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BACKGROUND: Fractures of the distal radius only rarely give rise to complications in the immediate postoperative period. Combined median and ulnar nerve palsy is a complication that can be missed by the surgeon. MATERIALS AND METHODS: Three cases diagnosed early after surgery are reported here. The patients were 15, 16, and 30 years of age, respectively. None had preoperative neurological deficits. The youngest patient was injured during sports and the other 2 patients during traffic accidents. All 3 patients had a displaced fracture of the distal radius combined with a fracture of the distal fourth of the ulna or ulnar styloid process and were treated by anterior plate fixation. Operative times were 47, 62, and 120minutes, respectively. Compartment syndrome was ruled out based on low pain intensity and absence of forearm tightness to palpation. RESULTS: The electrophysiological study performed 1 month post-injury in all 3 patients showed severe impairments of both median and ulnar nerve function. Median and ulnar nerve release surgery was performed in the 15-year-old 6 weeks post-injury. No nerve damage or fibrosis was seen during the procedure. All patients recovered fully within 3 months and had normal findings from follow-up electrophysiology testing after 6 months. DISCUSSION: Combined median and ulnar nerve palsy has rarely been reported and is among the rare complications of distal radial fractures that can develop in the event of a high-energy trauma and/or major displacement. Both previously published data and our experience indicate that surgical nerve release is unnecessary. Clinical recovery within 3 months is the rule. LEVEL OF EVIDENCE: IV, case-reports.

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 8years 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 1year later when the axle failed again. A custom-designed locking axle had to be used to stabilize the hinge mechanism. After 3years follow-up, the hinge was intact, there was no loosening of the components and function of the elbow was good.

Summary 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.

Summary 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.

Summary Elbow dislocations are the most frequently encountered dislocations after shoulder dislocations. In their vast majority these injuries involve only the joint and carry a good prognosis. Close anatomic proximity to the joint of neurovascular structures put them at risk of concomitant injury but this occurrence remains, actually very rare. The objective of this study is to retrospectively analyze the results of nine cases of elbow dislocations with brachial artery complications and to propose coherent therapeutic guidelines derived from this experience. Materials and methods From 1999 to 2004, 357 elbow dislocations were treated by the traumatology team at the Purpan University Hospital and 340 at the Rangueil University Hospital in Toulouse, France. These two teaching institutions combined their series, contributing to seven dislocations associated with a brachial artery partial rupture, resulting in ischemia. Between 2001 and 2006 at the Le Mans Regional Hospital Center, 138 dislocations of the elbow were treated, and included two cases involving rupture of the brachial artery. In all these institutions’ emergency departments, elbow dislocations were mainly treated on an outpatient basis: closed reduction under ultra short-acting products general anesthesia, with stability evaluation followed by cast immobilization. In the rare instances of ischemia, the artery was repaired in concert with the vascular surgery team. All the nine cases had a similar treatment protocol and were submitted to an identical outcome evaluation method. The patients were all males with a mean age of 37.3 years (range, 18–58 years). The combined injury occurred at sports in two cases, because of a fall in three cases and as a result of a traffic accident in four cases. Ischemia was complete in three cases (no radial or ulnar pulse and devascularized hand). In the six other cases, the clinical presentation was subacute. An arteriogram was obtained in five cases after reduction of the dislocation, confirming the brachial axis disruption. Median and/or ulnar nerve injury was suspected in six patients. Only five elbows remained stable after reduction allowing plaster cast immobilization. In the other cases, dislocation recurrence or consequential residual varus/valgus laxity required external fixation or a cross-pinning fixation. An autologous vein, brachial artery bypass was performed in eight cases and an end-to-end anastomosis was carried out in one case. Revascularization was reestablished between 4 and 19 h after injury (mean 10.5 h). Results All the patients were seen at a minimum of 2 years’ follow-up (mean of 4.3 years). On the basis of Mayo Clinic score, the results were considered excellent in three cases, good in four cases, and poor in two cases. No patients complained of elbow instability. The X-rays showed a reduced elbow in all cases and heterotopic ossifications in three cases. No degenerative lesion was observed at the longest follow-up. Discussion The incidence of a combined vascular injury with dislocation remains difficult to establish because the literature reports sporadic short series of clinical cases. The prevalence of this association is estimated to be between 0.3 and 1.7% in hospitals. The vascular lesion risk is probably related to the displacement extent and this later as a consequence of the injury intensity. This context calls for a diagnostic warning signal of possibly associated vascular involvement. Assessment of arterial vascularization should be systematic and mandatory with any osteoarticular injury. The slightest vascular status clinical doubt after reducing any dislocation presses for vascular patency work-up: echo-Doppler, angio-scan, arteriography. The multi-parametric nature of these combined injuries explain why their sometimes disappointing outcome remains dependent on the ability to deal with contradictory healing concerns: skin condition, capsular, and ligaments damages, type of revascularization procedure used, joint stability after closed reduction. This last parameter, being a substantial determinant for the period of immobilization, appears crucial to the final functional outcome, particularly in terms of range of motion loss or residual flexion contracture. Level of evidence Level IV. Therapeutic retrospective study.

Summary 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° to 80°, and in pronation from 66° to 84°. Improvements were 15° in ulnar inclination, 9° in radial inclination, 16° in flexion, and 23° 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.

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.

IntroductionResurfacing shoulder arthroplasty is proposed in primary osteoarthritis of the shoulder. The present study compared resurfacing versus 3rd generation stemmed hemiarthroplasty in terms of survival, functional results and implant positioning effects.Materials and methodsSeventy eight patients underwent arthroplasty for primary osteoarthritis of the shoulder: 41 by resurfacing and 37 by stemmed hemiarthroplasty. The two populations were comparable on all baseline variables. Minimum follow-up was 2 years. The principal assessment criterion was survivorship with surgical revision as end-point. Secondary criteria were functional results on Constant, quick-DASH, Neer and SSV scores, and implant positioning effects assessed on radiology.ResultsAt a mean 44 months’ follow-up (range, 24–118 months), there were no significant differences in functional scores. Radiologic analysis found greater varus positioning and lateral offset of the humeral head in resurfacing compared with stemmed hemiarthroplasty (128° vs 138°, P