Gaston Maignon

Evaluation of simplified Frykman and AO classifications of fractures of the distal radius. Assessment of interobserver and intraobserver agreement.

Summary. In order to evaluate interobserver and intraobserver agreement of the Frykman and AO classifications and their variations between assessors with different levels of experience, three hand specialists, a fellow and two senior residents classified radiographs of 200 fractures of the distal radius in anteroposterior and lateral views. Reproducibility was assessed by the use of the proportion of agreement and kappa coefficient between pairs of observers. The Frykman classification showed moderate interobserver reproducibility (kappa = 0.43) and good intraobserver reproducibility (kappa = 0.61). The experience of the reviewers did not significantly affect either of these. The AO system showed regular interobserver reproducibility (kappa = 0.37) and moderate intraobserver reproducibility (kappa = 0.57). The younger group obtained higher intraobserver agreement than the senior. Possible causes for the low reproducibility of both classifications are discussed together with a review of the literature. We do not recommend the Frykman or AO classifications for clinical application because of their questionable reproducibility.Résumé. Les classification des fractures de l’ extremité distal du radius est un thème de controverse. Les objectifes du travail sont de déterminer la reproductivité intra et interpersonnelle des classifications de Frykman et AO et évaluer ses variation avec l’expérience des observateurs. Trois spécialistes en chirurgie de la main et trois chirurgiens orthopédiques en formation ont evalué deux cents paires radiographiques en face et en profil. La reproductivité a été calculé en utilisant la proportion d’accord et le coefficient “kappa”. La classification de Frykman a obtenu une reproductivité interpersonnelle modéré (kappa = 0.43) et une bonne reproductivité intrapersonnelle (kappa = 0.61). L’experience des évaluateurs n’intervient pas. La classification AO a montré une reproductivité interpersonnelle régulière (kappa = 0.37) et une reproductivité intrapersonnelle modéré (kappa = 0.57). Ce sont les non spécialistes qui ont obtenu les meilleurs valeurs de reproductivité intrapersonnelle. Cette différence a été statistiquement significative. On discute les possibles causes de la baisse de reproductivité dans ce groupe d’observateurs avec la litterature. Nous ne recommandons pas l’usage de ces classifications dans la pratique quotidienne.

Case Reports: Heritable Thrombophilia Associated with Deep Venous Thrombosis after Shoulder Arthroscopy

Thromboembolic complications after shoulder arthroscopy are rare and their cause has not been well determined. Heritable thrombophilia has been studied in relation to numerous clinical conditions, and it has been associated with thromboembolic complications after some orthopaedic surgeries, especially after total hip or knee arthroplasty. We report three patients who had deep vein thrombosis develop after shoulder arthroscopy. All three tested positive for heritable thrombophilia, a condition undetected until this complication occurred. This report highlights the possibility that unrecognized coagulation disorders might seriously influence the clinical outcome of minimally invasive surgery. We suggest heritable thrombophilia is a possible risk factor for or etiology of deep vein thrombosis after shoulder arthroscopy.

Arthroscopic treatment of synovial chondromatosis of the shoulder: Report of three patients

Synovial chondromatosis (SC) is a rare arthropathy that affects diarthrodial joints. It is 3 times more common in men than in women, and it is most commonly diagnosed between ages 30 and 50. The disorder is characterized by multiple nodules of metaplastic cartilage cells that suffer endochondral ossification. The process follows 3 stages: (1) active intrasynovial disease without loose bodies, (2) transitional lesions with synovial proliferation and free loose bodies, and (3) loose bodies without synovial disease. Patients with SC often report a history of pain, swelling, and decreased range of motion (ROM); the symptoms may be present for several years. Although spontaneous regression has been recorded, the treatment of choice is the surgical removal of the loose bodies and synovectomy. The arthroscopic approach has been proposed as an attractive alternative with many advantages over open surgery. We report 3 patients with SC of the shoulder who were treated arthroscopically. Two of these patients also required capsular release for restriction of their ROM. We also discuss the correct time to perform the procedure.

Corticosteroid Injections Accelerate Pain Relief and Recovery of Function Compared With Oral NSAIDs in Patients With Adhesive Capsulitis A Randomized Controlled Trial

Background: Intra-articular corticosteroid injection is a common therapy for adhesive capsulitis, but there is a lack of prospective randomized controlled studies analyzing the efficacy of single injections applied blindly to accelerate improvement in pain and function. Hypothesis: In patients with adhesive capsulitis, a single intra-articular corticosteroid injection without image control applied before the beginning of a physical therapy program will accelerate pain relief and recovery of function compared with oral nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 74 patients with primary adhesive capsulitis in the freezing stage were randomized to receive either intra-articular injections with betamethasone or oral NSAIDs. Clinical outcome was documented at baseline and after 2, 4, 8, and 12 weeks and comprised a visual analog scale (VAS) for pain, the American Shoulder and Elbow Surgeons (ASES) Shoulder Score, the abbreviated Constant-Murley score, and the abbreviated Disabilities of the Arm, Shoulder and Hand (QuickDASH) score for function. Passive range of motion was measured with a goniometer. Results: Patients treated with corticosteroid injections achieved faster pain relief compared with control patients during the first 8 weeks after treatment (P < .001). However, no significant difference in pain was observed among the groups at final follow-up. Likewise, shoulder function and motion improved significantly in both groups at all follow-up points. Shoulder function scores and most motion parameters improved faster in the injection group up to week 8 (P < .001). Again, no significant differences in function or motion were seen at final follow-up. Conclusion: In patients with adhesive capsulitis, a single corticosteroid injection applied without image control provides faster pain relief and earlier improvement of shoulder function and motion compared with oral NSAIDs.

Return to Sports After Plate Fixation of Displaced Midshaft Clavicular Fractures in Athletes

Background: Recent prospective randomized trials support primary plate fixation of displaced midshaft clavicle fractures. However, the safety and efficacy of this practice have not been well documented in athletes, nor has the time to return-to-sport. Purpose: To analyze the time to return-to-sport, functional outcomes, and complications in a group of athletes with displaced midshaft clavicle fractures treated using precontoured locking plates. Study Design: Case series; Level of evidence, 4. Methods: A total of 54 athletes with displaced midshaft clavicle fractures were treated with plate fixation between November 1, 2008, and December 31, 2012. The mean follow-up time was 22.4 months. Patients completed a questionnaire focused on the time to return-to-sport and treatment course. Functional outcomes were assessed with the Constant score and short version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire. Pain was evaluated with the visual analog scale (VAS). Radiographs were reviewed to identify radiographic union time, malunion, and nonunion. Results: Of the 54 patients, 53 returned to sports after open reduction and internal fixation of their fracture; 94% returned to the same level. The mean time to return-to-sport was 68 days (range, 5-180 days). Nine (16.6%) of the cases returned to sports before 6 weeks after surgery, 40 (74%) returned between 6 and 12 weeks, and 5 patients (9.2%) returned 12 weeks after surgery. The mean Constant score was 94.1 ± 5.2 (range, 78-100), and the mean QuickDASH score was 0.4 ± 4.7 (range, 0-7.1). The mean VAS pain score during follow-up was 0.29 ± 1.0 (range, 0-5). Three major complications occurred: 1 extrinsic compression of the subclavian vein, 1 nonunion, and 1 hardware loosening. Hardware removal was necessary in 5 patients (9.3%). Conclusion: Plate fixation of displaced clavicle fractures in athletes is a safe procedure resulting in excellent functional outcomes, with an early return to the same level of sports in the majority of patients.

Arthroscopic Removal and Rotator Cuff Repair Without Acromioplasty for the Treatment of Symptomatic Calcifying Tendinitis of the Supraspinatus Tendon

Background: Calcified rotator cuff tendinitis is a common cause of chronic shoulder pain that leads to significant pain and functional limitations. Although most patients respond well to conservative treatment, some eventually require surgical treatment. Purpose: To evaluate the clinical outcome with arthroscopic removal of calcific deposit and rotator cuff repair without acromioplasty for the treatment of calcific tendinitis of the supraspinatus tendon. Study Design: Case series; Level of evidence, 4. Methods: This study retrospectively evaluated 30 consecutive patients with a mean age of 49.2 years. The mean follow-up was 35 months (range, 24-88 months). Pre- and postoperative functional assessment was performed using the Constant score, University of California Los Angeles (UCLA) score, and Quick Disabilities of the Arm, Shoulder, and Hand (DASH). Pain was assessed by visual analog scale (VAS). Radiographs and magnetic resonance imaging (MRI) were performed to evaluate the recurrence of calcifications and the indemnity of the supraspinatus tendon repair. Results: Significant improvement was obtained for pain (mean VAS, 8.7 before surgery to 0.8 after; P < .001). The mean Constant score increased from 23.9 preoperatively to 85.3 postoperatively (P < .001), the mean Quick DASH score decreased from 47.3 preoperatively to 8.97 postoperatively (P < .001), and the UCLA score increased from 15.8 preoperatively to 32.2 postoperatively (P < .001). MRI examination at last follow-up (70% of patients) showed no tendon tears, and 96.2% of patients were satisfied with their results. Conclusion: Arthroscopic removal and rotator cuff repair without acromioplasty can lead to good results in patients with symptomatic calcifying tendonitis of the supraspinatus tendon.

Entrapment of the ulnar nerve in heterotopic ossification of the elbow: A case report

A 32-year-old man involved in a car accident sustained an isolated traumatic head injury and remained in a coma for 1.5 months. No osteoarticular lesions were present. The patient’s neurologic recovery was complete, but he had HO develop in the left elbow and knee. The elbow was painless and fixed at 40°. The pronation/supination arc was 70°. After 6 months, he had insidious onset of hypoesthesia of the ring and small fingers and weakness of the intrinsic muscles. Ulnar nerve compression was suspected, and electromyography showed moderate to severe compromise of the ulnar nerve at the elbow with decreased conduction velocity. Radiographs showed one island of HO that measured 8 5 cm with well-defined cortices and trabeculae in the posteromedial aspect of the elbow (Figure 1). A computed tomography (CT) scan demonstrated complete inclusion of the nerve within the HO (Figure 2). The patient was operated on through a medial approach. The ulnar nerve was identified until its entry in the HO (Figure 3). With the use of a Kerrison rongeur (Waldemar Link, Barkhausenweg, Hamburg, Germany), the nerve was carefully dissected and released by opening the bony tunnel (Figure 4). The HO was then resected and complete range of motion obtained, making capsulotomy unnecessary. Because the canal was scarred and fibrous, an anterior submuscular nerve transposition was performed. Elbow mobilization started 24 hours after surgery, and the patient received indomethacin (75 mg daily for 11 days). One year after surgery, he had a flexion/extension arc of 80° and complete pronation-supination.

Snapping scapular syndrome secondary to rib intramedullary fixation device

Highlights • Intramedullary rib fixation has become popular.• Snapping scapula syndrome is a cause of persistent pain around the scapulothoracic joint.• We present a case of snapping scapula secondary to migration of a intramedullary rib splint into the scapulothoracic joint.

Modified Latarjet Without Capsulolabral Repair in Rugby Players With Recurrent Anterior Glenohumeral Instability and Significant Glenoid Bone Loss

Background: The optimal management of recurrent anterior shoulder instability with significant glenoid bone loss in high-demand collision athletes remains a challenge. Purpose: To analyze the time to return to sport, clinical outcomes, and recurrences following a modified Latarjet procedure without capsulolabral repair in rugby players with recurrent anterior shoulder instability and significant glenoid bone loss. Study Design: Case series; Level of evidence, 4. Methods: Between June 2008 and June 2015, 50 competitive rugby players (practice >2 times per week and competition during weekends) with recurrent anterior shoulder instability underwent operation with the modified congruent arc Latarjet procedure without capsulolabral repair in our institution. Cases included 18 primary repairs and 32 revisions. Return to sports, range of motion (ROM), the Rowe score, a visual analog scale for pain in sport activity (VAS), and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Recurrences were also evaluated. The postoperative bone block position and consolidation were assessed with computed tomography. The final analysis included 49 shoulders in 48 patients (31 revision cases). Results: The mean follow-up was 48 months (range, 24-108 months) and the mean age at the time of operation was 22.8 years (range, 17-35 years). Forty-five patients (93.7%) returned to playing rugby, all at their preinjury level of play. No significant difference in shoulder ROM was found between preoperative and postoperative results. The Rowe, VAS, and ASOSS scores showed statistically significant improvement after operation (P < .001). The Rowe score increased from a mean of 39.5 points preoperatively to 94 points postoperatively (P < .01). The VAS score decreased from 3.6 points preoperatively to 1.2 points postoperatively (P < .01). The ASOSS score improved significantly from a mean of 44 points preoperatively to 89.5 points postoperatively (P < .01). No recurrence of shoulder dislocation or subluxation was noted. The bone block healed in 43 shoulders (88%). Conclusion: In rugby players with recurrent anterior shoulder instability and significant glenoid bone loss, the modified Latarjet procedure without capsulolabral repair produced excellent functional outcomes, with most athletes returning to rugby at their preinjury level of play without recurrences.

Arthroscopic Stabilization After a First-Time Dislocation: Collision Versus Contact Athletes

Background: There is no universally accepted definition of “contact” or “collision” sports in the literature. The few available studies evaluating contact and collision sports consider them to be synonymous. However, athletes in collision sports purposely hit or collide with each other or with inanimate objects with greater force and frequency than in contact sports, which could jeopardize functional outcomes. Purpose: To compare the functional outcomes, return to sports, and recurrences in a series of contact and collision athletes with a first-time anterior shoulder dislocation treated using arthroscopic stabilization with suture anchors. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 56 athletes were enrolled in this study, including 22 contact athletes and 34 collision athletes. All athletes underwent arthroscopic shoulder stabilization using suture anchors. Range of motion, the Rowe score, a visual analog scale (VAS) for pain, and the Athletic Shoulder Outcome Scoring System (ASOSS) were used to assess functional outcomes. Return to sports and recurrences were also evaluated. Results: The mean age at the time of surgery was 22.2 years, and the mean follow-up was 62.4 months (range, 36-94 months). No significant difference in shoulder motion was found between preoperative and postoperative results or between the contact and collision groups. The Rowe, VAS, and ASOSS scores showed statistical improvement in both groups after surgery (P = .001). Patients in the contact group returned to sports significantly faster than those in the collision group (5.2 vs 6.9 months, respectively; P = .01). In all, 43 athletes (76.8%) returned to near-preinjury sports activity levels (≥90% recovery) after surgery: 86.4% of patients in the contact group and 70.6% in the collision group (P = .04). The total recurrence rate was 8.9%. There were 5 recurrences (14.7%) in the collision group and no recurrences in the contact group (P < .01). Conclusion: Arthroscopic stabilization for anterior instability of the shoulder is a reliable procedure with respect to shoulder function, range of motion, and postoperative return to sports in contact and collision athletes. Compared with the contact group (0%), the collision group yielded a higher failure rate (14.7%). Moreover, patients in the contact group returned significantly faster (5.2 vs 6.9 months, respectively) and to and more returned to preinjury or near-preinjury activity levels (86.4% vs 70.6% of patients, respectively) than patients in the collision group.