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Loosening of the trapezial component is a main cause of failure of trapeziometacarpal prostheses. This report presents the preliminary results of scaphometacarpal prostheses used for revision of trapeziometacarpal prostheses and failed trapeziectomies. A retrospective multicentre study was conducted on ten patients. Four had revision surgery after failure of trapeziometacarpal prostheses, five after trapeziectomy and one after a trapezial silicone implant. Pain, mobility, strength, QuickDASH, satisfaction score and radiographs were assessed. Nine patients were assessed (one was lost to follow-up), with a mean follow-up of 34 months. The mean pain score was 1.2/10, Quick-DASH was 39 and opposition according to the Kapandji score was 8.6. Strength was 3 kg for key pinch and 13.6 kg for power grip. One failure was observed, with early loosening of the scaphoid cup. Scaphometacarpal arthroplasty is a reliable medium-term solution for revision of the loosening of a trapeziometacarpal prosthesis with trapezial damage and for failed trapeziectomy. Level of evidence: IV

Introduction: Repeated transfers and wheelchair propulsion in patients with a neurological deficit of the lower limbs overloads the upper limbs mechanically, particularly the shoulders, which become weight-bearing. Under these conditions, arthroplasty implants are subjected to large stresses, even though this indication is controversial in such a context. We hypothesized that joint replacement in weight-bearing shoulders will relieve pain and improve range of motion, with a positive impact on function and autonomy, without increasing the complication rate relative to the able-bodied population. Materials and Methods: This retrospective study involved 13 implants in 11 patients (4 total shoulder arthroplasty, 4 hemi-arthroplasty and 3 reverse shoulder arthroplasty) who had a mean follow-up of 33.7 ± 27 months (12-85 months). The clinical assessment included active and passive range of motion, pain, Constant score, and the Wheelchair User’s Shoulder Pain Index (WUSPI). Radiographs were evaluated to look for signs of loosening and scapular notching. The patients’ autonomy was evaluated through the number of transfers, means of locomotion (manual or electric wheelchair) and the functional independence measure (FIM). Two subgroups were defined based on the initial pathology: neurological shoulder or functional shoulder. Results: The 11 patients had a mean age of 64 ± 19 years (23-85 years) and were all long-term wheelchair users (electrical or mechanical). The pain level on VAS decreased from 8 ± 3 preoperatively to 4 ± 2 postoperatively (p = 0.003). The mean Constant score increased 90% from 22 ± 11 preoperatively to 42 ± 23 postoperatively (p = 0.008). The WUSPI score decreased by 73% from 80 ± 30 to 21 ± 15 (p = 0.001). The range of motion improved in the subgroup of patients with functional shoulders but not in the subgroup of patients with neurological shoulders. The means of locomotion was altered in five patients (63%) by the acquisition of an electric wheelchair, but with no significant change in the number of daily transfers. There were no radiographic signs of implant loosening at the final assessment. Two implants had to be revised: one anatomical prosthesis was converted to a reverse configuration because of a secondary rotator cuff rupture; one case of early infection required a two-stage implant change. Discussion: Joint replacement in weight-bearing shoulders is an effective medium-term solution for cuff tear arthropathy and glenohumeral OA, mainly for addressing pain, with slight improvements in range of motion, depending on the initial pathology. This intervention requires lifestyle adaptations such as changes in daily transfer practices and means of locomotion. Level of evidence: IV, retrospective study.

International audience; Study design: Psychometric Study.Objectives: To assess responsiveness of the Motor Capacities Scale (MCS) in people with tetraplegia who have undergone upper limb reconstructive surgery.Settings: Rehabilitation clinics in France.Methods: The MCS is an arm/hand function test with 31 basic tasks, subdivided into four sub-categories (MCS A, MCS B, MCS C, and MCS D). Data were recorded preoperatively and following full completion of the surgical program. The Functional Independence Measure (FIM) and a ten-point numeric scale related to patients' satisfaction with the overall surgical result were included. Data were analyzed using responsiveness measures-the effect size (ES), the standardized response mean (SRM), and the minimal clinically important difference (MCID).Results: Twenty-seven participants were included. Fourteen patients underwent unilateral surgery and 13 bilateral surgery. ES and SRM were moderate or good (ES/SRM of MCS B = 0.76/0.81, ES/SRM MCS C = 0.68/0.77, and ES/SRM MCS D = 0.77/0.88). For MCS A and FIM, both SRM and ES showed a small degree of responsiveness. For the MCS total score, the ES value indicated a moderate degree of responsiveness while SRM was excellent. Total MCS score, MCS C subscore and MCS D subscore showed significantly higher ES values in the "bilateral surgery" group than in the "unilateral group". The estimation of MCIDs showed low threshold values of MCS scores changes (total score and subscores) beyond which the satisfaction rate is >6.Conclusions: This study provides evidence of acceptable responsiveness of the MCS to changes using the SRM following upper limb reconstruction in patients with tetraplegia.

BackgroundFunctional Electrical Stimulation (FES) is used for decades in rehabilitation centers. For patients with a spinal cord injury (SCI), FES can prevent muscular atrophy, reduce spasticity and/or restore limb movements. To this last aim, FES external devices can be used, but elicit imprecise movements. FES implanted devices used neuromuscular stimulation and required implantation of one electrode for each site (muscle) to stimulate, an heavy surgical procedure and 10 times more electrical charges than nerve stimulation. Moreover, complications related to the numerous implanted components could appear over time. The purpose of this work is to evaluate whether a multi-contact nerve cuff electrode can selectively activate forearm and hand muscles and restore functional movements in patient with a complete tetraplegia.MethodsA 12-contacts cuff electrode was designed to selectively activate, without damage it, multi fascicular peripheral nerve (1). Six subjects rwith at least one extensor or one flexor muscle stimulable by surface electrical stimulation, have been enrolled into the study. During the surgical procedure, radial or median nerve was stimulated through up to 35 different configurations of stimulation at an intensity up to 2.1 mA (25 Hz, pulse width 250 µs, inter-pulse 100 µs). Surface electrodes were positioned upon the forearm to record compound muscle action potentials elicited by nerve electrical stimulation. Recruitments curves and videos were recorded.ResultsThe multicontact cuff electrode allowed us to selectively activate group of muscles to produce multiple, independent and functional hand and forearm movements in persons with tetraplegia. A surface electrical stimulation did not allow all those movements.

When the proximal humeral anatomy is altered because of malunion, shoulder arthroplasty is a challenge for the orthopaedic surgeon, and tuberosity osteotomy should be avoided whenever possible. The purpose of this study was to investigate the clinical and radiological outcomes of anatomic stemless shoulder arthroplasty in cases of malunion. We hypothesized that a stemless prosthesis can be implanted without performing tuberosity osteotomy. We conducted a continuous, single surgeon, retrospective case series study with a minimum follow-up of two years (mean of 44 months, range 24–80). The Constant-Murley score, active range of motion and X-rays were evaluated in 27 patients (mean age of 60 years, range 37–83) with proximal humeral malunion who were treated with a stemless anatomic shoulder prosthesis. In all patients, the prosthesis was implanted without the need for tuberosity osteotomy. The Constant score improved from 27 to 62 (p ≤ 0.001), active anterior elevation from 81° to 129° (p ≤ 0.001), and external rotation from 5° to 40° (p ≤ 0.001). There was no evidence of radiological loosening. Use of a stemless anatomic shoulder prosthesis avoids the need for tuberosity osteotomy and certain surgical difficulties, even in cases of severe tuberosity malunion, and leads to good functional outcomes in the short term.

PURPOSE: Constructing a lateral key pinch (KP) is a universal aim of any functional upper limb surgery program for tetraplegia. Three stages are required: (1) activating the pinch mechanism by flexor pollicis longus tenodesis to the radius or by tendon transfer to the flexor pollicis longus, (2) simplifying the polyarticular chain, and (3) positioning the thumb column. We compared 2 techniques for accomplishing the latter stage, 1 utilizing arthrodesis of the carpometacarpal joint (CMC) and 1 that did not require arthrodesis of the CMC. MATERIALS AND METHODS: We reviewed 40 cases of KP reconstruction at a mean follow-up of 7.4 years: 17 who had undergone CMC arthrodesis and 23 without CMC arthrodesis. In this group, an abductor pollicis longus tenodesis was necessary to properly position the thumb column in 17 patients. RESULTS: Active KP cases with CMC arthrodesis were significantly stronger than those without an arthrodesis. For passive KP cases, the difference between those cases with CMC arthrodesis and those without was not significant. Regarding opening, for active KP cases with CMC preservation alone, the mean distance between the thumb pulp and the index finger was 4.0 cm at rest and 5.8 cm when passively grasping large objects; for active KP cases without arthrodesis, these values were 3.4 and 6.8 cm, respectively, with the wrist in flexion. For passive KP cases, these values were 2.2 and 3.5 cm with CMC arthrodesis compared with 2.4 and 6.9 cm without arthrodesis. Overall, 23.5% of patients with CMC arthrodesis could not maintain contact between the thumb and the index finger compared with 30.4% without arthrodesis. CONCLUSIONS: Active KP is stronger with than without CMC arthrodesis; however, the KP reconstruction does not open as far when grasping large objects. For passive KP, CMC arthrodesis significantly limits passive opening, with no gain in strength. Neither technique is superior in terms of KP stability. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

International audience; BACKGROUND:Reverse total shoulder arthroplasty (RSA) is a recent concept that enables good functional outcomes in cases of massive rotator cuff tear and cuff tear arthropathy. Design parameters influence the functional results and complications. The purpose of this study is to present the results of a novel RSA, the Total Evolutive Shoulder System (TESS; Biomet, Warsaw, IN, USA), based on a reverse corolla without a stem.METHODS:We enrolled 101 patients with 105 RSAs in a prospective study, with a minimum follow-up period of 24 months. The analysis concerned 91 RSAs in 87 patients (61 men and 26 women), with a mean age of 73 years, at a mean follow-up of 41 months (range, 24-69 months).RESULTS:Ninety-six percent of patients rated their satisfaction as good or excellent. Mean flexion was 143° (range, 90°-170°), and mean external rotation was 39° (range, 20°-70°). The Constant score improved from 40 points preoperatively to 68 points at last follow-up (P < .001). The mean American Shoulder and Elbow Surgeons score was 24 points. The mean neck-shaft angle was 154° (range, 142°-165°). Inferior scapular notching occurred in 17 cases (19%). The notching rate was higher when the glenometaphyseal angle increased (P < .001), when the inferior tilt decreased (P = .003), and when the neck-shaft angle increased. There was no evidence of component loosening.CONCLUSION:TESS RSA provided encouraging midterm results with favorable outcomes and a low rate of complications. The stemless TESS with a reverse corolla is a reliable, less invasive system.

To improve control of the upper limb in high-level tetraplegic patients, the proximal shoulder must be the first consideration. Medialization of the anterior part of the deltoid muscle provides stabilization and is then an antagonist to the posterior deltoid when a pectoralis major palsy exists. It can also be performed in isolation in high-level tetraplegia even when there is little hope of distal extremity reconstruction to stabilize the shoulder. It also precedes the ability to restore elbow extension and perform further reconstructive hand surgery. We describe the surgical technique and report a clinical case.

Trapezio-metacarpal (TM) prosthesis has show good results in the surgical treatment of rhizarthrosis. One of the main causes of failure is tapezium loosening. For the revision of a failed prosthesis, trapeziectomy can be a solution. Another possibility is to implant a cup into the distal extremity of the scaphoid, thus performing a scapho-metacarpal arthroplasty. This scapho-metacarpal arthroplasty can also be used in the event of failed trapeziectomies. The purpose of this study is to present preliminary results of 10 cases of scapho-metacarpal prosthesis. A retrospective multicentric study was carried out on 10 patients, 9 women and 1 man, with an average age of 74 years, who underwent surgery between 2009 and 2015. Four had revision surgery after trapezio-metacarpal arthroplasty, 5 after trapziectomy, one hade a revision of silicon implant. The prosthesis that has been used was MAIA ® Prosthesis, with long or extra-long neck. Assessment covered – Visual Analog Pain Scale, mobility, strength, Quick-DASH, satisfaction score, preoperative, postoperative and the most recent X-rays (Kapandji incidences). Results Nine patients were assessed with a mean follow-up of 34 months, 1 patient was lost during the follow-up. Out of these 9 patients, we had 1 who failed, due to an early scaphoid cup loosening. There are 4 out of 9 patients who underwent surgery on their dominant hand. Four patient said they were very satisfied with the outcome, 4 were satisfied and 1 was not very satisfied. The average pain score was 1.2/10 and the average Quick-DASH was 38.5. The mean mobility of the carpometacarpal joint was – 48° in abduction, 40° in antepulsion, opposition according to Kapandji was 8.6, retropulsion was 1.9. Tumb strength measurements were 3 kg for key pinch, and 13.6 kg for grip strength. Radiographic assessment showed only one scaphoid cup loosening, and measurement of the length of the thumb column showed a shortening of 0.2 cm after surgery. Other surgical procedures has shown good results for revision of failed prosthesis such as secondary trapeziectomy, but only with short follow-up. Surgical procedures for failed trapeziectomy are very limited. Scapho-metacarpal arthroplasty is a reliable medium-term solution for revision of the loosening of a trapezio-metacarpal prosthesis with trapezium damage, as well as for failed trapeziectomy.

Introduction Coracoid bone graft transfer has become the gold standard in patients with recurrent anterior shoulder instability associated with bony defect. Several studies have shown that the main stabilizing component of this procedure is the sling effect by the conjoint tendon and the lower portion of subscapularis (SS). The purpose of this study was to determine whether a larger SS volume below the bone block was correlated to greater postoperative shoulder stability. Materials and methods This prospective study included a cohort of patients who underwent open coracoid bone graft transfer for post-traumatic recurrent anterior shoulder instability. Forty patients were reviewed at 2 years with a clinical and CT scan evaluation. A correlation analysis assessed the relation between the SS volume index (ratio of SS volume below the bone block to volume over the bone block) and Rowe and Walch-Duplay instability scores. Results There exists a positive and significant correlation between SS volume index and postoperative Rowe score, r = 0.37 (P = 0.03). The same trend was observed for Walch-Duplay score without statistical significance. A larger inferior SS volume did not result in a limitation of external rotation, greater fatty infiltration, or malposition of the coracoid graft. Conclusion A larger SS volume below the bone block is related to greater postoperative shoulder stability. We recommend performing the split in the middle of the SS or higher instead of the junction of the superior two-thirds and inferior one-third as usually reported. Level of evidence III, prospective study.

Purpose Trapeziometacarpal (TMC) total joint replacement is increasingly being performed in Europe. MAIA TMC total joint arthroplasty is a modular uncemented ball-and-socket hydroxyapatite-coated implant. This study assessed the midterm clinical and radiological results of the MAIA TMC prosthesis. Methods This single-center retrospective study involved 80 patients who underwent 96 MAIA TMC prosthesis implantations from February 2006 to April 2009, and who had a minimum of 5 years' follow-up. Indications for the procedure were painful TMC joint osteoarthritis affecting activities of daily living and a failure of at least 6 months of nonsurgical treatment. Pre- and postoperative clinical and radiographic data were reviewed. Results The mean age at surgery was 68 years (range, 53–84 years) and the median follow-up was 76 months (range, 60–102 months). The mean Quick Disabilities of the Arm, Shoulder, and Hand score improved from 61.3 ± 17.1 to 17.5 ± 16. The mobility of the thumb was restored to a range of motion comparable with that of the contralateral thumb. Opposition, defined by the Kapandji score, was almost normal (9.2 of 10; range, 6–10), as was the final mean key pinch and grip strength, which improved by 26% and 43%, respectively. Among the 96 implants, 4 (4.2%) were surgically revised for trapezium loosening. One dislocation was treated with closed reduction; 3 (3.1%) posttraumatic trapezium fractures were immobilized for 8 weeks. Among the 26 preoperative reducible z-deformities, only 5 (19.2%) were not totally corrected after surgery. The procedure success, by survival analysis over 6 years, was 93% (95% confidence interval, 87–98). Conclusions MAIA TMC total joint arthroplasty may be a reliable treatment option for TMC joint osteoarthritis, with very good results for pain relief, strength, mobility, and restoration of the thumb length, providing correction of most thumb z-deformities. Type of study/level of evidence Therapeutic IV.

International audience; This article introduces a new approach of selective neural electrical stimulation of the upper limb nerves. Median and radial nerves of individuals with tetraplegia are stimulated via a multipolar cuff electrode to elicit movements of wrist and hand in acute conditions during a surgical intervention. Various configurations corresponding to various combinations of a 12-poles cuff electrode contacts are tested. Video recording and electromyographic (EMG) signals recorded via sterile surface electrodes are used to evaluate the selectivity of each stimulation configuration in terms of activated muscles. In this abstract we introduce the protocol and preliminary results will be presented during the conference.

Background This article is a prospective review of patients with spinal cord injury who underwent multidisciplinary consultation from January 2005 to September 2013 for pain in one or both shoulders. Methods We performed clinical, functional, and lesion evaluations of 38 patients with paraplegia and quadriplegia presenting with rotator cuff pathologies. Results Surgery was indicated and performed on 38 shoulders in 28 patients. The lesion assessment during surgery showed injuries that were more severe than one would have thought based on imaging data. The mean pain intensity rating in the operative and nonoperative groups was 0 and 1.6, respectively, at rest and 2 and 4.9, respectively, during paroxysmal peaks. On average, for patients who had surgery, the Functional Independence Measure score decreased by 2.3. The mean satisfaction index in operated patients was 8.5 of 10. Conclusions When the surgical indication was based on a multidisciplinary decision, no negative results were reported that could have challenged the validity of this decision. Pain relief was the primary benefit reported after surgery. The functional status was modified because of the technical aids needed to prevent shoulder overuse. There are several arguments in favor of rotator cuff surgery for wheelchair-bound patients with spinal cord injury. Because of their functional impairments, wheelchair-bound patients will continue to overburden their shoulders after rotator cuff surgery. A multidisciplinary approach emerges as the solution to inform and educate patients to limit the risk of recurrence.

Progressive ankylosis of the trapeziometacarpal joint in flexion-adduction with closure of the first web in advanced trapeziometacarpal osteoarthritis gradually leads to compensatory dislocation of the metacarpophalangeal joint with hyperextension in the sagittal plane and abduction in the frontal plane. This deformity of the MP joint, initially reducible, but subsequently irreducible, results in the classical 'Z' deformity of the thumb in the sagittal plane. A less well known 'Z' deformity can also occur in the frontal plane due to distension of the medial collateral ligament. Surgical treatment of trapeziometacarpal osteoarthritis by arthroplasty must correct this secondary deformity of the MP joint to obtain an optimal result. The classical sagittal 'Z' deformity of the thumb can be easily corrected while this deformity is still reductible by releasing the fist metacarpal by tightening the abductor pollicis longus. When it is irreducible, this deformity can only be treated by MP arthrodesis, which contraindicates insertion of the ARPE trapeziometacarpal implant. Correction of the frontal 'Z' deformity of the thumb requires repair of the medial collateral ligament of the MP joint by ligamentorraphy (retightening) or ligamentoplasty.

Hypothesis In total shoulder arthroplasty, the humeral component, particularly the stem, can be involved in some of the complications and technical difficulties increase in posttraumatic arthritis with proximal humeral malunion. To decrease the intraoperative complications related to the stem, the TESS (Biomet Inc, Warsaw, IN) humeral implant, was designed in 2004 hypothesis that we can obtain a good fixation with a stemless prothesis. This investigation reports the preliminary results of this prosthesis with more than 3 years of follow-up. Methods Between March 2004 and June 2005, 70 patients underwent 72 shoulder replacements with the TESS humeral prosthesis. Sixty-three patients were reviewed with a follow-up of more than 36 months (average, 45.2 months; range, 36-51 months). The mean preoperative Constant score was 29.6. Results Gain in active mobility was 49° for forward flexion and 20° for external rotation. The postoperative Constant score was 75. Radiographic analysis showed no radiolucencies or implant migration. Functional results are comparable with previous reports on prosthetic glenohumeral replacement. Discussion Our clinical results are similar to this with classical prosthesis. The humeral head removal facilitates the glenoid exposure and implantation. After the initial cases any specific complication was seen. Conclusions Owing to the automatic central positioning of the implant, an anatomic reconstruction was achieved. In malunions, no tuberosity osteotomy was required. At 3 years of follow-up, there is radiologic evidence of maintained implant stability. These encouraging preliminary results confirm our belief that a stemless prosthesis can be used to obtain an anatomic reconstruction of the proximal humerus. A longer-term follow-up study is needed to validate these results.

In the tetraplegic patient, restoring an adequate grip requires primary restoration of proper hand opening. This opening (or "extensor") surgical stage is performed 3 or 4 months before the closing (or "flexor") stage. Surgical strategy is based on group 5 of the IC, which represents a turning point. Above this group (i.e., in IC groups 2-4), opening is essentially based on passive procedures (such as tenodesis and arthrodesis). Starting at group 5, restoration of active digital extension is [table: see text] feasible, as well as active stabilization of the thumb ray in lower groups. In those lower groups, all efforts should aim at re-establishing an intrinsic balance, keeping in mind the difference between supple and rigid claw deformities, which require different corrective procedures (Table 1).

The arterial supply of the collateral ligaments of the second, third, fourth, and fifth metacarpophalangeal joints has not been described. We studied the blood supply of these collateral ligaments, the palmar plate, and the dorsal articular capsule after arterial injection of a radiopaque substance in 20 hands. These ligaments obtain their blood supply from five pedicles, which form anastomotic rings proximal and distal to the joint.

The rabbit fibula was used as the experimental model in this study of the biological changes in nonvascularized and vascularized bone grafts (N = 72). Radiological study showed that the time required for union was about the same for both types of graft. Histological study with tetracycline as a marker showed that there were cellular changes in these two types of graft: moderate hematopoietic and osteocytic loss associated with an increase in bone porosity in vascularized grafts and virtually total osteocytic renewal and marrow necrosis in nonvascularized bone grafts. Quantitative study of vascularization by flow measurement using labeled microspheres showed a brief initial phase of hypervascularization in vascularized grafts, while revascularization took place early in nonvascularized grafts and was followed by hyperemia from the first to the third month. Calcium uptake curves for the two types of graft were quite closely superimposable upon blood flow rate curves. However, the comparative results presented in this study may be tempered by the fact that all grafts were applied to a recipient bed of excellent quality, consisting of well-vascularized muscles.