaque discomfort and 1 due to bone and joint infection. Seven patients showed CRPS. CONCLUSION: Total wrist arthrodesis provided good results in terms of pain relief and satisfaction, at the cost of loss of motion. It is a reliable surgical technique, with an essential place in the therapeutic algorithm for post-traumatic osteoarthritic wrist, particularly in manual workers. LEVEL OF EVIDENCE: IV, single-center retrospective observational study.

Feasibility of the abductor pollicis longus hemitendon transfer for thumb opposition: An anatomical study.

INTRODUCTION: The abductor pollicis longus (APL) presents two muscle bellies and multiple accessory tendons available for transfer, amongst these an accessory tendon inserting on the thenar aponeurosis (APLTh). Edgerton described an opponensplasty using the whole APL tendon, but its results were limited due to the short size of the donor tendon. HYPOTHESIS: The purpose of this study is to assess the feasibility of transferring the APLTh for thumb opposition. MATERIAL AND METHODS: Eleven cadaver upper limbs were dissected to assess the presence of the two heads of the APL as well as their main and accessory tendon insertions. The accessory tendon of the APL inserting on the thenar aponeurosis (APLTh) was harvested with a slip of the thenar aponeurosis. The length of the transplant, the number of tendon slips and their location, as well as pre and postoperative radial and palmar abduction provided by the APL were assessed. RESULTS: The APL was present in all cadavers whereas its insertion on the thenar aponeurosis was absent in 18% of the cases. When the APLTh was present and could be used for opponensplasty, the mean gain in palmar abduction was 16 degrees, and the mean loss in radial abduction was 21 degrees. DISCUSSION: Although the experiments revealed a variability in APL anatomy, when present, the APLTh represents a suitable donor for the restoration of thumb opposition. In some cases of high median nerve palsies, thumb opposition can't be restored using median innervated muscles. In these cases, when the APLTh is present, it can be used to restore thumb opposition without functional loss. LEVEL OF EVIDENCE: IV; anatomical feasibility study.

WALANT for hand wound exploration in isolated conditions: Feasibility study.

INTRODUCTION: Military doctors usually deal with hand wound management. Their practice sometimes takes them far from any specialized surgical center. The WALANT could be a powerful tool for doctors operating in nuclear submarines or as part of special forces. This is a comparative, prospective and multicenter study. The hypothesis was that the management of hand wounds by military doctors specifically trained in WALANT and in the surgical exploration of hand wounds allowed a diagnosis as effective as in the FESUM center. PATIENTS AND METHODS: Military doctors, usually operating in isolated conditions, were trained at WALANT. Then, this method was used for the exploration of hand wounds in the emergency room, in a center outside FESUM. At the end, two different questionnaires were completed respectively by the patient and the operator. They aimed to assess various criteria such as the overall satisfaction of the patient and the operator, the level of pain felt or the ability of the operator to establish a precise lesion assessment. The results were compared with those obtained under the same conditions by hand surgeons in the FESUM centre. RESULTS: No significant difference was found between the two centers in terms of diagnostic capacity, satisfaction, comfort and perceived pain intensity. DISCUSSION: Under cover of prior training, the WALANT is effective for the exploration of hand wounds by submariner doctors and members of the special forces. Its use makes it possible to establish a precise injury report and this in material and human conditions approaching as closely as possible those of the armed forces on mission. The comfort of the patient remains preserved. CONCLUSION: The WALANT represents an effective tool for the exploration and lesion assessment of hand wounds outside the FESUM centre. Since emergency conditions are similar to those encountered in operational conditions, its use is also possible in situations specific to military doctors: nuclear submarines, special forces on mission. LEVEL OF EVIDENCE: III; comparative study, retrospective, multicentre.

Long-term outcomes of trapeziectomy with Gore-Tex® ligament reconstruction for trapezio-metacarpal osteoarthritis.

BACKGROUND: Trapezio-metacarpal osteoarthritis is a common condition for which the reference standard treatment after failure of non-operative measures is trapeziectomy. Several techniques have been devised to avoid proximal migration of the first metacarpal bone (M1) with impingement on the scaphoid bone. We have developed a Gore-Tex® ligament reconstruction technique that avoids potential complications of tendon harvesting. The objective of this study was to assess the long-term outcomes of this technique. HYPOTHESIS: Trapeziectomy with Gore-Tex® ligament reconstruction is a reliable option for providing lasting pain relief in patients with trapezio-metacarpal osteoarthritis. MATERIALS AND METHODS: We conducted an observational, single-centre, single-surgeon, retrospective cohort study in consecutive patients managed by primary trapeziectomy. We excluded patients with revision trapeziectomy or less than 10 years' follow-up. The primary outcome was event-free survival, defined as absence of revision surgery and of a numerical rating scale score for pain above 3/10. The secondary criteria were clinical tolerance of the Gore-Tex® implant and radiological changes. The patients were assessed at last follow-up either in person or during a teleconsultation. RESULTS: Of 78 included joints, 64 were assessed during patient visits and 24 by teleconsultation. At 10 years, the event-free survival rate was 91.3%, and 60.3% of patients were free of pain. Evidence of osteolysis was visible in 24% of patients. No patient experienced clinical intolerance of the Gore-Tex® implant. The mean Disabilities of Arm, Shoulder and Hand score was 25.5. Metacarpo-phalangeal hyperextension was significantly increased, to 30.6°, and the mean trapezial space ratio was significantly decreased, to 39.1% of the baseline value. CONCLUSION: Long-term event-free survival was high. Functional outcomes and pain were similar to previous reports. Trapeziectomy with Gore-Tex® ligament reconstruction obviates the need for tendon harvesting. Osteolysis developed in some patients but did not correlate with clinical intolerance. Long-term clinical and radiological monitoring is in order after Gore-Tex® implantation. LEVEL OF EVIDENCE: IV, Observational, single-centre, single-surgeon, retrospective cohort study.

Does total wrist denervation give reliable long-term results? Survival curve with an average follow-up of 8.2 years.

INTRODUCTION: Pain is the main reason why patients consult for degenerative and posttraumatic wrist conditions. While the many surgical techniques make choosing the appropriate procedure difficult, total wrist denervation, which has an "analgesic" aim, remains an accessible therapeutic solution to treat this symptomatology. Nevertheless, long-term results remain controversial, and few studies have focused on the survival of this procedure. HYPOTHESIS: Total wrist denervation provides lasting pain relief. PATIENTS AND METHODS: This was a single center, single operator (DLN), retrospective observational study. We analyzed 63 wrists. The mean age at the time of the procedure was 53.7 years. We verified the primary endpoint for survival, which included no further analgesic procedures and no significant residual pain (NRS≤3). Patient satisfaction and the quality of the wrist function were also assessed. RESULTS: The mean follow-up was 8.2 years. Some of the patients (12.7%) did not respond to treatment. We reported 1 neuroma of the superficial sensory branch of the radial nerve, 2 CRPS and 11 revision surgeries. We observed that the treatment became less effective over time. The median survival was 8.8 years. The survival rate of the procedure fell to 13.5% at the last follow-up. The mean residual pain was 3.4 on a numerical rating scale and the mean DASH score was 23.5. The mean satisfaction level, on a scale from 0 to 10, was 7.3 and most patients (79.6%) would undergo this procedure again. DISCUSSION: Survival of the total wrist denervation at the last follow-up was low in our study. Even though the treatment became less effective over time, the quality of the wrist function remained satisfactory and similar to the different studies previously published on the subject. There were very few complications and revisions. CONCLUSION: Total wrist denervation therefore remains an interesting surgical solution for patients with chronic wrist pain as it preserves mobility. LEVEL OF EVIDENCE: IV; Single center, single operator retrospective observational study.

Ultrasound Ulnar Nerve Measurement in a Healthy Population.

INTRODUCTION: Ulnar tunnel syndrome at the elbow is a common pathology. The ultrasound cross-sectional area is a well-known metric widely accepted in radiology for the description of nerve entrapment. However, the pathological cut-off value remains challenging. The objectives of this study were to (1) describe the ultrasound cross-sectional area measurement of the ulnar nerve at three locations, and (2) to evaluate the inter-observer reliability by two independent ultrasonographers. METHODS: One-hundred ulnar nerves of 50 asymptomatic individuals were scanned using B-mode and power Doppler ultrasonography. The ultrasound cross-sectional area measurements of the ulnar nerve were performed at three different levels: 2 cm proximal to the epicondyle, at the level of the epicondyle, and 2 cm distal to the epicondyle. RESULTS: In our healthy population, we found 21, 24 and 7% of ultrasound cross-sectional area ulnar nerve > 8 mm2, respectively, at three different levels of measurement and 4, 7, and 0% US-CSA ulnar nerve > 10 mm2. The intraclass correlation coefficient measured at three different site levels were good (0.7943, 0.7509) to moderate (0.5701). CONCLUSIONS: Almost one-quarter of our healthy population had an ultrasound cross-sectional area ulnar nerve more than 8 mm2 and few more than 10 mm2. A cut-off of ultrasound cross-sectional area ulnar nerve measurement more than 10 mm2 could be considered as pathological. No abnormal elbow ulnar nerve vascularization has been seen. This is the first step towards normal B-mode ulnar nerve values at the elbow to further detect pathological US findings as ulnar nerve entrapment.

Effect of arthroscopic shoulder release on shoulder mobility and bone deformity following brachial plexus birth injury: a systematic review and meta-analysis.

BACKGROUND: Specific information to guide clinical practice is lacking for the effects of arthroscopic release on bone and joint deformities, as well as the additional benefits of tendon transfer, in children with brachial plexus birth injury. The aims of this study were (1) to evaluate changes in shoulder mobility and bone and joint deformity, (2) to evaluate the effect of release with and without tendon transfer on the same outcomes, and (3) to evaluate the perioperative and long-term complications. METHODS: We conducted a systematic review and meta-analysis. Four databases were searched using relevant inclusion and exclusion criteria from inception until May 2020. The quality of articles was evaluated using the Methodological Index for Non-randomized Studies (MINORS) scale. Data regarding patients, interventions, and clinical and radiologic outcomes were reported. RESULTS: Thirteen articles were included: 6 of low quality and 7 of moderate quality separated into 17 studies (266 children). The mean follow-up duration was 32.4 months (standard deviation, 15.2 months). Arthroscopic release significantly improved the Mallet score (standardized mean difference [SMD], 3.1 [95% confidence interval (CI), 1.5-4.7]; P < .001) and passive external rotation (SMD, 3.6 [95% CI, 2.3-4.9]; P = .02). The percentage of humeral head anterior (SMD, 1.3 [95% CI, 0.7-1.9]; P = .003) and glenoid retroversion (SMD, 1.4 [95% CI, 0.9-2]; P = .01) also improved. Descriptive analysis of the data suggested that concomitant tendon transfer further improved mobility. Recurrence of internal-rotation contracture was reported in 8 of 157 children. DISCUSSION: This systematic review showed that arthroscopic release effectively improves both shoulder mobility and bone deformity, with few complications in young children with brachial plexus birth injury. As such, it seems reasonable to propose a stepwise approach starting with a release without transfer.

Topographic anatomy of structures liable to compress the median nerve at the elbow and proximal forearm.

INTRODUCTION: Several structures liable to compress the median nerve have been described around the elbow and proximal forearm. Signs of deficit justify surgical exploration and decompression by exoneurolysis. Better knowledge of the locations of these structures would ensure reliable and effective exploration. HYPOTHESIS: The study hypothesis was that compressive structures show precise topography, with few variations in distance along the median nerve course. MATERIAL AND METHODS: The study was performed on 36 upper-limb cadaver specimens. The measurement reference level was the humeral bi-epicondylar line. Proximal-to-distal dissection located: (1) Struthers' ligament, (2) the pronator teres bellies (PT) with their anatomic particularities of structure and insertion, (3) the lacertus fibrosus, (4) the fibrous arcade of the flexor digitorum superficialis (FDS), (5) the accessory muscles, (6) the origin of the anterior interosseous nerve (AIN), (7) and the vascular arches. RESULTS: Struthers' ligament was not located, but 1 case of medial bicipital fibrous arcade was found. The lacertus fibrosus crossed the median nerve at +1.5±0.6cm. PT insertion was high in 19 cases (53%). The humeral PT belly was thin in 21 cases (58%), crossing the median nerve more distally (+1.8±0.8cm) than the thicker muscles (+1±1.1cm) (p=0.016). The ulnar PT belly was fibrous in 14 cases (39%). A fibrous arcade was found between the 2 PT bellies in 23 cases (64%). The FDS arcade was located at 4.5-7cm from the bi-epicondylar line. An accessory flexor pollicis longus belly was found in 11% of cases. The AIN origin was at +4±1.6cm from the reference. A vascular pedicle crossed the median nerve in 3 cases. DISCUSSION: The present study inventoried and mapped 6 potentially compressive structures neighboring or crossing the median nerve. Except for the FDS arcade, they showed very precise proximal-to-distal location, with variations of 0.5 to 1.5cm. LEVEL OF EVIDENCE: IV; case series.

Evaluation of the accuracy of the Sureshot® electromagnetic targeting system in distal locking of long-nailed humeral diaphyseal fractures.

INTRODUCTION: Osteosynthesis of humeral diaphyseal fractures by long intramedullary nailing is a widespread practice. Distal interlocking is a delicate and uncertain step in the procedure, and the free-hand method is adopted by most surgeons. We evaluated the accuracy of a magnetic field-guided system for distal interlocking of long intramedullary nailed humeral diaphyseal fractures. HYPOTHESIS: The field magnetic method to interlock distal screws procured satisfying success rates at first attempt in each hole. STUDY DESIGN: Single center, retrospective, descriptive and continuous. MATERIAL AND METHODS: We used the Sureshot® Distal Targeting System (DTS) and the Trigen® (Smith & Nephew) nail. All patients who presented to our center for osteosynthesis of a fracture of the humeral diaphysis by long intramedullary nailing between April 1, 2016 and June 30, 2018 were retrospectively included. RESULTS: The analyses included 32 of the 34 patients who presented during this period (mean age, 64 years). There were 51 attempts to install distal interlocking screws. The screws were interlocked successfully in 40 cases (78.4%), and there were 11 failures (21.6%). There was an average of 29 fluoroscopic views and an average cumulative dose area product of 36.90 cGcm2. DISCUSSION: We found a lower success rate than that found in the literature for the accuracy of Sureshot® DTS in long humeral nailing. We found also a lower success rate than for tibial and femoral centromedullary nailing with this system. Our study showed a success rate of only 78.4% at the first attempt for distal interlocking of Trigen® humeral long nails. LEVEL OF EVIDENCE: IV; retrospective study without control group.

The Radial Floating Cup radial head prosthesis to treat radial head fractures: functional and radiographic results after more than 12 years of mean follow-up.

INTRODUCTION: This study was performed to evaluate the long-term clinical and radiographic results of patients presenting with a radial head fracture who were treated surgically with a Judet Radial Floating Cup 2 (RFC 2) radial head prosthesis. MATERIALS AND METHODS: This was a retrospective, monocentric, observational, multi-operator, and continuous study performed between July 1997 and June 2009 on the treatment of radial head fracture using an RFC 2 radial head prosthesis. The primary efficacy endpoint was the functional status of the operated elbow, evaluated using the Disability of Arm-Shoulder-Hand (Quick-DASH) score and the Mayo Elbow Performance Index (MEPI). The secondary endpoints were mobility and stability of the operated elbow, residual pain and grip strength, nature and rate of complications, as well as possible radiographic abnormalities during follow-up. RESULTS: Twenty-two patients were treated with the RFC 2 for radial head fractures over the study period. Three (13.6%) were lost to follow-up, including one death. Of the remaining 19 patients, three RFCs had to be removed (15.8%). The final analysis involved 16 patients. The mean follow-up was 144 months (range 109-225 months; standard deviation [SD] = 49.9 months) or 12 years. The average Quick-DASH score was 23.01/100 (range 0-50; SD = 7.8) and three cases were rated as having "excellent" results according to the MEPI (18.7%), nine cases were rated as having "good" results in (56.2%), and four cases were rated as having "average" results (25%). The average mobility values were: 132° of flexion (range 120°-150°; SD = 11), 14.5° of extension deficit (range 0°-40°; SD = 5), 84.4° of pronation (range 20°-90°; SD = 8°), and 67.7° of supination (range 25°-85°; SD = 10). All patients had a stable elbow. The average grip strength on the affected side thus corresponded to 79% (range 44-100%; SD = 8.3%) of the grip strength on the healthy side. Four patients (25%) developed complications: three cases of algodystrophic syndrome (18.7%) and one case of early dislocation (6.2%). Radiographic evaluation revealed that there was a periprosthetic radio-lucencies in eight patients (50%), periarticular ossifications in 12 patients (75%), and lysis of the capitulum in two patients. There was no significant difference in MEPI ratings between patients with and without a periprosthetic radio-lucencies (P = 0.8018). CONCLUSIONS: Our results indicated that using the RFC 2 prosthesis to surgically treat radial head fractures provides good long-term functional results, including satisfactory mobility and stability.

Glenoid subchondral bone density in osteoarthritis: A comparative study of asymmetric and symmetric erosion patterns.

BACKGROUND: Recent studies have shown variations in glenoid bone density in asymmetric wear patterns but have yet to analyze non-arthritic or concentrically worn glenoids. QUESTIONS/PURPOSES: The purpose of this study is to characterize and compare subchondral glenoid bone densities in both non-arthritic and A1, A2, B1, B2 and B3 osteoarthritic glenoids, as well as to assess uniformity in symmetric and asymmetric erosion wear patterns. METHODS: In all, 150 computerized tomography (CT) scans containing equal numbers of non-arthritic (N), A1, A2, B1, B2 and B3 glenoids were segmented semi-automatically. Each reconstructed glenoid was divided first into anterior and posterior quadrants, and then further subdivided into four quadrants. Volumes of interest (VOI) were defined at depths of 0-2.5mm (Zone A), 2.5-5mm (Zone B) and 5-7.5mm (Zone C). Average bone densities were measured at each VOI depth and in each quadrant. RESULTS: Osteoarthritic glenoids had higher mean bone densities than N glenoids. Mean bone densities were uniform amongst all quadrants for N glenoids, but not for osteoarthritic glenoids. In A1 glenoids, the antero-superior quadrant was less dense in Zone C. A2 glenoids had increased bone density measured posteriorly in Zones B and C. In B1 and B2 glenoids, Zones B and C demonstrated increased bone densities of posterior quadrants compared to anterior quadrants. B3 glenoids presented similar results as A1 and A2 glenoids. Cystic changes were more pronounced in anterior quadrants of A2, B1, B2 and B3 glenoids. CONCLUSION: This study demonstrates that osteoarthritic glenoids have greater bone density than non-arthritic glenoids, independent of depth of interest. It also confirms that N glenoids have uniform erosion wear patterns and that B1 and B2 glenoids have irregular wear patterns. It is the first study to reveal that A1, A2 and B3 glenoids, though geometrically symmetrical, have irregular bony densities similar to B2 glenoids. These findings have clinical implications for reaming the glenoid and implant fixation. LEVEL OF EVIDENCE: Basic Science, Anatomy, Imaging.

Predicting epiphyseal screw length in anterior plating of distal radial fractures.

The purpose of this study was to determine whether optimal epiphyseal screw length could be predicted with reference to a given diaphyseal screw length when fixating a plate to the anterior surface of the distal radius. Computerized tomography scans of 40 wrists of 28 men and 12 women were semi-automatically segmented. A virtual anterior plate model was fixed to the distal radius. The mean maximal appropriate length of one diaphyseal screw and of the four distal epiphyseal screws were measured and linear regression analyses were performed. We found that the epiphyseal screw lengths were highly correlated to the diaphyseal screw length. Based on the data derived from measurements, we recommend epiphyseal screw lengths from ulnar to radial of 18, 18, 20 and 16 mm, respectively, if the diaphyseal screw is 14 mm or less. For diaphyseal screws longer than 14 mm we recommend epiphyseal screws of 20, 20, 22 and 18 mm. Using these recommended screw lengths as general guidelines may reduce the risk of intra-operative and postoperative extensor tendon injury.

Advantages of expulsion-proof pins in the treatment of olecranon fractures with tension band wiring: Comparison with a control group.

INTRODUCTION: Tension band wiring is considered the standard treatment for transverse olecranon fractures. Its main complications are pin migration and discomfort caused by the hardware. We have designed and used "expulsion-proof" pins (EPP) that are shaped to prevent migration and reduce discomfort. This study compared the complication rate between our device and Kirschner pins (controls). HYPOTHESIS: We hypothesised that EPP would have lower migration rates and fewer complications than standard Kirschner pins. MATERIALS AND METHODS: This retrospective, single-center, multi-operator, observational, study examined data from January 1996 to December 2014. The primary outcome was the occurrence of pin migration. Secondary outcomes were the occurrence of one or more additional complications and the hardware removal rate. RESULTS: The study enrolled 101 patients: 53 (52.4%) with expulsion-proof pins and 48 (47.6%) controls. The mean follow-up was 240.6days in the EPP group and 268.9days in the control group. No cases of migration (0%) were found in the EPP group versus 21 (43.7%) cases in the controls (p<0.05). One or more complications occurred in 18 (33.9%) patients in the EPP group versus 46 (95.8%) controls (p<0.05). There was material discomfort in 13 (24.5%) cases and 1 (1.9%) case of secondary displacement in the EPP group, compared with 38 (79.2%) and 7 (14.6%) cases, respectively, in the controls (p<0.05). The rate of delayed consolidation was statistically identical in the two groups (p=0.103). The hardware was removed in 13 (24.5%) cases in the EPP group compared with 36 (75%) controls (p<0.05). CONCLUSION: EPPs are useful for management of olecranon fractures treated via TBW: the pins do not migrate and can reduce complications, discomfort, secondary displacement, and the hardware removal rate. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Functional and socioprofessional outcome of surgery for Volkmann's contracture.

OBJECTIVES: Volkmann's ischemic contracture is rare and surgical treatment remains a challenge. The goal of treatment is to obtain permanent recovery of joint range of motion and strength. The goal of this study was to evaluate the functional and socioprofessional outcome of surgical treatment of Volkmann's ischemic contracture. METHODS: This retrospective study was performed in two centers with one surgeon. Seven patients were included; mean age 23.6 years old. The Quick-Dash score, Patient Rated Wrist Questionnaire (PRWE) scores were obtained. Grip strength was compared to the contralateral side. Satisfaction was evaluated by the question: would you have surgery again? The surgical technique included 7 muscle slide procedures. RESULTS: Wrist and finger range of motion was good at least 6.1years in all cases according to the system by Buck-Gramcko. Grip strength on the operated side was 72.3% of the contralateral side. The mean PRWE was 14.64/100, mean QUICK-DASH score was 7.9/100. Patients returned to their professional activities in all cases. Patients who were questioned were all satisfied with surgery. CONCLUSIONS: Once the contracture is established in Volkmann's contracture Page-Scaglieti-Gosset muscle slide procedure can be used with good results allowing a return to socioprofessional activities. LEVEL OF EVIDENCE: IV, retrospective study.

Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations.

BACKGROUND: Covering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects. HYPOTHESIS: The posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot. MATERIAL AND METHOD: Patients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit. RESULTS: Thirteen patients with a mean age of 46.9 years (range: 25-73 years) were reviewed after a mean follow-up of 19.5 months (range: 16-63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients. DISCUSSION: The posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate. LEVEL OF EVIDENCE: IV, retrospective study.

Arthroscopic arthrodesis of the shoulder in brachial plexus palsy.

BACKGROUND: Shoulder arthroscopic arthrodesis is an uncommon and non-standardized procedure. Results are poorly evaluated. We describe the findings in 8 patients who underwent shoulder arthroscopic arthrodesis for brachial plexus injury. METHODS: The humeral head and glenoid were excised through standard arthroscopic portals. A Hoffmann external fixator and cannulated screws were used to stabilize the shoulder. Standard clinical assessment and radiographic evaluation were performed each month until bony fusion occurred. With a mean follow-up of 28 months, functional evaluation included pain level (on a 0- to 10-mm visual analog scale); American Shoulder and Elbow Surgeons index; Disabilities of the Arm, Shoulder and Hand score; and Simple Shoulder Test score. Mobility was systematically investigated. Blood loss was assessed by measuring hematocrit proportion. RESULTS: Glenohumeral fusion was achieved in all 8 patients. The mean time to arthrodesis was 3 months (range, 2-8 months). At last follow-up, the mean pain level was 1 (range, 0-4); the mean American Shoulder and Elbow Surgeons score was 69; the mean Disabilities of the Arm, Shoulder and Hand score was 36; and the mean Simple Shoulder Test score was 4. Mean active flexion and abduction were 80° (range, 60°-90°) and 59° (range, 40°-80°), respectively. Mean blood loss during the perioperative period was 432 mL (range, 246-792 mL). We observed one superficial wound infection and one migration of an acromiohumeral screw. These complications did not compromise the final results. CONCLUSIONS: Arthroscopic arthrodesis of the shoulder can be a reliable procedure and associated with a low rate of complications.