B. Coulet

Comparative Clinical Outcomes of Submuscular and Subcutaneous Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome

PURPOSE To determine retrospectively whether the technique of ulnar nerve transposition (subcutaneous versus submuscular) is associated with clinical sensory and motor recovery in cubital tunnel syndrome, and whether recovery is influenced by prognostic factors such as preoperative McGowan stage, age, and duration of symptoms. METHODS Twenty-five patients (average age, 53 years; follow-up, 7 years) with cubital tunnel syndrome had submuscular transposition, and 24 patients (average age, 46 years; follow-up, 3 years) were treated by subcutaneous transposition. There were 11 McGowan stage II and 14 stage III patients in the submuscular group and 14 stage II and 10 stage III patients in the subcutaneous group. Preoperatively, all patients presented with diminished 2-point discrimination. Postoperative sensory and motor recovery was evaluated clinically. RESULTS There was no significant difference between subjective results in the submuscular and subcutaneous groups: 20 of 25 patients in the submuscular group versus 17 of 24 patients in the subcutaneous group were clearly improved, and 3 of 25 patients in the submuscular group versus 6 of 24 patients in the subcutaneous group partially improved. The logistic multivariate regression analysis indicated that sensory and motor function were both significantly improved following both surgical techniques. Sensory function recovered (2-point discrimination <6 mm) in 17 of 25 patients in the submuscular group and in 17 of 24 patients in the subcutaneous group, and motor function recovered (intrinsic strength grade 5) in 19 of 25 patients in the submuscular group and in 19 of 24 patients in the subcutaneous group. Symptoms lasting more than 6 months were associated with a poor prognosis. CONCLUSIONS Sensory and motor recovery for patients with McGowan stages II and III of cubital tunnel syndrome were similar following submuscular and subcutaneous transposition techniques, and patients with symptoms lasting longer than 6 months had a worse prognosis regardless of surgical technique.

A Comparison of Intercostal and Partial Ulnar Nerve Transfers in Restoring Elbow Flexion Following Upper Brachial Plexus Injury (C5-C6±C7)

PURPOSE Restoring active elbow flexion is essential in the surgical management of C5-C6 +/- C7 brachial plexus palsies. This study compares the clinical results of 2 techniques to restore elbow flexion: the partial ulnar nerve transfer and the intercostal nerve transfer. METHODS Partial ulnar nerve transfer was performed in 23 patients, and intercostal nerve transfer was performed in 17 patients. For both techniques, the transfer to the musculocutaneous nerve was made at the same anatomical point. Age and preoperative delay were comparable between groups of patients. RESULTS Biceps reinnervation time was significantly earlier (p = .001) in the ulnar nerve technique (mean, 5.1 mo) than the intercostal nerve technique (mean 9.9 mo). Ten of 17 patients recovered useful elbow flexion force (British Medical Research Council grade >M3) in the intercostal nerve transfer group, compared with 20 of 23 patients in the ulnar nerve transfer group. No patient who had surgery more than 6 months after the injury recovered useful elbow flexion force in the intercostal nerve transfer. Elbow flexion strength was better in patients less than 30 years old in the intercostal nerve group. No complications were observed in either group. CONCLUSIONS This study shows that transferring fascicles of the ulnar nerve yields better results than intercostals nerve transfer for restoring elbow flexion. Moreover, preoperative delay and age are important preoperative prognostic factors for the intercostal nerves transfers. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Injured metamere and functional surgery of the tetraplegic upper limb

The size of injured metamere (IM) in tetraplegia exhibits a high variability that explains the different clinical presentations in patients who have the same neurologic level. Even when functional electrical stimulation is not planned, the lower motor neuron (LMN) integrity of paralyzed muscles must be evaluated, especially in patients with high-level tetraplegia. During the acute phase, detecting the size of the IM is important to prevent supination contracture and stiffness of the thumb and finger joints. When planning functional surgery, the LMN integrity of intrinsic muscles helps the surgeon adapt his surgical procedures. Assessing IM size must be integrated systematically into the evaluation of tetraplegic patients.

Transplantation of adult myoblasts or adipose tissue precursor cells by high-density injection failed to improve reinnervated skeletal muscles

We previously showed that transfer of adult myoblasts (MB) into cardiotoxin‐damaged muscle improved the properties of reinnervated tibialis anterior muscle of rabbits. However, this cell therapy protocol cannot be applied to humans because of the hazardous effects of the myotoxin. To circumvent this approach, we used the recently developed high‐density injection technique to autotransplant cultured cells 1 mm from each other into the tibialis anterior muscle without previous cardiotoxin‐induced damage. Two months after transection and immediate suture of the common peroneal nerve, we transferred by this technique two types of precursor cells, MB or cells isolated from the adipose tissue stromal vascular fraction. In contrast to our previous results, muscles studied at 4 months showed no benefits in terms of function or morphology, whatever the transferred cells. These results, together with the results of earlier studies, emphasize the importance of delivery methods and the muscle environment in supporting cell integration into host tissues. Muscle Nerve, 2007

Free Gracilis muscle transfer to restore elbow flexion in brachial plexus injuries.

INTRODUCTION Restoration of elbow flexion is an important step in managing brachial plexus injuries. After more than one year of functional denervation, the muscle atrophy is significant enough that transferring a free muscle to act as a new effector becomes a treatment option. The goal of this study was to evaluate the effectiveness of transferring a gracilis free muscle, innervated by three intercostal nerves, to restore elbow flexion. MATERIAL AND METHODS This was a retrospective study of a series of gracilis transfer procedures in 12 men having an average age of 25.6 years (23-37) and average follow-up of 112 months (28-260). The patients were operated on average at 42 months (14-153) following their motor vehicle accident; five had a partial paralysis (C5C6C7) and seven had a complete paralysis (C5-T1). The surgical technique and rehabilitation protocol were the same for all the patients. RESULTS There were two cases of acute arterial thrombosis (17%) that led to functional failure. When these two cases were excluded from the analysis, all the remaining patients had a useful result (British Medical Research Council score ≥ M4) and 2.5 kg of elbow flexion strength measured on a dynamometer. The strength was 3.8 kg (2.7 to 55) for partial plexus injuries and 1.6 kg (0.3 to 1.5) for complete plexus injuries. For partial injuries, active elbow flexion was 128° and extension -38°, versus 103° and -23° for complete injuries. The average DASH score was 42 for partial injuries and 32 for complete injuries. DISCUSSION Free Gracilis muscle transfer is a challenging technique that leads to reproducible and encouraging results, but has vascular failure rate that cannot be ignored. When compared to published results, our series provides similar results to primary suturing performed within 6 months for cases of complete paralysis and within 12 months for cases of C5C6C7 partial paralysis; our series was better for cases beyond 12 months.

Impact of cardiovascular risk factor on the prevalence and severity of symptomatic full-thickness rotator cuff tears

INTRODUCTION The natural history of rotator cuff (RC) tears is likely multifactorial. Two theories have been put forward to explain them: extrinsic and intrinsic. Cardiovascular (CV) risk factors may be important in the context of the intrinsic theory. OBJECTIVES The objectives of this study were to demonstrate the influence of CV risk factors and their cumulative effect on the prevalence of symptomatic full-thickness RC tears and on the severity of these lesions. MATERIAL AND METHODS A prospective observational case-control study was carried out with 206 consecutive patients undergoing arthroscopic rotator cuff repair. The control population consisted of 100 consecutive patients of the same age who had asymptomatic unoperated shoulders and were being operated in the orthopedics unit. The full-thickness RC tears were classified intraoperatively using the Southern California Orthopaedic Institute (SCOI) classification described by Snyder. CV risk factors were rated as either present or absent: smoking, high blood pressure (HBP), diabetes, alcoholism, dyslipidemia, obesity and CV history. RESULTS Using a multivariate analysis, two factors were identified as having a significant influence on the prevalence of RC tears: smoking (OR=8.715, 95%CI=4.192-18.118, P<0.0001) and dyslipidemia (OR=4.920, 95%CI=2.046-11.834, P=0.0004). The following factors had a significant effect on the severity of RC tears: smoking (OR=1.98, P=0.0341, 95%CI=1.05-3.74), HBP (OR=3.215, P=0.0005, 95%CI=1.67-6.19) and history of CV disease (OR=6.17, P<0.0001, 95%CI=2.5-14.78). The case patients had an average of 2.09 CV risk factors while the control patients had an average of 0.74 (OR=3.56, 95%CI=2.18-6.33, P=0.0012). The average number of CV risk factors increased as the severity of the tear increased: 0.19 for stage 1, 1.75 for stage 2, 2.75 for stage 3 and 2.90 for stage 4. DISCUSSION Modification of the vascular background appears to influence the severity and prevalence of tears. This corroborates anatomical studies in which a hypovascular area was identified in the tendon, 10-15 mm from the lesser trochanter attachment. Smoking, high blood pressure and obesity have been identified in other published studies as risks factors for the severity and prevalence of RC tears. However, it will be important to dissociate prevalence issues from that of RC healing in patients with compromised vascularity. CONCLUSION Cardiovascular risk factors have a significant role in the pathology of RC tears. The prevalence of RC tears is greater in patients who smoke or have dyslipidemia. Their severity is greater in patients who smoke, have high blood pressure or have experienced at least one CV event. The next step will be to study how these factors affect tendon healing, as this information could change our indications for cuff repair.

Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients: TECHNIQUE AND RESULTS

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2 degrees pronation (-70 degrees to 80 degrees ) to 95.8 degrees supination (80 degrees to 140 degrees ). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6 degrees (60 degrees to 90 degrees ) in pronation and 50.4 degrees (0 degrees to 90 degrees ) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.

Calcified glomus tumor of the shoulder. A case report.

The authors report a case of calcified glomus tumor of the shoulder in a 54-year-old woman. The nonspecific clinical findings and the noncharacteristic imaging results made diagnosis of this tumor impossible before surgery. The diagnosis was confirmed by a biopsy. The outcome after surgical resection was excellent.

Radiocapitate Congruency as a Predictive Factor for the Results of Proximal Row Carpectomy

PURPOSE To evaluate whether the congruency between the joint surfaces of the lunate fossa of the distal radius and the proximal capitate might be a prognostic factor for functional, clinical, or radiographic results after proximal row carpectomy (PRC). METHODS After reconstructing the computed tomographic arthrogram of patients with PRC, we evaluated the shape of the proximal capitate by measuring the radius of curvature of the tip of the capitate. The congruency of the future radiocapitate joint was then evaluated by the radiocapitate index in the frontal and sagittal planes. This was calculated by dividing the radius of curvature of the tip of the capitate by the mean radius of curvature of the lunate fossa. We determined the relationship between these morphological results and the functional (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Wrist score, and pain relief), clinical (mobility and strength) and x-ray results (radiocapitate arthrosis). RESULTS A total of 27 patients were reviewed at a mean follow-up of 59 months. The shape of the proximal capitate did not affect outcomes. In the frontal plane, a better radiocapitate congruency was significantly associated with an increase in wrist flexion and better functional results for the DASH. There was a non-significant relationship between congruency and improvement of Mayo Wrist score and pain relief. In the sagittal plane, the DASH score tended to improve when congruency was better. CONCLUSIONS The shape of the capitate was not a prognostic factor for functional outcome after PRC. The radiocapitate index seems more relevant in predicting results at last follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.

Proximal interphalangeal joint arthroplasty with Neuflex® implants: relevance of the volar approach and early rehabilitation.

Proximal interphalangeal joint arthroplasty through a volar approach preserves the extensor apparatus, which allows for early active rehabilitation. Here, we report on the results of 28 silicone implants in patients suffering from rheumatoid arthritis (12 joints) or osteoarthritis (16 joints) with a mean follow-up of 39 months. Pain was reduced significantly after arthroplasty. Range of motion increased significantly by 29° with a mean postoperative value of 58°; the mean extension deficit was reduced from 14° to 5°. There were 18 cases of preoperative ulnar drift with a mean value of 13°, compared with 13 cases postoperatively with a mean value of 7°. Three cases (10%) of implant fracture were noted on the radiology reports. The mean DASH score at follow-up was 35/100. Immediate active mobilization led to significant shortening in recovery time. The improvement in mobility and extension seems to be higher than that obtained with other approaches. Clinodactyly remains problematic no matter the type of arthroplasty.