Three-dimensional analysis of the gap space under forearm casts.

PURPOSE: Secondary displacement represents a frequent complication of conservative treatment of fractures, particularly of the distal radius. The gap space between skin and cast may lead to a certain degree movements and this increased mobility might favor redisplacement. The aim of this study was to develop a new 3D method, to measure the gap space in all 3 geometrical planes, and to validate this new technique in a clinical setting of distal radius fractures. METHODS: This study applies 3D imaging to measure the space between plaster and skin as a potential factor of secondary displacement and therefore the failure of conservative treatment. We developed and validated a new methodology to analyze and compare different forearm casts made of plaster of Paris and fiberglass. An unpaired t-test was performed to document differences between the investigated parameters between plaster of Paris and fiberglass casts. The significance level was set at p < 0.05. RESULTS: In a series of 15 cases, we found the width of the gap space to average 4 mm, being slightly inferior on the radial side. Comparing the two different casting materials, plaster of Paris and fiberglass, we found a significantly larger variance of space under casts made of the first material (p=0.39). A roughness analysis showed also a markedly significantly higher irregularity of the undersurface of plaster of Paris as compared with fiberglass. CONCLUSION: This study allows for a better understanding of the nature of the "gap space" between cast and skin and will contribute to develop and improve new immobilization techniques and materials.

Ulnar lateral digital flap for Dupuytren's disease of the fifth finger, a technique not be forgotten.

Dupuytren's disease is a common condition in hand surgery. The fifth finger is frequently affected, pre- senting the highest recurrence rate after surgical treatment. The ulnar lateral-digital flap is used when a skin defect prevents direct closure after fasciectomy of the fifth finger at the level of the MP joint. Our case series comprises of 11 patients undergoing this procedure. Their mean preoperative extension deficit was 52° at the MP joint and 43° at the PIP joint. Full extension of the MP joint and a mean of 8° extension deficit at the PIP joint was achieved with surgery. All patients maintained full extension at the MP joint, with a follow-up of 1 to 3 years. Minor complications were reported. The ulnar lateral digital flap is a simple and reliable alternative when surgically treating Dupuytren's disease of the fifth finger.

Three-Corner Arthrodesis (lunate - hamate - capitate) : clinical and kinematical evaluation.

In the absence of prosthetic arthroplasty offering good results for the treatment of wrist osteoarthritis, we studied the arthrodesis of three carpal bones (lunate - hamate - capitate) completed by triquetrum and scaphoid excision in the presence of Scapholunate Advanced Collapse (SLAC) or Scaphoid Nonunion Advanced Collapse (SNAC) stage II or III. Clinical data on eight patients between the ages of 32 and 61 years at an average of 29 months after surgery was analyzed. Seven patients reached fusion with a carpal height ratio of 0.39. These arc of dorsal-palmar flexion (DPF) attended 54° and the arc of radio-ulnar deviation (RUD) 29° using the optoelectronic stereophotogrammetry system. The mean polar radius (R) was 14.5° and the envelope shape coefficient (K) was 1.66. This operation could be considered as an alternative for the treatment of patients suffering of SNAC or SLAC stage II and III. Type of study/level of evidence : Therapeutic IV.

Joint contact areas after radial head arthroplasty: a comparative study of 3 prostheses.

BACKGROUND: Contact stresses of radial head prostheses remain a concern, potentially leading to early capitellar cartilage wear and erosion. In particular, point contact or edge loading could have a detrimental effect. The purpose of this study was to compare 3 different types of radial head prostheses in terms of joint contact areas with each other and with the native situation. The hypothesis was that the joint contact areas would be lower after monopolar arthroplasty. METHODS: Seven fresh-frozen cadaveric upper limbs were used. Radiocapitellar contact areas of a monopolar design, a straight-neck bipolar design, and an angled-neck bipolar design were compared with each other and with the native joint. After standardized preparation, polysiloxane was injected into the loaded radiocapitellar joint to create a cast from which the joint contact area was measured. Measurements were performed at 3 angles of elbow flexion and in 3 different forearm positions. RESULTS: In the native elbow, contact areas were highest in supination. Elbow flexion had no significant effect on native and prosthetic joint contact areas. Contact areas were decreased for all types of arthroplasties compared with the native joint (from 11% to 53%). No significant contact area difference was found between the 3 designs. However, bipolar prostheses showed lateral subluxation in neutral forearm rotation, resulting in a significant decrease in the contact areas from pronation to the neutral position. CONCLUSIONS: All types of radial head prostheses tested showed a significant decrease in radiocapitellar contact area compared with the native joint. Bipolar designs led to subluxation of the radial head, further decreasing radiocapitellar contact.

A New Clinical Sign of Lumbrical Plus Finger.

Paradoxical finger extension is the classical clinical presentation of the lumbrical plus syndrome. We report a new additional sign, increased metacarpophalangeal flexion of the involved finger when the patient tries to make a fist. Three cases of lumbrical tightness are discussed, illustrating this new sign in 3 different clinical settings. The new sign was present in all 3 cases. Lumbrical tenotomy corrected the paradoxical interphalangeal extension and partly the increased metacarpophalangeal flexion. The lumbrical tendon has a relatively high moment arm relative to the metacarpophalangeal joint, which could explain the basis of this clinical sign. This new physical examination sign may help in diagnosing the lumbrical plus syndrome, a subtle complication of flexor digitorum profundus lesions that is not easily diagnosed but which is easily addressed.

Risk of vascular injury when screw drilling for tibial tuberosity transfer.

PURPOSE: During tibial tubercle transfer, popliteal vessels are at risk from drills and screws. The risk is around 0.11%, as described in the literature. We reviewed knee injected CT scan for analysis of the location of arteries, identified landmarks allowing minimizing risks, and defined a safe zone. MATERIAL AND METHOD: Distances between the posterior cortex and arteries were measured on CT scans from 30 adults (60 knees) at three levels (proximal part of the tibial tuberosity, 20 mm and 40 mm distally). Data were used to create a "risk map" with different angular sectors where the frequency of the presence of arteries was analyzed in each area. We also analyzed the position of 68 screws of 47 patients who underwent a medial tibial tuberosity transfer. RESULTS: The nearest distance between artery and the posterior tibial cortex was found at the level corresponding to the top of the tuberosity with less than 1 mm, while the largest distance was found at the distal level. We were able to define a safe zone for drilling through the posterior tibial cortex which allows a safe fixation for the screws. This zone corresponds to the medial third of the posterior cortex. When the safe zone is not respected, screws that overtake the posterior cortex may be close to arteries as observed for 37 of the 68 screws analyzed. CONCLUSION: We described new landmarks and recommendations to avoid this complication during tibial tuberosity transfer.

Virtual 3D planning and patient specific surgical guides for corrective osteotomy of the clavicle : report of three cases.

Although many clavicular malunions result in minimal functional deficit, in some symptomatic cases a corrective osteotomy might be necessary. Recently, computer-assisted surgical planning combined with patient-specific surgical guides was introduced as a powerful technology with the potential to improve the accuracy, efficiency, and consistency of corrective osteotomies, as shown for osteotomies in other anatomical regions. We describe the use of this technique in three cases of clavicular malunion.

Treatment of displaced supracondylar humeral fractures in children by humero-ulnar external fixation.

PURPOSE: Humero-ulnar external fixation has been proposed to treat complex supracondylar humeral fractures in children. It facilitates fracture reduction and reduces the risk of ulnar nerve lesion, which can occur after cross pinning. METHODS: In a ten year period, 28 children have been operated on in our centre by humero-ulnar external fixation, for Lagrange-Rigault stages III and IV supracondylar humeral fractures. The data about fracture management and early follow-up were obtained from our medical database. The long-term evaluation was done at a minimum six months' follow-up. The range of motion and carrying angle measurements were classified according to Flynn. The final X-rays were evaluated for quality of reduction, presence of malunion, late infection signs, osteo-arthritis and myositis ossificans. The elbow function was evaluated by Mayo Elbow Performance Index (MEPI), Disabilities of the Arm, Shoulder and Hand (DASH) or modified DASH scores. RESULTS: The treatment was well tolerated by children and parents. There was no neurological complication related to the insertion of the pins, and no Volkmann syndrome. The median duration of external fixation was 33.5 days. Twelve patients were reviewed after a median follow-up duration of seven years (mean, 7.5 years; range, 3-21 years). One child had a refracture, three years after his original fracture, which was treated non-operatively. This case ended up in a cubitus varus deformity with a pronation deficit. All other patients had excellent clinical and radiological results. CONCLUSIONS: For the treatment of complex supracondylar humeral fractures in children, humero-ulnar external fixation is a good alternative to lateral or crossed pinning. The advantages are the ease to obtain the reduction, the absence of neurological risk to the ulnar nerve and the possibility to obtain good stabilisation of the fracture with moderate elbow flexion.

The effect of humerus diaphyseal shortening on brachial plexus tension: a cadaver study.

PURPOSE: To assess the extent to which diaphyseal shortening of the humerus can allow direct suture in case of rupture or transection injuries of the brachial plexus. METHODS: The use of 3 fresh cadaver specimens allowed for the study of 6 brachial plexuses. Distance measurements were made between reference points placed on the clavicle and on different parts of the plexus. Those measurements were repeated after shortening the humerus by 2, 4, and 6 cm. RESULTS: None of the dissected plexuses had classic anatomy. A humeral shortening of 6 cm allowed for a statistically significant reduction of length between the supraclavicular part of the plexus and the terminal branches, which did not exceed 17 mm on average. The difference of length was much greater for the specimen in which the musculocutaneous nerve did not pierce the coracobrachialis muscle proximally. CONCLUSIONS: In clinical situations, nerve defects are usually larger than the gain observed when doing a 6-cm humeral shortening. Moreover, this procedure implies a large dissection, a functional loss of certain muscles, and a risk of humeral nonunion. CLINICAL RELEVANCE: In the absence of extensive nerve dissection, the observed change of length is insufficient in the most brachial plexus disruptions to allow for a direct suture instead of long nerve grafts.

Reconstruction of Intercalary Bone Defects After Tumour Resection with the Use of a Free Vascularised Fibular Graft: the Concealed Advantages of the External Fixator.

The free vascularised fibular graft represents the mainstay of intercalary bone defect reconstruction after tumour resection. Different reconstruction techniques are described, favouring internal fixation and possibly overlooking potential advantages of external fixation. This series is a description of the technique performed at our institution using an external fixator for the reconstruction of segmental bone defects which enables to maintain limb length and rotational alignment after large segmental bone resection. Data collected were demographic, surgical and histological data, perioperative complications and postoperative data. Eighteen different complications were encountered in seven patients. Mean reoperation rate was 1.3 per patient but no patient required further interventions in order to correct limb length or rotational alignment. Pin-track infection rate was 6%. The limb salvage rate was 100%. Solid final bone healing was obtained in all patients. External fixation for the reconstruction of intercalary bone defects after tumour resection is a safe technique which might offer the advantage of limb length and alignment preservation.

Prospective evaluation of a novel device for ultrasound-guided percutaneous treatment of carpal tunnel and trigger finger disease. Efficacy and safety of sono-instruments®.

PURPOSE: To evaluate the safety and effectiveness of percutaneous release procedures under sonography using Sono-Instruments® in the treatment of carpal tunnel syndrome (CTS) and trigger finger (TF). METHODS: Prospective study involving 30 patients, divided into two groups (15 CTS, and 15 TF). The primary outcomes were surgical performance-related outcomes (visibility, ease of use, satisfaction, duration) using Sono-Instruments® and patient-related outcomes (pain, activity limitations, time to return to work, functional scores). Secondary outcomes included complications. Patients were followed for two months post-operatively. RESULTS: In the CTS group, the average age of the patients was 58.7 years. The percutaneous release of the transverse carpal ligament was effectively completed in all cases, with excellent device performance and no adverse events. At one week, all patients could wash their hands, 80% could perform activities of daily living, and 80% of those working had returned to their activities. At two months, all patients had resumed all activities. Pillar pain was still present in 53.3%. In the TF group, the patients had an average age of 57.9 years. The percutaneous release of the A1 annular pulley was successful in all cases, with excellent device performance and no adverse events. At one week, all patients could wash their hands, 93.3% could do all activities of daily living, and 75% of those working were back to their professional activities. At two months, all patients were back to all activities of daily living and work. The DASH score was significantly improved at two months, compared to preoperative, for both groups (p < 0.001). CONCLUSION: Percutaneous sono-guided release using Sono-Instruments® is safe and efficient, and associated with quick functional recovery. LEVEL OF EVIDENCE: II.

Retrograde Percutaneous Release of Trigger Finger or Thumb Using Sono-Instruments®: Detailed Technique, Pearls, and Pitfalls.

Percutaneous release is a common treatment option for trigger finger stenosing tenosynovitis. While surgical and conservative treatments are available, percutaneous techniques offer several advantages, including faster recovery time, reduced complications, and simultaneous treatment of multiple trigger fingers. The sono-instrument is a minimally invasive device designed for surgical release of the A1 pulley in adults. The device is efficient and safe, and in addition, several design features enhance the visibility of the instrument under ultrasound imaging. The technique is truly percutaneous, as the whole operation is done through a single needle puncture. This minimizes postoperative discomfort and allows an immediate return to daily living and professional activities. The technique can be performed in an outpatient clinic under local anesthesia. The learning curve is quick; however, surgeons must acquire experience in hand sonography to master this new form of surgery. The aim of this article is to provide an in-depth exposition of the technical nuances, pearls, and pitfalls of this novel retrograde percutaneous release method. To our knowledge, this is the first retrograde truly percutaneous release technique yet described, facilitated by the novel Sono-Instruments®.

Smoking as a predictor of negative outcome in diaphyseal fracture healing.

PURPOSE: The purpose of this study was to evaluate the impact of tobacco abuse in the consolidation of fractures. METHODS: We retrospectively identified all patients with a diaphyseal fracture (femur, tibia, or humerus), between January 1999 and December 2010, in our orthopaedic trauma registry (Erasme hospital, Brussels, Belgium). Thirty-eight diaphyseal nonunions (ten femurs, 16 tibias and 12 humerus) were identified. Each nonunion was paired (on age, sex and location) with two control-healed fractures (76 control patients). The chi-squared test and a binary logistic regression were used for statistical analysis. RESULTS: In multivariate analysis, smoking (tobacco use) was significantly associated with nonunion, whether the fracture was open or closed (p < 0.01). In univariate analysis, open fracture was associated with a higher risk of nonunion (p < 0.05), while external fixation was associated with better bone healing (p < 0.05). CONCLUSION: Tobacco is confirmed as a deleterious factor for diaphyseal bone healing.

Innervation of the elbow joint: Is total denervation possible? A cadaveric anatomic study.

The aim of this anatomical study was to find out if total denervation of the elbow joint is technically feasible. The endbranches of the brachial plexus of eight fresh-frozen upper arm cadavers were dissected with optical loupe magnification. All major nerves of the upper limb (except the axillary and the medial brachial cutaneous nerve) give some terminal articular endbranches to the elbow. The articular endbranches arise from muscular endbranches, cutaneous endbranches, or arise straight from the main nerves of the brachial plexus. A topographic diagram was made of the different nerves innervating the elbow joint. The ulno-posterior part of the elbow is innervated by the ulnar nerve and some branches of medial antebrachial cutaneous nerve. The radial-posterior part of the elbow is innervated exclusively by the radial nerve. The ulno-anterior part of the elbow is innervated by the median nerve and the musculocutaneous nerve. The radio-anterior part of the elbow is innervated by the radial nerve and the musculocutaneous nerve. These elbow innervation findings are relevant to both anatomical and clinical field as they provide evidence that the total denervation of the elbow joint is impossible. Nevertheless, partial denervation, like denervation of the lateral epicondyle or the ulnar part of elbow, is technically possible.

Osteonecrosis of the Lunate Following Three-Corner Arthrodesis: A Case Report.

Scaphoid lunate advanced collapse (SLAC) is the most frequently encountered cause of wrist osteoarthritis. Proximal row carpectomy (PRC) and four-orner arthrodesis (4CA) are the two main surgical options to address it. Three three-corner arthrodesis (3CA) was introduced in 1997 as an alternative to PRC and 4CA. It is a motion preserving midcarpal arthrodesis easier to perform than 4CA, for which the literature has documented satisfactory outcomes and low complication rates. We report a case of a SLAC wrist treated with 3CA complicated by postoperative osteonecrosis of the lunate. To our knowledge, this complication has not been previously reported. Our patient developed osteonecrosis of the lunate 1 year after 3CA despite a good consolidation of the arthrodesis. In this case study, we discuss reasons this may have occurred, the aetiology of which is likely multifactorial. We are reporting this case to inform surgeons of this potential complication after 3CA. Level of Evidence: Level V (Therapeutic).

Volar Ganglion Cyst and Echo-Guided Assistance for the Arthroscopic Removal.

The ganglion of the wrist is very common but with uncertain prognosis. The arthroscopic resection seems to improve the result compared with open procedure, in decreasing recurrence and morbidity. Volar ganglions are close to the radial artery, the flexor pollicis longus tendon, and even the median nerve. Ultrasonography combined with arthroscopy offers incomparable safety for the resection of volar ganglions. The technical steps of this combined procedure are described, and the first published series are discussed.

Results of open arthrolysis for elbow stiffness. A series of 22 cases.

Severe posttraumatic elbow stiffness represents a significant invalidity. Between 1990 and 2005 two surgeons performed open elbow arthrolysis in 30 adult patients (6 women, 24 men, mean age 30.8 years). All cases resulted from severe initial trauma, which had occurred on average 15.5 months previously. Four patients had extrinsic and 18 had mixed contractures; 13 had heterotopic ossifications. Operative complications included two peroperative joint instabilities and 3 transient nerve palsies. Seven elbows were remobilized under anaesthesia, one month after the arthrolysis. Twenty-two patients could be reviewed, on average 56 months after the arthrolysis. Seventy seven percent of the patients were satisfied. At final follow-up, the average arc of flexion-extension was 95 degrees +/- 15 degrees (average flexion 120 degrees +/- 13 degrees, average flexion contracture 31 degrees +/- 6 degrees), with a mean improvement of 51 degrees relative to the preoperative range (p < 0.001). The average arc of forearm rotation at final follow-up was 151 degrees +/- 23 degrees, with a mean improvement of 41 degrees (p < 0.05). No patient suffered persistent weakness or instability. The average VAS was 5/10, the average MEPI score 76, with 6 excellent, 6 good, 6 fair and 4 poor results, mainly because of persisting pain. The average DASH score was 31.6 and the average SF-36 was 66. Significant correlations were observed between VAS and DASH, MEPI and SF-36. This series demonstrates that open arthrolysis may restore acceptable elbow motion in young active patients presenting with elbow stiffness following major trauma. However, full restoration of motion is rare; only 18% of the patients regained the functional arcs of motion reported by Morrey, but the majority were satisfied, given their preoperative degree of elbow stiffness. The ultimate result from both the patient's and the surgeon's perspectives is strongly dependent on persisting pain, which was frequent in this series and influenced the DASH, MEPI and the SF-36 scores. Arthrolysis did not address the issue, if pain was the chief complaint.

Arthroscopically Assisted Eaton-Littler Trapeziometacarpal Ligamentoplasty.

Background Eaton-Littler ligamentoplasty has proven its efficacy in the treatment of trapeziometacarpal (TMC) instability. Description of Technique In this article, we describe the arthroscopically assisted Eaton-Littler ligamentoplasty through two clinical cases. Patients and Methods Arthroscopy is used to accurately place the metacarpal bone tunnel and pass the slip of flexor carpi radialis tendon in the latter. This procedure avoids soft-tissue dissection and could improve the outcome of this well-known surgery. Results The two clinical cases showed good short-term outcome with a decrease of pain and good function. Conclusions Arthroscopy to assist Eaton-Littler TMC ligamentoplasty is technically feasible, allowing a less invasive surgery. A larger prospective controlled study with a longer term outcome is mandatory to assess the real advantages of this modified procedure.

Radiocapitellar joint contacts after bipolar radial head arthroplasty.

PURPOSE: The purpose of this study was to determine radiocapitellar contacts before and after radial head replacement, using the bipolar design of Judet. METHODS: Joint contacts were measured by moulding the joint surfaces of 6 fresh-frozen cadaveric specimens, in various positions of elbow flexion and forearm rotation. RESULTS: Expressed as function of the radial cup, contact areas averaged 44% in the normal elbow, decreasing with flexion and increasing with supination (P < .05). After prosthetic implantation, contact areas averaged 33% and remained quite similar, irrespective of elbow position. Subluxation of the prosthetic head over the lateral margin of the trochlea was seen systematically with supination. CONCLUSIONS: Because of intraprosthetic mobility, contact areas were not dependant on elbow position. This adaptability, however, also led to abnormal positioning of the prosthetic radial head with supination, subluxing over the trochlea lateral margin.

Treatment of diaphyseal clavicular nonunion with special emphasis on microsurgery.

Diaphyseal fractures of the clavicle had until recently the reputation to always heal with abundant callus formation, except if operated, due to a reported high rate of nonunion after plate fixation by older series. The reason would be that the bone has only periosteal vascularization, easily destroyed by periosteal stripping for implant apposition. Bone autograft and external fixation has been reported as the best technique to heal a nonunited clavicle nonunion. Are these classical considerations still valid nowadays? The purposes of this article focusing only on diaphyseal clavicular fractures are to review the vascularization of the bone, the rate of nonunion after nonoperative treatment, the indications and techniques of osteosynthesis, and the treatment possibilities of an established nonunion. This article will not deal with the specific problems of the lateral clavicular fractures, which are equivalent to acromio-clavicular fracture-dislocations, nor of medial fractures, close to the sterno-clavicular joint.