Stemless Shoulder Arthroplasty.

Stemless humeral components for shoulder arthroplasty represent the fourth generation of modern prosthetic shoulder implants. Because of their metaphyseal fixation, the implantation technique is rather straightforward and preserves the humeral canal from violation. Substantial benefits have been highlighted with such a design, including less perioperative morbidity, independence from the proximal humeral anatomy, preservation of bone stock, ease of potential revision surgeries, and limited risk of complex periprosthetic fractures. Initially conceived to better re-create the center of rotation of the humeral head in anatomic arthroplasties, their use has been successfully extended to reverse total shoulder arthroplasty. Provided that contraindications are respected (eg, poor proximal humeral bone quality, proximal humerus fractures, patients who are elderly and/or overweight), short-term and midterm functional outcomes as well as postoperative complications appear to be similar to those of traditional stemmed implants, without increased risk of loosening of the humeral component.

Inverted human umbilical artery as a 3D scaffold for sciatic nerve regeneration in rats.

Treatment of peripheral nerve injuries (PNIs) remains a challenge. Interposing a graft delivers better regenerative outcomes. Autografts present major drawbacks which have given rise to the development of alternatives such as artificial scaffolds, some of which are very promising. This study was designed to investigate the potential use of an inverted human umbilical cord artery (iHUA) as a 3D scaffold nerve chamber, for nerve regeneration after transection of the sciatic nerve (SN) in rats. Rats underwent surgical SN transection in their right hindlimb, followed by suture of the device at the resected stumps. Local tolerance, insert biodegradability and nerve reconstruction over time were thoroughly studied by histopathological and morphometric analysis, completed by functional test assessment of sensitivity and motricity recovery. We have demonstrated that nerve reconstruction in the presence of an iHUA insert is effective. The device is well tolerated and highly biodegraded. Although the regenerated nerve is still immature at the end of our study, signs of sensitivity and partial functional recovery were witnessed, confirming our histological findings. Our results support the potential clinical use of iHUA as a 3D scaffold to bridge nerve discontinuity and guide axonal regrowth in selected cases of PNIs.

Should the supraspinatus tendon be excised in the case of reverse shoulder arthroplasty for fracture?

PURPOSE: In the case of reverse shoulder arthroplasty (RSA) for proximal humeral fractures (PHFs) with tuberosity reconstruction, it is unclear whether the supraspinatus tendon continues to play a role. The aim of this study was to evaluate the clinical and radiological outcomes of RSA for PHFs in a large cohort of elderly patients and compare the results in the case of supraspinatus excision or preservation. METHODS: In this retrospective multicentre study, 150 patients (mean age 77 years, 93% female) were reviewed and radiographed with a minimum follow-up of 24 months. The same Grammont prosthetic design was used in all cases (inclination angle 155°, non-lateralised glenosphere). Patients were divided into two groups: Group A (n = 117) underwent supraspinatus excision and Group B supraspinatus preservation (n = 33). Complications were recorded, and shoulder function, active mobility and subjective results were assessed. RESULTS: At a mean follow-up of 59 months, there was no statistical difference in the complication rate (6% vs. 6.8%, p = 1), mean Constant score (61 points vs. 59 points, p = 0.52), simple shoulder value (74% vs. 73.9%, p = 0.9), active anterior elevation (125° vs. 128°, p = 0.45) and internal rotation (4.9 points vs. 4.1 points, p = 0.2). However, mean active external rotation was better in Group A (22° vs. 13°, p = 0.01). The greater tuberosity healing rate in satisfactory position did not differ statistically between the groups (68% vs. 55%, p = 0.14). CONCLUSION: In the case of RSA with tuberosity reconstruction for acute PHFs, there is no clear evidence that supraspinatus preservation is advantageous.

In vitro osteodifferentiation of intact human amniotic membrane is not beneficial in the context of bone repair.

The human amniotic membrane (hAM) is an attractive biomaterial for regenerative medicine, as it contains amniotic mesenchymal stromal cells (hAMSC), epithelial cells (hAEC) and growth factors. We examined the potential use of hAM in orthopaedic and maxillofacial bone surgery, integrating the requirements of current regulations regarding advanced therapy medicinal products (ATMP) in the European Union. Previous studies have described the potential osteodifferentiation of intact hAM during whole-tissue culture in osteogenic conditions. The present study aims to determine whether in vitro osteodifferentiation of hAM is needed in the context bone repair, and the influence of this process on tissue structure, cell phenotype and cell function. Different conditions (fresh or cultured hAM; intact or hAM-derived cells) were tested. Phenotypic and functional analyses were performed with standard approaches (cell culture and staining, histological and immunolabelling) as well as original approaches (tissue staining, energy dispersive X-ray and X-ray diffraction). In our study, non-osteodifferentiated hAM (i.e., fresh or native hAM) exhibited innate pre-osteoblastic potential. Osteodifferentiation of fresh hAM induced a change in tissue structure, cell phenotype and function. Therefore, we hypothesize that pre-osteodifferentiation may not be necessary, especially if it induces unwanted changes. To our surprise, in these osteogenic conditions, hAEC had a mesenchymal phenotype with osteocyte function, and even native synthesis of hydroxyapatite, focusing osteogenic potential mainly in this epithelial layer. In conclusion, in vitro osteodifferentiation by tissue culture does not appear to be necessary for hAM to be used as an innovative ATMP for bone repair.

Non-recommended dosing of direct oral anticoagulants in the treatment of acute pulmonary embolism is related to an increased rate of adverse events.

Dose adjustment of direct oral anticoagulants (DOACs) is not required in the setting of acute PE treatment according to the manufacturer's labelling, beyond the contraindication in severe renal insufficiency. We designed a prospective, multicenter cohort study to investigate the impact of prescription of non-recommended DOAC doses on 6-month adverse events. The primary endpoint was a composite of all-cause death, recurrent VTE, major bleeding, and chronic thromboembolic pulmonary hypertension (CTEPH). In total, among 656 patients discharged with DOACs between 09/2012 and 10/2016, 28 (4.3%) were not treated with a recommended DOAC dose. All the non-recommended DOAC dose prescriptions were under-dosed according to the drug labelling. After multivariate adjustment, age > 70 years, a history of coronary artery disease, creatinine clearance < 50 mL/min and concomitant aspirin therapy were independently associated with non-recommended DOAC dose prescription (C-statistic: 0.82; Hosmer Lemeshow test: 0.50). The primary composite endpoint occurred in 7/28 patients (25.0%) in the non-recommended dose group and in 38/628 patients (6.1%) in the recommended dose group, yielding a relative risk of 3.19 in the non-recommended dose group (95% CI 1.16-8.70; p < 0.001). The higher primary endpoint rate observed in the non-recommended dose group was driven by a significantly higher rate of major bleeding (7.1 vs. 1.4%; p = 0.008), with a non-significant trend toward a higher rate of death (7.1 vs. 2.2%; p = 0.23), recurrent VTE (3.6 vs. 1.4%; p = 0.31), and CTEPH (7.1 vs. 1.6%; p = 0.32). In conclusion, empiric dose reduction of DOACs was associated with 6-month adverse events in our real-life registry.

Treatment of distal radius fractures with locking plates: an update.

Internal fixation with volar locking plates has revolutionized the treatment of distal radius fractures. Manufacturers have introduced plate designs that closely follow the anatomy of the distal radius. However, use of volar plates has also led to the emergence of new types of complications. While the use of monoaxial or polyaxial locking screws and of minimally invasive techniques (arthroscopy, preservation of pronator quadratus) increases the cost of the surgical procedure, it results in a tangible benefit for patients, allowing them to move their wrist almost immediately after surgery and to quickly regain their autonomy. We reviewed the literature to analyze the level of proof.

Fresh and in vitro osteodifferentiated human amniotic membrane, alone or associated with an additional scaffold, does not induce ectopic bone formation in Balb/c mice.

The human amniotic membrane (hAM) has been successfully used as a natural carrier containing amniotic mesenchymal stromal cells, epithelial cells and growth factors. It has a little or no immunogenicity, and possesses useful anti-microbial, anti-inflammatory, anti-fibrotic and analgesic properties. It has been used for many years in several indications for soft tissue repair. We previously reported that hAM represents a natural and preformed sheet containing highly potent stem cells, and could thus be used for bone repair. Indeed, native hAM possesses pre-osteoblastic potential that can easily be stimulated, even as far as mineralization, by means of in vitro osteogenic culture. However, cell culture induces damage to the tissue, as well as to cell phenotype and function. The aim of this study was to evaluate new bone formation by fresh and in vitro osteodifferentiated hAM, alone or associated with an additional scaffold presenting osteoinductive properties. Moreover, we also aimed to determine the effect of in vitro hAM pre-osteodifferentiation on its in vivo biocompatibility/tissue degradation. Results showed that neither fresh nor osteodifferentiated hAM induced ectopic bone formation, whether or not it was associated with the osteoinductive scaffold. Secondly, fresh and osteodifferentiated hAM presented similar in vivo tissue degradation, suggesting that in vitro hAM pre-osteodifferentiation did not influence its in vivo biocompatibility.

Repair of distal biceps brachii tendon assessed with 3-T magnetic resonance imaging and correlation with functional outcome.

OBJECTIVE: Objectives were to study the MRI appearance of the repaired distal biceps tendon (DBT), anatomically reinserted, and to search for a correlation between tendon measurements and functional results. MATERIALS AND METHODS: Twenty-five patients (mean age, 49 ± 4.9 years old) who benefited from 3-T MRI follow-up of the elbow after surgical reinsertion of the DBT were retrospectively included and compared to a control group (n = 25; mean age, 48 ± 10 years old). MRI was performed during the month of clinical follow-up and on average 22 months after surgery. Delayed complications (secondary avulsion, new rupture), intratendinous osteoma, tendinous signal on T1-weighted (T1w) and fat-suppressed proton density-weighted (FS-PDw) images as well as DBT measurements were recorded. The maximum isometric elbow flexion strength (MEFS) and range of motion of the elbow were assessed. RESULTS: Repaired DBT demonstrated a heterogeneous but normally fibrillar structure. Its low T1w signal was less pronounced than that of normal tendons, and the FS-PDW image signal was similar to that of T1w images. MRI detected seven osteomas (Se = 53 % vs. plain radiography), one textiloma and one secondary avulsion. Repaired DBT measurements were significantly correlated with MEFS (dominant arm R2: 0.38; nondominant arm R2: 0.54); this correlation involved the insertion surface (Δ = -75.7 mm(2), p = 0.046), transverse diameter (Δ = -2.6 mm, p = 0.018), anteroposterior diameter at the level of the radial head (Δ = -3.9 mm, p = 0.001) and DBT cross-sectional area (Δ = -50.2 mm(2), p = 0.003). CONCLUSION: The quality of functional outcome after anatomical elbow rehabilitation of DBT correlates with the extent of tendinous hypertrophy during the healing process.

Early postoperative improvements in the QuickDASH score after distal radius fracture are related to the type of surgical treatment.

The goal of this prospective study was to evaluate the real-life experience of 52 patients and their recovery kinetics in the first 6 weeks after surgical treatment of distal radius fractures. The fractures were treated with either a fourth-generation volar locking plate (34 patients, mean age 67 years, range 54-82) or by percutaneous pinning (18 patients, mean age 56 years, range 43-69). These patients were evaluated every week for 6 weeks with the QuickDASH (QD) questionnaire. A lower QD score indicated that the patient's physical function and symptoms had improved. At postoperative week 1, all the patients who had undergone percutaneous pinning had a QD of 80 (out of 100). One-third of patients who had undergone plate fixation had a QD of 80, while the remainder had a QD of 65. Out of all the patients who had a QD of 80 at postoperative week 1, the patients who had undergone plate fixation improved more quickly. After 6 weeks, the patients who had undergone plate fixation had a greater reduction in the QD (50 points) than the ones who had undergone pinning (30 points). Although the direct costs of locking plate fixation are 10 times higher than those of K-wire pinning, evidence suggests that these plates reduce the indirect costs. This study has shown that a patient's recovery rate, day-to-day life and physical function are better over the first 6 weeks postsurgery when the distal radius fracture is fixed with a locking plate.

Plate fixation of distal radius fracture and related complications.

INTRODUCTION: Distal radius fractures are common. In cases where surgical treatment is needed, volar plates can be used to obtain stable, long-lasting fixation. The design of these plates has continually improved over the years, but complications remain a problem. PURPOSE: The goal of this study was to evaluate the types of complications that occur with different types of volar plates with a view towards preventing them. MATERIALS AND METHODS: The emergency department at our hospital saw 524 patients with distal radius fractures between 2006 and 2008. Some of these were treated surgically with a volar plate. All of the post-operative complications were documented. RESULTS: With a minimum follow-up of 6 months, 152 patients who had undergone plate fixation were reviewed: 31 had received plates with non-locking screws or uniaxial locking screws and 121 had received plates with polyaxial locking screws. The complication rate was similar in these two groups (16.1 and 16.5%, respectively). The main complications were tendon ruptures and problems related to the plate itself. DISCUSSION: Plate-related complications have been described in published studies, but few of these studies link them to the plate design or surgical technique. Manufacturers must continue to refine these plates to minimise their thickness while keeping their strength. Surgeons must be sure to use a highly exacting technique.

Bone morphogenetic protein and orthopaedic surgery: can we legitimate its off-label use?

PURPOSE: Bone morphogenetic proteins (BMP) are recombinant osteoinductive proteins with their primary role being to promote bone formation. The off-label use of BMP in orthopaedic surgery has dramatically increased. However, reports of complications with BMP have emerged, and the safety of these proteins in orthopaedics is questioned. The purpose of this review was to evaluate safe situations in which BMP should be used and situations in which their use should be restricted. METHOD: We recorded all studies from PubMed database from 2002 (date of first authorisation for both BMPs) until January 2014 using "BMP" or "bone morphogenetic protein". Then we screened and extracted all studies dealing with orthopaedic surgery. All situations in which BMP were used, even cases reports, were considered, and complications reported were then listed. RESULTS: Situations in which it seems safe and efficient to use BMP are long-bone nonunions, or arthrodesis as an alternative or combined to autograft in small-bone loss. Surgeons and patients should be aware of transient aseptic wound swelling when BMP is located superficially. The use of BMP in spine surgery for intersomatic fusion is efficient but should be restricted to approaches that respect the vertebral canal to avoid neurological complications. CONCLUSION: This review is an off-label map of BMP use in orthopaedics during the past 10 years. Our results could provide a useful tool to help decisions around when to use a BMP in a specific complex, and sometimes off-label, situation.

Storage and qualification of viable intact human amniotic graft and technology transfer to a tissue bank.

Human amniotic membrane (hAM) is known to have good potential to help the regeneration of tissue. It has been used for over 100 years in many medical disciplines because of its properties, namely a scaffold containing stem cells and growth factors, with low immunogenicity and anti-microbial, anti-inflammatory, anti-fibrotic and analgesic properties. In order to use this "boosted membrane" as an advanced therapeutic medicinal product for bone repair, we aimed to observe the influence of tissue culture and/or cryopreservation on cell viability and tissue structure, and secondly, to adapt to a tissue bank, identify easy processes to store hAM containing viable cells and to verify the quality of the graft before its release for use. To this end, we tested different published culture or cryopreservation storage conditions and cell viability assays. Tissue structure was evaluated by Giemsa staining and was compared to histological analysis. Preliminary results show no dramatic decrease in cell viability in cultured hAM as compared to cryopreserved hAM, but tissue structure alterations were observed with both storage conditions. Histological and immunohistochemical data highlight that tissue damage was associated with significantly modified protein expression, which could lead to a possible loss of differentiation potential. Finally, we report that trypan blue and Giemsa staining could constitute controls that are "materially and easily transferable" to a tissue bank.

Distal humerus fracture in older patients: ORIF vs. total elbow arthroplasty.

Distal humerus fractures are a contemporary problem because the life expectancy, autonomy and functional demands of older patients continue to grow. This is combined with surgical advances in bone reconstruction, especially in fragile patients. A distal humerus fracture in an older adult is a serious injury with an uncertain prognosis. In fact, damage to the elbow joint in this complex anatomical area overwhelmed by low-quality bone occurs in patients who often have unfavorable characteristics (fragile skin, low physiological reserves, organ failure) combined with pharmaceutical treatments that can be iatrogenic. The treatment indication must not be based solely on the conventional radiographs used for classification purposes; the fracture and bone quality must be analyzed in three dimensions. Also, the surgeon must understand the patient's needs, worries and risks fully to decide between conservative treatment and anatomical locking plate fixation or elbow arthroplasty (hemi or total). In the end, the chosen treatment must allow at least 100̊ and preferably 120̊ of flexion-extension at the elbow. In this age range, the choice between arthroplasty and plate fixation is definitive; the surgical approach must make it possible to carry out either option, with arthroplasty implants available in case the trochlear fracture cannot be plated. The aim of this lecture is to provide a fresh perspective on the anatomy of the distal humerus, its fracture and the best surgical approaches, discuss how to decide on the indication, outline the safest and most reliable ways to reconstruct and stabilize the elbow, and lastly, summarize the expected outcomes and potential complications of each treatment option. Level of evidence: V; expert opinion.

Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty.

HYPOTHESIS: Reverse shoulder arthroplasty in complex shoulder fractures is now a common practice. Unfortunately, loss of rotation is observed when tuberosity excision is used, impairing function and patient satisfaction. The purpose of this study was to evaluate the advantage of tuberosity repair in terms of the functional result. MATERIALS AND METHODS: We reviewed 41 patients, with a mean age at trauma of 76.9 years, at a mean follow-up of 24 months. Tuberosities were repaired in 27 patients and totally removed in the other 14 cases. RESULTS: Two-thirds of the repaired tuberosities consolidated in anatomic position. We compared a group with tuberosity healing in anatomic position versus a group without repair and with malunion or nonunion of the tuberosities. In the first group, all sectors of motion, especially external rotation (49° vs 10°), were improved and both Constant scores (65 vs 50) and Disabilities of the Arm, Shoulder and Hand scores (30 vs 40) were significantly better. CONCLUSION: Management of complex fractures of the superior extremity of the humerus by reverse shoulder arthroplasty is an accepted approach, but such treatment is restricted to elderly patients. Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant. However, their consolidation should be anatomic; otherwise, the result is impaired by the lack of rotation. Nonunion or malunion does not lead to a functional disaster, as is sometimes the case with hemiarthroplasty without tuberosity healing.

[Traps in tendon and joint injuries at hand level]. / Pièges des traumatismes ostéo-articulaires et tendineux de la main.

The patient with an injury of the hand has unfortunally not choose the type of injury, the time and the medical doctor; this patient is not sick but injuried. Even if this is an open or closed trauma, begnin or not, the patient is going to discover dressing, immobilisation and time to recover function with a "new hand" .... Hand injuries have shown their impact on global function in case of inadequate treatment. After hand trauma, finding the right diagnosis and choosing the right treatment depend on the capacity of avoiding the traps.

The impact of COVID-19 on hand surgery: A French retrospective comparative study in COVID-19 and non-COVID-19 hand trauma centers.

INTRODUCTION: In 2020, the pandemic divided France into two zones: COVID-19 and non-COVID-19. The main objective of our study was to compare the variability of surgical and emergency consultation activity amongst two hand trauma centers, between the pandemic period and outside the pandemic period. The secondary objective was to identify at-risk patients in order to develop preventative strategies in hand trauma. METHODS: This bi-centric retrospective study considered the epidemiology of admissions to trauma centers during the first French lockdown. The data were compared to the same period in 2019 (control group). Two thousand and fifty-five patients underwent consultations for hand or wrist trauma. RESULTS: The first French lockdown was associated with a 35% decrease in hand and wrist injuries in the COVID-19 zone versus 24% in the non-COVID-19 zone, compared to the same period in 2019 (p<0.0001, 95% CI: 6.5-15.6). Comparing 2019 and 2020, the incidence of wounds significantly increased in the COVID-19 zone (58% vs. 78%, p<0.0001) and significantly decreased in the non-COVID-19 zone (55% vs. 50%, p<0.0001). Complex wounds (16% vs. 35%, p<0.0001 and 15% vs. 17%, p<0.0001) and open fractures (8% vs. 14%, p=0.019 and 4.5% vs. 5.3%, p<0.0001) significantly increased in both zones during the pandemic. The rate of male, non-manual workers injured in domestic accidents (76% vs. 36%, p<0.0001) was significantly increased in all areas. CONCLUSION: Hand and wrist trauma was less frequent but more severe during the pandemic compared to the same period in 2019. By encouraging the public to be aware of the risks and the means to avoid trauma, such as better information and compliance with safety instructions, we could minimize these risks. This data can be useful in planning preventative strategies for future lockdowns. LEVEL OF EVIDENCE: III; case-control study.

Has the COVID lockdown altered the incidence and management of fragility fractures in older adults? Case-control study at a French University Hospital.

INTRODUCTION: In France, a national lockdown related to the COVID-19 pandemic was imposed from March 17 to May 11, 2020, drastically changing our professional and organizational practices. We were interested on the impact of the lockdown on fragility fractures in older adults (65 years and older). The primary objective of this study was to evaluate the incidence of peripheral and pelvic fragility fractures during the lockdown. The secondary objectives were to carry out an epidemiological analysis of the fractures, treatments and hospitalization data. HYPOTHESIS: The main hypothesis was that the number of peripheral and pelvic fragility fractures was lower during the lockdown in 2020 than in the same (non-lockdown) period in 2019. MATERIALS AND METHODS: We retrospectively collected epidemiological (age, sex), clinical (type of fracture, treatment) and hospitalization data from patients 65 years and older who came to the emergency room because of a peripheral and/or pelvic fracture between March 17 and May 11 of the years 2019 and 2020. RESULTS: We included 192 patients in 2019 and 157 patients in 2020. The mean age and sex ratio were not statistically different. The number of peripheral and/or pelvic fragility fractures decreased by 16%. The share of patients treated surgically was similar in both years (46% in 2019; 51% in 2020 (p=0.47)). The number of proximal femur fractures dropped by 21%. The mean time to surgery for these fractures was shorter in 2020 (p=0.02) although the mean length of hospital stay was unchanged (p=0.72) The mortality rate of patients hospitalized for fragility fractures did not increase significantly (p=0.51). DISCUSSION: We observed a reduction in the number of peripheral and pelvic fragility fractures in patients 65 years and older during the lockdown. To ensure that we met our goals of optimal care for proximal femur fractures, a general reorganization of the operating room was necessary. The continued availability of fully functional technical facilities despite this health crisis was crucial to being able to treat these fractures and to prevent increased mortality. LEVEL OF EVIDENCE: III, case-control study.

Reverse Shoulder Arthroplasty for Patients with Massive Rotator Cuff Tears or Cuff Tear Arthropathies at a Minimum Follow-up of 7 Years.

Purpose: To evaluate indications and factors that influence long-term clinical outcomes and revision rates for reverse shoulder arthroplasty (RSA) in shoulders with irreparable massive rotator cuff tears (mRCTs) or cuff tear arthropathies (CTAs). Methods: The authors retrospectively evaluated a consecutive series of shoulders with no fracture sequelae that underwent primary RSA between 2011 and 2013. Independent observers collected demographic data, surgical techniques, and implant types, as well as primary outcome measures such as American Shoulder and Elbow Society (ASES) score and Constant score (CS). Study design: Case series, level IV. Results: From the initial series of 123 patients that underwent RSA, 29 patients died (24%) for reasons unrelated to the shoulder arthroplasty, 11 were lost to follow-up (9%), and 4 required revision surgery (3%). The final cohort of 79 patients comprised 55 women (70%), and 24 men (30%), aged 72.7 ± 7.0. At a final follow-up of 8.9 ± 0.6 years (range: 7.4-10.3) the absolute CS was 59.0 ± 16.2, the age-/sex-adjusted CS was 76.6 ± 41.2, and ASES was 77.1 ± 20.3. Univariable analysis revealed no associations for absolute CS, but revealed that age-/sex-adjusted CS was significantly lower for patients with high blood pressure (ß = -15.8, p = .025). Conclusions: At a minimum follow-up of 7.4 years, the absolute CS was 59.0 ± 16.2, the age-/sex-adjusted CS was 87.4 ± 24.1 and ASES was 77.1 ± 20.3. When stratifying the outcomes of RSA by indication, there were no significant differences in patients with mRCTs versus CTA in terms of absolute CS, age-/sex-adjusted CS, and ASES. Univariable analysis revealed no association with absolute and age-/sex-adjusted CS for type of indication or surgical approach.

Acromioclavicular joint separation: Retrospective study of non-operative and surgical treatment in 38 patients with grade III or higher injuries and a minimum follow-up of 1 year.

INTRODUCTION: Acromioclavicular (AC) joint separation is a common shoulder injury. When the injury is graded as type III or higher in the Rockwood classification, surgical treatment can be proposed. However, an increasing number of practitioners are shifting back to conservative treatment as it is associated with fewer complications and seemingly close functional outcomes. The aim of our study was to evaluate the functional recovery of operated and non-operated patients with grade III or higher AC joint injuries. Secondarily, the reliability and relevance of the Rockwood classification was evaluated within and between raters. MATERIALS AND METHODS: We did a retrospective two-center study of 38 patients treated between 2014 and 2020. The clinical evaluation involved various functional outcome scores (Constant, QuickDASH, ASES, UCLA, SSV, STT) and a pain assessment (VAS). Return to sports and to work was also documented. The radiological evaluation consisted of Zanca AP and lateral axillary views immediately after the injury and at each radiographic follow-up visit until the final visit. An intra- and inter-rater analysis was also done for the Rockwood classification. RESULTS: There was no significant difference in the functional scores (Constant score surgery group=91, nonoperative group=83; p=0.09) or the pain on VAS at the final assessment. Return to work and to sports was significantly faster in patients treated non-operatively. No complication was found in the non-operated patients, while nine of the operated patients suffered a complication. The inter-rater reliability of the Rockwood classification was found to be poor (kappa=0.08) to fair (kappa=0.35), while the intra-rater reliability was moderate (kappa=0.6) to good (kappa=0.63). DISCUSSION/CONCLUSION: No matter which treatment is used, the functional outcomes and patient satisfaction level a minimum of 1 year after the injury appear to be identical. Thus, surgery should be only for patients whose AC joint is painful 7 days after the injury (VAS>7) and whose function has not improved. For young and athletic patients or for patients who simply want to regain nearly normal function, it is important to remember that the time to return to work and sports is longer with surgical management and to take into consideration the potential postoperative complications. While none of the patients who received the non-operative treatment required a secondary stabilizing surgery, this is a possible recourse. LEVEL OF EVIDENCE: III.

Should the artery be trimmed before anastomosis in every finger replantation/revascularization case? Prospective, single-center, multidisciplinary study over 46 months.

INTRODUCTION: Despite optimal arterial anastomosis, some finger replantations fail. Our objective was to evaluate how the mechanism of injury (MOI) affects the artery's microscopic appearance and the success of anastomosis. We hypothesized that the MOI influences arterial histology and microsurgical success. METHODS: This single-center prospective study enrolled patients who had an acute traumatic arterial injury of the hand and/or wrist. The proximal and distal ends of the artery were trimmed before anastomosis in every case. The arterial margins were analyzed in anatomical pathology. Clinical follow-up along with an ultrasound arterial patency check was carried out at 1 month postoperative. RESULTS: Between 2018 and 2022, 104 patients were enrolled with a follow-up of 12 months. Macroscopically, 42% of the arterial margins were dilapidated. Histological analysis found damage in 74% of surgical specimens: blast (100%)>laceration by mechanical or power tool (92%; 82%)>amputation by mechanical or power tool (80%; 67%)>laceration by glass (50%)>crush injury (33%). The arterial margins were more likely to be normal based on the histological analysis when the MOI was laceration by glass (p<.05; OR=3.72) and the patient was 65 years or older (p<.01). Risk factors for anastomosis failure were an amputation by power tool (p<.01, OR 8.19) and shorter length of arterial resection (p<.02). The clinical failure rate was 7.8% and the patency failure rate was 10.4%. DISCUSSION: Histological arterial lesions correlate with the MOI. Trimming >2mm from the proximal and distal arterial ends is recommended for all MOI before arterial end-to-end anastomosis. For blast injuries or amputation, we recommend trimming>4mm and using a vein bypass graft. This study's findings could lead to a change in surgical practices. LEVEL OF EVIDENCE: II; well-conducted non-randomized comparative study; recommendation grade B: scientific presumption.