P. Mansat

Results with a minimum of 10 years follow-up of the Coonrad/Morrey total elbow arthroplasty

INTRODUCTION Few series have evaluated the long-term results of total elbow arthroplasty (TEA). MATERIALS AND METHODS Fifteen patients with a Coonrad/Morrey total elbow implant were reviewed with a minimum follow-up of 10 years. There were nine women and six men with a mean age of 55 years at surgery. The aetiology was rheumatoid arthritis in eight cases, post-traumatic arthritis in five, psoriatic arthritis in one, and sequelae of neonatal septic arthritis in one. The TEA was performed as primary surgery in ten cases and during a revision surgery in four. RESULTS At 136 months average follow-up (120-160), MEPS was 82 ± 14 points (range 60-100) with a Quick DASH score of 41 points (range 13-83). Fourteen patients had no or slight pain and six had a functional range of motion. Elbow function was normal in eight of 15 patients. Radiolucent lines were found around the humerus in six cases (all of them incomplete) and around the ulnar component in eight (five of them complete) with loosening and migration of the ulnar stem occurring in two cases. Wear of the bushings was moderate in five cases and severe in two. There were ten complications with a revision needed in three cases. Revision-free survival rate for the implant was 100% at 5 years and 90% at 10 and 13 years. DISCUSSION The Coonrad/Morrey total elbow gives long-term satisfactory results. Increased incidence of radiolucent lines around the ulnar stem and bushing wear with longer follow-up is of concern and represents the failure mode for this total elbow arthroplasty implant. LEVEL OF EVIDENCE IV.

Long-term outcome of distal ulna resection-stabilisation procedures in post-traumatic radio-ulnar joint disorders.

INTRODUCTION Distal radius fractures represent 20% of fractures in adults. Although good results are usually obtained with treatment, functional sequelae are not uncommon, with injury of the distal radio-ulnar joint (DRUJ) being the most frequent. Various treatments have been described to address these disorders. Distal ulna resection-stabilisation (DURS) is our technique of choice when preservation of the DRUJ is impossible. PATIENTS AND METHOD Twenty patients operated between 1985 and 1996 were reviewed with minimum 6-year follow-up. Nine of them were men and 11 were women, with an average age 45 years. The initial trauma was a distal radius fracture in all cases. The main complaint was ulnar pain with no limitation of mobility in five patients, painful limitation of prono-supination in 14, and palmar subluxation of the ulna in one case. Radiographic evaluation and CT scan showed DRUJ incongruence in 14 patients with ulna head instability, and ulno-carpal abutment with degenerative changes at the DRUJ in six cases. In three patients, malunion of the distal radius was associated with degenerative DRUJ lesions. RESULTS The satisfaction rate was 95% at an average follow-up of 11 years (range 6.7 to 18.6 years). Pain scores decreased progressively from 2.2 to 0.5 post-operatively. Range of motion improved in supination from 37 degrees to 80 degrees , and in pronation from 66 degrees to 84 degrees . Improvements were 15 degrees in ulnar inclination, 9 degrees in radial inclination, 16 degrees in flexion, and 23 degrees in extension. Distal ulna palpation was not painful, and no instability was observed on movement. Wrist strength was equivalent to 80.8% of the healthy contra-lateral side. Radiographic results showed no anomaly of the resected ulna, no sign of abutment on the radius and no ulnar translation of the carpus at follow-up. Only one patient, who presented algoneurodystrophic syndrome after the initial trauma, had a recurrence after DURS. DISCUSSION-CONCLUSION DRUJ injuries are frequent in the context of wrist trauma. If not well-treated, they could lead to significant functional sequelae of the wrist. Radiographic evaluation should clarify the status of the DRUJ to choose between conservative or radical surgical treatment. If the DRUJ surfaces are preserved, conservative treatment, which consists of correcting the distal radius malunion and stabilising or shortening the ulna, is the treatment of choice. When the DRUJ surfaces are injured, DURS is our treatment of choice. This approach presents a low complication rate and more than 90% of satisfactory results, often with a pain-free wrist, functional range of motion and good strength. However, a rigorous technique, with limited ulna head resection, dorsal capsuloplasty, reconstruction of the extensor retinaculum and dorsal placement of the extensor carpi ulnaris tendon, is a prerequisite for success. LEVEL OF EVIDENCE Level IV retrospective therapeutic study.

The role of total elbow arthroplasty in traumatology

UNLABELLED Fractures of the distal humerus account for 5% of osteoporotic fractures in subjects older than 60 years. A history of osteoporosis, co-morbidities, and joint comminution make their management difficult. The therapeutic options are limited to functional treatments, osteosynthesis, or either partial or total arthroplasty. Functional treatment of distal humerus fractures in the elderly subject provide inconsistent results, often with persistence of pain with a stiff or unstable elbow. Osteosynthesis remains the reference treatment for these fractures, following the principle of stable and rigid osteosynthesis allowing early mobilization. However, joint comminution and a history of osteoporosis occasionally make it impossible to meet this objective, with a considerable rate of complications and surgical revisions. Total elbow arthroplasty remains an alternative to osteosynthesis with very satisfactory immediate results restoring a painless, stable, and functional elbow. These results seem reproducible and sustainable over time. The complication rate is not uncommon with an approximately 10% surgical revision rate. Elbow hemiarthroplasty remains to be validated in this indication. LEVEL OF EVIDENCE V.

Outcomes of two surgical revision techniques for recurrent anterior shoulder instability following selective capsular repair.

INTRODUCTION Conventional capsulolabral reconstruction for anterior shoulder instability fails with recurrent instability in up to 23% of cases. Few studies have evaluated surgical revision strategies and outcomes. The objective of this study was to evaluate clinical and radiographic outcomes in a homogeneous series of surgical revisions after selective capsular repair (SCR). HYPOTHESIS Observed anatomic lesions can guide the choice between repeat SCR and coracoid transfer (Latarjet procedure). MATERIALS AND METHODS From January 2005 to January 2009, 11 patients with trauma-related recurrent anterior shoulder instability (episodes of subluxation and/or dislocation) after SCR were included. Mean age was 31 years (range, 19-45 years). At revision, a glenoid bony defect was present in six patients. Repeat SCR was performed in five patients and coracoid transfer in six patients. RESULTS After a mean follow-up of 40 months (range, 24-65 months), no patient had experienced further episodes of instability. However, four patients had a positive apprehension test. External rotation decreased significantly by more than 20° after both techniques. The Simple Shoulder Test, Walch-Duplay, and Rowe scores were 10.5, 79, and 85, respectively. No patient had a subscapularis tear. Of these 11 patients, nine were able to resume their sporting activities and eight reported being satisfied or very satisfied with the subjective outcome. Radiographs showed fibrous non-union of the coracoid transfer in one patient. CONCLUSION In patients with recurrent anterior shoulder instability after SCR, repeat SCR and coracoid transfer produce similarly satisfactory outcomes. The size of the glenoid bone defect may be the best criterion for choosing between these two procedures. However, open revision surgery may decrease the range of motion, most notably in external rotation. LEVEL OF EVIDENCE Level IV.

Description and ultrasound targeting of the origin of the suprascapular nerve

Anatomical variations in the suprascapular nerve (SSN) and its depth in the suprascapular notch can make it difficult to target with ultrasonography (US). One alternative could be a proximal approach to the SSN, if US provides a reliable description of its origin (orSSN). The primary objective of this study was to demonstrate that US can reliably locate the orSSN. The secondary objective was to describe the features of the proximal SSN. Seventy brachial plexuses (BPs) from 30 healthy volunteers (60 BPs) and 5 cadavers (10 BPs) were included. There were two parts to this study: (1) description of the proximal SSN in healthy volunteers using US to determine the diameter, depth and location of the orSSN; (2) targeting of the orSSN with US in cadaver limbs to determine its distance from the needle, ink marking and locating the orSSN. In Part I, the diameter of the orSSN averaged 1.33 mm (1–9 mm) and its depth averaged 5.12 mm (2.7–10.6 mm). The orSSN was located in the upper trunk of the BP (53) or its posterior division (7). In Part II, the orSSN was successfully targeted in nine of the 10 specimens by US; the needle/orSSN distance averaged 3.8 mm (0–8 mm). The implanted needle was at the orSSN in two cases, proximal to it in seven and distal to it in one. US is a valid modality for describing and pinpointing the orSSN, irrespective of patient morphology. Clin. Anat. 30:747–752, 2017.

Mechanical failure of the Coonrad-Morrey linked total elbow arthroplasty: A case report

Semiconstrained (linked design) total elbow arthroplasty is indicated in a wide variety of cases. Long-term survival is better than with non-linked prostheses. However, mechanical failure of the hinge mechanism is a complication that may occur during follow-up. We report a case of failure of the axle assembly of a Coonrad-Morrey elbow prosthesis 8 years after implantation for nonunion of a supracondylar distal humerus fracture. Initial revision surgery included changing the axle and the polyethylene bushings. Revision surgery was necessary 1 year later when the axle failed again. A custom-designed locking axle had to be used to stabilize the hinge mechanism. After 3 years follow-up, the hinge was intact, there was no loosening of the components and function of the elbow was good.

Bilateral clavicle fracture external fixation

Fractures of the middle third of the clavicle are frequent and their conservative treatment ends in bone union in nearly 95% of cases. Surgical treatment is unanimously indicated with open fractures or in cases of cutaneous damage, neurovascular complications, and impaction of the shoulder stump syndromes. We report herein a case of bilateral fractures of the clavicle that required double stabilization with an external fixator following major cutaneous damage appearing after the initial conservative management. The intraoperative discovery of Propionibacterium acnes infection and bone union obtained within the classical time frame, with a satisfactory functional result, all retrospectively proved the soundness of this indication.

Periprosthetic shoulder infection: an overview

Periprosthetic shoulder infection (PSI) is rare but potentially devastating. The rate of PSI is increased in cases of revision procedures, reverse shoulder implants and co-morbidities. One specific type of PSI is the occurrence of low-grade infections caused by non-suppurative bacteria such as Propionibacterium acnes or Staphylococcus epidemermidis. Success of treatment depends on micro-organism identification, appropriate surgical procedures and antibiotic administration efficiency. Post-operative early PSI can be treated with simple debridement, while chronic PSI requires a one- or two-stage revision procedure. Indication for one-time exchange is based on pre-operative identification of a causative agent. Resection arthroplasty remains an option for low-demand patients or recalcitrant infection. Cite this article: EFORT Open Rev 2017;2:104-109. DOI: 10.1302/2058-5241.2.160023

Distal radius fracture malunion: Importance of managing injuries of the distal radio-ulnar joint

BACKGROUND Distal radius malunion is a major complication of distal radius fractures, reported in 0 to 33% of cases. Corrective osteotomy to restore normal anatomy usually provides improved function and significant pain relief. We report the outcomes in a case-series with special attention to the potential influence of the initial management. MATERIAL AND METHODS This single-centre retrospective study included 12 patients with a mean age of 35years (range, 14-60years) who were managed by different surgeons. There were 8 extra-articular fractures, including 3 with volar angulation, 2 anterior marginal fractures, and 2 intra-articular T-shaped fractures; the dominant side was involved in 7/12 patients. Initial fracture management was with an anterior plate in 2 patients, Kapandji intra-focal pinning in 5 patients, plate and pin fixation in 2 patients, and non-operative reduction in 3 patients. The malunion was anterior in 10 patients, including 2 with intra-articular malunion, and posterior in 2 patients. Corrective osteotomy of the radius was performed in all 12 patients between 2005 and 2012. In 11/12 patients, mean time from fracture to osteotomy was 168days (range, 45-180days). The defect was filled using an iliac bone graft in 7 patients and a bone substitute in 4 patients. No procedures on the distal radio-ulnar joint were performed. RESULTS All 12 patients were evaluated 24months after the corrective osteotomy. They showed gains in ranges not only of flexion/extension, but also of pronation/supination. All patients reported improved wrist function. The flexion/extension arc increased by 40° (+21° of flexion and +19° of extension) and the pronation/supination arc by 46° (+13° of pronation and +15° of supination). Mean visual analogue scale score for pain was 1.7 (range, 0-3). Complications recorded within 2years after corrective osteotomy were complex regional pain syndrome type I (n=1), radio-carpal osteoarthritis (n=3), and restricted supination due to incongruity of the distal radio-ulnar joint surfaces (n=3). This last abnormality should therefore receive careful attention during the management of distal radius malunion. DISCUSSION In our case-series study, 3 (25%) patients required revision surgery for persistent loss of supination. The main error in these patients was failure to perform a complementary procedure on the distal radio-ulnar joint despite postoperative joint incongruity. This finding and data from a literature review warrant a high level of awareness that distal radio-ulnar joint congruity governs the outcome of corrective osteotomy for distal radius malunion.

Neurotization of the Superficial Sensory Branch of Ulnar Nerve by the Distal Posterior Interosseous Nerve: Cadaveric Feasibility Study

Background In 2014, Delclaux et al described a case wherein the Battiston and Lanzettas technique, modified by utilization of the posterior interosseus nerve (PIN), was used to perform double neurotization of the ulnar nerve (UN). This study evaluates the feasibility of transfer of proprioceptive fascicles of the PIN to the superficial sensory branch of the UN (SSBUN). Methods The surgeries were performed on 16 fresh cadaveric wrist specimens. PIN transfer was performed through the interosseous membrane and sutured to the SSBUN. The diameter for each nerve, number of fascicles, and the percentage of fascicles without axons, under ×10, ×40, and ×100 magnifications were performed by two observers. Results Neurotization of the SSBUN by the PIN was successful in all cases. The median diameter of the SSBUN and PIN was 3.5 (3‐4) and 2.3 mm (1.6‐3), respectively. The SSBUN contained 5.5 fascicles (4‐7), while the PIN contained 2 fascicles (0‐4). The 16 PIN had limited (10 cases) or no axonal reserve (6 cases). Conclusion This study supports the surgical and anatomical feasibility of neurotization of the SSBUN by the PIN. However, the PINs limited axonal reserve may partially or totally compromise recovery.