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The clinical assessment of a hypertonic upper limb in central neurological diseases should be analytical, systematic (shoulder, elbow, extrinsic and intrinsic hand) and focused on the patient or caregiver's wishes and on the expected objectives (esthetic, hygienic, functional). Nerve blocks can help to separate mixed contractures, show the existence of antagonist muscles or find a starter muscle in dystonia patterns. The etiology (especially the evolving nature of the disease), general health condition (especially in older adults), associated deficits (cerebellar, sensory and cognitive; hemineglect) are considered together to arrive at a contract with patients and/or caregivers., (Copyright © 2021. Published by Elsevier Masson SAS.)

Neuro-orthopedic complications of the upper limb affect all of its joints and lead to a multitude of clinical pictures. The clinical assessment, which should be multidisciplinary, will have to answer basic questions to define the goal(s) and the appropriate surgical strategy. What is the patient's and family's complaint? What is the possible utility of the deformities? What is the type of deformity? Is it reducible or not? What is the contribution of the upper limb deformities versus that of any associated injuries to the discomfort? Several difficulties exist in the clinical assessment: evaluation of the antagonists especially the wrist extensor muscles; the intrinsic deformity component, which can be masked by the extrinsic component when retracted, the muscles responsible for a wrist flexion contracture and the complex shoulder deformities. Many patients have multiple deformities, which creates a problem for the hierarchy of corrections depending on the objectives. The answer to these questions helps to define a clear objective that will be formalized in a contract with the patient and subsequently to define the surgical strategy. Surgery is based on a simple principle: relax the muscles on the side of the deformity, either by selective neurotomy if there is a simple hypertonia, or by a tendon procedure if the muscle is retracted; compensate for the antagonists if they are deficient, and potentially stabilize the joint. Conservative procedures are preferred to preserve the possibility of functional recovery in the future. The wide range of medical and surgical solutions allows the patient's care to be personalized. In the upper limb, the results are better for hygienic, positioning, and analgesic objectives. They remain more difficult to obtain for functional objectives, due to the biomechanical complexity of gripping., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Neurogenic heterotopic ossifications (NHOs) are periarticular ectopic ossifications that frequently develop after a central nervous system injury, most often a traumatic one. They limit range of motion and cause pain, interfering with limb positioning and function, whether active or passive. Highly described in the lower limbs, NHOs can also develop in the upper limb, with specific characteristics depending on their location. This article provides a summary of the diagnostic and therapeutic management of NHOs in the upper limb, based on the current literature., (Copyright © 2021 SFCM. Published by Elsevier Masson SAS. All rights reserved.)

Background: Neurogenic heterotopic ossification (NHO) is usually treated by surgical excision. Postoperative infection (POI) is a possible complication, whose epidemiology, causative organisms, and risk factors are poorly known. We therefore conducted a case-control study to (1) identify the risk factors for POI after surgical excision of NHO at the hip, (2) determine the frequency of POI, (3) and identify the causative organisms., Hypothesis: Risk factors for POI after NHO excision at the hip can be identified., Material and Methods: In this retrospective case-control study, the BANKHO database for patients with NHO at our centre was used to identify risk factors by comparing patients with and without POI after NHO excision at the hip. To this end, odds ratios (ORs) with their 95% confidence intervals (95%CIs) were computed for each main criterion. Postoperative follow-up was at least 6 months., Results: Between 1993 and 2013, 411 hip NHO excisions were performed. Among them, 42 (10%) were followed by POI. The American Society of Anesthesiologists (ASA) score was I in 2/42 (5%) patients with vs. 74/369 (20%) patients without POI, II in 30/42 (71%) patients with vs. 258/369 (70%) patients without POI, and III in 10/42 (24%) patients with vs. 37/369 (10%) patients without POI (P<0.01). Mean age was 31±11 years (range, 17-79years) in the group with POI and 39±14 years (range, 15-77years) in the group without POI (P<0.01). The NHO was related to spinal cord injury in 26/42 (62%) patients with POI compared to 92/369 (25%) patients without POI (P<0.01). ORs indicated a significant risk increase in patients with an ASA score of III (2.84; 95%CI, 1.28-6.31), age younger than 30 years (1.85; 95%CI, 1.03-3.32), and spinal cord injury as the cause of NHO (4.89; 95%CI, 2.67-8.98). The predominant organisms were staphylococci (skin flora) in the patients with spinal cord injury and bacteria commonly found in intensive care units in the other patients., Discussion: A higher ASA score, younger age, and spinal cord injury as the cause of NHO at the hip are risk factors for POI. The proportion of patients with POI after hip NHO excision was 10%, in accordance with previous reports. POI was more common among patients with spinal cord injury (22% vs. 5% in the other patients). Neither changes in prophylactic antibiotic therapy regimens nor the institution of a detailed skin preparation protocol affected the frequency of POI. Skin pH alterations may deserve to be investigated with the goal of diminishing the risk of POI, most notably in spinal cord injury patients., Level of Evidence: III, case-control study., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Introduction: Because the extreme diversity of clinical situations makes formal clinical trials difficult to carry out, animal models of periprosthetic infection in orthopaedics are needed to understand the aetiology and pathology of these infections, and to test new treatment methods. These experimental models must reproduce the features of the infections encountered in clinical practice. One of the model variables is the method of inoculation: local (intra-articular), intravenous or intra-arterial. Another is the timing of the inoculation: intra-operative or postoperative. Together, these options simulate the different contamination methods: direct, by proximity or blood-borne. However, the chosen inoculation route can also affect the infection rate and severity in the various models, and in some cases do not accurately reproduce the postoperative infections encountered clinically., Hypothesis: The direct inoculation method is the most effective for inducing a local infection on a foreign body in a joint, and the least iatrogenic., Methods: A critical analysis of published studies was carried out to evaluate each model against three endpoints, according to the type of inoculation. The primary endpoint was the infection rate, which should be as close as possible to 100%. The secondary endpoints were the mortality rate and rate of spontaneous healing, both of which should be as low as possible. Twenty-one articles were reviewed., Results: Intra-articular and intra-medullary inoculations had induction rates between 70 and 100%; intra-arterial inoculations had an induction rate of 100%, while intravenous inoculation had a rate of 47 to 77%. The mortality rates were lower with the intra-articular and intramedullary inoculations (5 to 23%) than for the intra-arterial inoculations (37%) and intravenous inoculations (28 to 56%). The spontaneous healing rate was 0 to 30% for intra-articular and intramedullary inoculations, 30 to 53% for intravenous inoculations and 0% for intra-arterial inoculations., Conclusion: Direct inoculation methods are most effective at reproducing chronic periprosthetic joints infections, without putting the animal's life at risk or allowing for spontaneous healing. The simulation of blood-borne infections is more random., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Introduction: Patients with neurological disorders often exhibit dislocation or subluxation of the hip. Anterior dislocation is rare, little known, and often associated with deformities. Its surgical treatment has rarely been studied., Hypothesis: Hip surgery (with open reduction, femoral and pelvic osteotomy, and adapted tenotomies) could provide a centered hip that is supple and painless., Materials and Methods: Ten hips (seven dislocated, three subluxated) in six patients with a mean age of 8.3 years were operated between 1995 and 2009 and revised with a mean follow-up of 6.5 years. The deformities comprised four cases of abduction, extension, and external rotation and six cases of adduction, extension, and external rotation. Four patients had lost the ability to walk or maintain the sitting position. Intraoperative findings were an increased neck-shaft angle, anterosuperior acetabular dysplasia, and in only one case increased femoral anteversion. In all cases of dislocation, open reduction was necessary, and all hips underwent pelvic and femoral osteotomy., Results: At the longest follow-up, hips were centered on X-rays. Five patients could walk or sit as they had done before and hips were supple, with no deformities., Discussion: The study of deformities and intraoperative findings is mandatory for surgical management, whose mid-term results are encouraging. Femoral anteversion does not seem to be excessive, but the increase of femoral valgus is constant, as is anterosuperior acetabular dysplasia. We propose a decision tree for the management of these patients., Design of Study: Retrospective. LEVEL OF SCIENTIFIC EVIDENCE: IV., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)