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Elbow flexion paralysis is one of most significant deficiencies in the upper limb. When secondary to brachial plexus palsy or nerve trunk lesions, restoration of elbow flexion by means of early nerve surgery or palliative transfers should be part of a comprehensive treatment plan. Tendon transfers are indicated in long-standing palsies, in those who are poor candidates for nerve surgery or when the results of nerve surgery are inadequate. A regional pedicled muscle transfer is performed if available. In this case, a "strong" donor is preferred (pectoralis major with pectoralis minor transfer, triceps brachii to biceps brachii transfer, or bipolar latissimus dorsi transfer). A "weak" transfer is indicated in patients who have incomplete recovery of elbow flexion (MRC 2 strength): isolated pectoralis minor transfer, medial epicondylar muscle transfer according to Steindler technique, or advancement of biceps brachii tendon on forearm. When no donor muscle is available, a free reinnervated muscle transfer may be indicated if age and nerve regeneration conditions are favorable.

The aim of our study is to describe the assessment of the upper limb in tetraplegic patients to follow his (her) neurological progression and to define the medical or surgical treatment program. We selected upper limb assessment tools and scales for tetraplegic patients described in the medical literature through a PubMed search over the last four decades. For each method, we present the implementation rules and its metrological properties, including its validity in French. We selected five clinical scales for functional evaluation of grasping, as well as four scales for evaluating the overall function of these patients. Finally, we identified three complementary precision assessment tools. The AIS (ASIA Impairment Scale) classification describes the level and the severity of the spinal cord lesion. The Giens classification is more practical for describing the upper limb in middle and low tetraplegia. Impairments can be assessed with most common generic scales and nonspecific measurement devices: range of motion, strength, sensory loss, spasticity, joint pain. Measurement of pinch and grip strength is widely used and easy to perform. The Capabilities of Upper Extremity (CUE) and the Jebsen Taylor Test are the best validated and usable scales. At a general functional level, the Spinal Cord Independence Measure (SCIM) is the most relevant scale in these patients. Motor nerve blocks, electromyography, movement analysis and echography are promising additional methods. Assessment of the upper limb of tetraplegic patients relies both on generic and specific assessment tools and scales.

Purpose Quantifying changes in shoulder external rotation range of motion and strength after lower trapezius transfer in children with obstetric brachial plexus palsy (OBPP). Methods This prospective study included five children with sequelae of OBPP, with a mean age of 6.4 years (range: 4-12 years) who underwent lower trapezius tendon transfer to restore active external rotation (ER) of the shoulder. Pre-operatively and at a 12-month follow-up assessment, we analyzed the passive and active shoulder ER, the modified Mallet score, and the shoulder rotator muscles strength using an isokinetic device. Results Clinical parameters improved significantly after trapezius transfer pre-operative passive ER from -8° (range: -20-0°) to 37° (range: 15-50°) (p = 0.035), the modified Mallet score from 13 (range: 10-15) to 18 (range: 17-19) (p = 0.035). Strength testing revealed improved ER muscle strength in all five cases; the mean Peak Torque increased from 1.95 to 4.46 N·m, albeit non-significantly (p = 0.062). Two patients exhibited a winged scapula post-operatively. Conclusion Lower trapezius transfer seems encouraging to restore shoulder external rotation in OBPP children but with non-significant strength improvement. Trial registration 18/07/31/5783, December 22, 2018.

The aim was to evaluate the results of radial head prostheses (RHP) in Essex-Lopresti injury (ELI) and to compare results after RHP between acute and chronic ELI. Thirty-one patients treated with RHP for ELI were selected from a multicenter retrospective series of 310 RHP, with follow-up greater than two years. Two groups were acute ELI group (n=19, average diagnosis = 5+/−9 days) and chronic ELI group (n=12, average diagnosis 8.4+/−7.1 months). RHP was associated in some cases with K-wires: during acute ELI to stabilize the distal radio-ulnar joint (n=4) or during chronic ELI with ulnar osteotomy or palliative surgery (n=4). Clinical and radiologic evaluation was performed including analysis of the complications and revisions rates, pain level, range of motion, and MEPS (Mayo Elbow Performance Score) and DASH score (Disabilities of the Arm, Shoulder and Hand). At last follow-up (71+/−38 months), survival of RHP in the acute ELI group was 84% (16/19) and 92% (11/12) in the chronic ELI group without statistically significant difference. Flexion (acute=131degrees+/−13.4 vs chronic=22+/−12.8, p=0.041) and supination (ELI=71+/−16.8 vs chronic=58+/−17.4; p=0.045) were better in acute ELI group. The DASH score was also better in the acute group (15+/−9.1 versus 24+/−15.2, p=0.048). There was more advanced stage of humero-radial osteoarthritis in the chronic ELI group (0.7+/−0.5 versus 1.4+/−0.6, p=0.041). RHP in acute ELIs provide better clinical results, although RHPs are part of the therapeutic arsenal to treat chronic ELI.

Total wrist arthrodesis in severe wrist flexion deformities (greater than 60°) due to spasticity represents a valid therapeutic option. It aims to improve the hand's appearance, hygiene, function and to prevent the deformity from getting worse. The objective of this study is to evaluate the clinical and anatomical results of wrist shortening arthrodesis using a classic volar plate in the dorsal position in functional surgery for central spastic hands. We conducted a single-center analysis of a series of patients who underwent this shortening arthrodesis. The review at a minimum 1-year follow-up included a clinical evaluation (House score, INOM score, patient satisfaction and complications), and anatomical evaluation (arthrodesis position, bone healing and carpometacarpal arthropathy). Twenty-eight patients with a mean age of 40.6 years (18-74) were included at a mean follow-up of 30.6 months (12-75). The fusion rate was 100%. No carpometacarpal arthropathy was noted. The mean position of the fused wrist was 11° extension and 15° ulnar tilt. There were two complications (7%): one postoperative hematoma and one case of discomfort due to impingement that required plate removal. The House score was significantly improved postoperatively (2.4 (0-5) versus 1.8 (0-4), p < 0.001), as was the INOM score (45 (12-64) versus 63 (36-84), p < 0.001). The patient satisfaction rate was 93%. The use of a simple and common material (volar plate in dorsal position) during this challenging surgery (spastic wrist contracture), provides good anatomical results and high patient satisfaction. LEVEL OF EVIDENCE: Level 4, case series, therapeutic study.

Background No surgical management is better than another regarding functional recovery for trapeziometacarpal joint osteoarthritis. Metacarpophalangeal (MCP) hyperextension, directly due to the shortening of thumb height, appears to be a factor of poor prognosis. Hypothesis MCP hyperextension can be corrected by implantation of a trapeziometacarpal prosthesis (TMP), as opposed to trapeziectomy and ligamentoplasty (TL), and pinch strength is greater with TMP in this indication. Material and methods Sixty-nine patients (41 TMP and 28 TL) were retrospectively evaluated. The following were evaluated: pain, mobility of the metacarpophalangeal joints, palmar grip and pinch strength. Thumb height was measured on radiographs as a post/preoperative ratio. Results The mean follow-up was 20 months (6–38). The TMP group showed greater reduction of the metacarpophalangeal hyperextension in all hyperextension groups, especially hypertension >30°, compared with TL. The TMP group provided significant greater pinch strength in all the subgroups with preoperative MCP hyperextension. Patient with postoperative MCP hyperextension had a significant lower grip and pinch strength compared with patient without MCP hyperextension. Radiographic analysis showed that thumb height changes were related to the degree of preoperative hyperextension. Postoperatively, patients with postoperative MCP hyperextension had a significant lower thumb height than patient without MCP hyperextension. Discussion Metacarpophalangeal hyperextension appears to be a factor of poor prognosis for surgical treatment of trapeziometacarpal osteoarthritis when it is not managed. TMP provides better metacarpophalangeal stabilization by restoring thumb length and would avoid surgery on the metacarpophalangeal joint. TMP may be recommended in patients having symptomatic trapeziometacarpal joint osteoarthritis and MCP joint hyperextension. Level of evidence III, retrospective observational case control study.

International audience; No abstract available

International audience; Thumb metacarpophalangeal instability is commonly found in conjunction with trapeziometacarpal osteoarthritis. If not corrected, it can have detrimental effects on the outcome. The authors describe the two types of metacarpophalangeal deformities - hyperextension and valgus - their pathophysiology and the surgical repair techniques available to surgeons. An algorithm for treating this instability is presented.

The aim of this study was to assess the clinical and radiographic outcomes after radioscapholunate (RSL) fusion for posttraumatic osteoarthritis. This was a retrospective, dual-center study of all patients who underwent RSL fusion between 1995 and 2015 for posttraumatic radiocarpal osteoarthritis. Patients were assessed at the final review to determine clinical (pain, wrist range of motion and strength), self-reported (QuickDASH, PRWE and MWS scores) and radiological (degenerative osteoarthritis in the scaphotrapeziotrapezoid (STT) or midcarpal joint and radiocarpal fusion) outcomes. We analyzed three groups: RSL fusion alone, RSL fusion with distal scaphoid excision (DSE) and RSL fusion with DSE and triquetrum excision (TE). Eighty-five patients were included; 10 were lost to follow-up and 11 required conversion to total wrist fusion before the final review. Finally, 64 patients had both clinical and radiographic evaluations. The mean follow-up was 9.1 years (range 1-21.4). RSL fusion alone was performed in 29 patients, RSL fusion with DSE in 23 and RSL fusion with DSE and TE in 12. At the final follow-up, the three groups did not differ in their pain or wrist motion. Overall, 47 (73%) patients were satisfied or very satisfied with the procedure. DSE significantly decreased STT osteoarthritis and radiocarpal non-union. The total wrist osteoarthritis rate after RSL fusion was 55%. RSL fusion is an effective procedure to preserve some motion in wrists with posttraumatic radiocarpal osteoarthritis. DSE prevents STT osteoarthritis by removing bony impingement and increases the fusion rate. LEVEL OF EVIDENCE: Level IV, Case series, Therapeutic studies.

International audience; Composite-allograft reverse shoulder arthroplasties are a surgical alternative in malignant tumor reconstructions following segmental bone resection of the proximal humerus. They allow reinsertion of the rotator cuff tendons and reliable restoration of humeral height, increasing prosthetic stability and mobility. Preoperative local tumor extension assessment must be thorough and a strict surgical technique must be followed to obtain satisfactory functional results. The indications for this procedure include a strictly intraosseous tumor of the proximal humerus corresponding to an S3-S4 A resection following criteria provided by the Musculoskeletal Tumor Society as described by Enneking and colleagues in 1990. Certain conditions must question the procedure such as extended S3-S4-S5 bone resections, partial sacrifice of the deltoid muscle, preoperative deltoid impairment, and glenohumeral arthrectomy. Here, we report technical details and indications of composite-allograft reverse shoulder arthroplasty in the context of tumor segmental resection of the proximal humerus, especially in the humeral preparation.

We retrospectively compared results of 27 wrists with bicolumnar arthrodesis with mean follow-up of 67 months to 28 wrists with three-corner arthrodesis adding triquetral excision with mean follow-up of 74 months in 54 patients (55 wrists). Minimal follow-up was 2 years for all patients. Capitolunate nonunion occurred in three wrists with bicolumnar arthrodesis and six wrists with three-corner arthrodesis, and radiolunate arthritis developed in four wrists with three-corner arthrodesis. Among patients with bicolumnar arthrodesis, hamatolunate arthritis occurred in seven wrists, all with a Viegas type II lunate; and pisotriquetral arthritis occurred in three wrists. At mean 5 years after surgery, 45 wrists had not needed revision surgery, and both groups had similar revision rates. The wrists with three-corner arthrodesis and bicolumnar arthrodesis had similar functional outcomes, and range of wrist motion was not significantly different between the two groups. We concluded that bicolumnar arthrodesis results in greater longevity than three-corner arthrodesis for a type I lunate. We do not recommend bicolumnar arthrodesis for type II lunate. We also concluded that three-corner arthrodesis has a greater incidence of radiolunate arthritis and capitolunate nonunion.Level of evidence: III

In addition to motor deficits, central nervous system disorders combine major alterations in the motor pattern with spasticity and over time, contractures. Their varied clinical presentation makes their assessment and the therapeutic strategy more complex. For these reasons, tendon transfers in this population will have more limited indications and above all, will have to be integrated into a complex surgical program combining other procedures such as tendon lengthening, selective neurotomies and joint stabilization. The surgical strategy is far from being obvious. When faced with clinical presentations having very different objectives – functional or comfort only – it is difficult at first sight to build a standardized surgical program. We therefore propose a method to evaluate these patients, thanks to a score (INOM) that integrates prognostic factors and parameters to be corrected surgically. Three components guide this program: a prognostic factor (proximal motor control of the shoulder and elbow), correction of abnormal limb postures and restoration of active elbow, wrist and finger extension. The surgical strategy can be constructed from the INOM score which establishes the priorities for care. Nerve blocks and botulinum toxin injections are essential tools for this analysis. They help distinguish between spasticity and contracture, and can unmask certain antagonistic muscles. A tendon transfer in this population will be just as effective by the function it restores as by the action it suppresses in a malpositioned limb. For each joint, we describe the indications for tendon transfers and their relative role among the techniques with which they must be combined.

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.

Management of proximal humeral tumours remains a surgical challenge. No study to date has assessed the quality of life scores following the composite reverse shoulder arthroplasty for this indication. We, therefore, evaluated function and quality of life following reconstruction with allograft for malignant tumour of the humerus. A series of six cases of humeral tumour treated by a single surgeon in a single centre was reviewed after a mean follow-up of 5.9 years. The tumours included two chondrosarcomas, one plasmocytoma and three metastases. Resection involved bone epiphysis, metaphysis and diaphysis in five cases (S3S4S5A) and epiphysis and metaphysis in one case (S3S4A). For reconstruction, an allograft composite reverse shoulder arthroplasty was used in all the cases. Outcomes were assessed with range of motion, the QuickDash score and the Short Form 12 (SF-12) Health Survey. Radiographs assessed osseointegration and complications. At the final follow-up, the mean shoulder range of motion were respectively 95°, 57° and 11° for forward flexion, abduction and external rotation. Mean QuickDASH score improved from 28 to 41 and VAS-pain scores improved from 5.1 to 2.3. The post-operative MSTS score was 73% and the Constant score was 46.1/100. The SF-12 PCS and MCS scores were also improved, respectively from 44.4 and 39.7 to 45.5 and 56.1. The mean satisfaction score was 8.1/10. Composite reverse shoulder arthroplasty is a viable alternative for reconstruction after resection of malignant humeral tumour. Although total tumour resection was the most important objective, the functional and quality of life scores were satisfactory.

The midcarpal joint can be classified into two anatomical types – Viegas type I and Viegas type II – based on the absence or presence of a medial facet for the hamate on the lunate (lunohamate facet). Type I is associated with a round capitate shape, which theoretically allows better congruence with the lunate fossa of the distal radius following proximal row carpectomy (PRC). This morphological feature has never been considered as a predictive factor of clinical outcome for this surgical procedure. This study aimed to compare the clinical and radiological outcomes of the two Viegas types following PRC. A retrospective single-center study was carried out on patients who underwent PRC for wrist osteoarthritis. Minimum follow-up was 2 years. Lunate type was determined based on preoperative CT arthrography. The clinical evaluation included range of motion (ROM) and strength as well as the functional DASH, Mayo Wrist scores and a VAS for pain. The outcome of radiocapitate osteoarthritis was assessed on plain radiographs. Forty patients were reviewed with a mean follow-up of 57 months. Twenty-one Viegas type I and 19 Viegas type II were identified on preoperative CT arthrography. The etiologies included 23 SLAC wrists (12 Viegas type I, 11 type II), 8 SNAC wrists (4 Viegas type I, 4 type II), 6 cases of Kienbock's disease (3 type IIIa, 3 type IIIb with 3 Viegas type I and 3 type II), 1 Preiser's disease and 2 cases of transscaphoid perilunate dislocation of the carpus. Patients with a Viegas type I lunate had significantly greater flexion-extension ROM: 83.5° vs. 71° ( P = 0.04) and radial deviation: 12° vs. 7° ( P = 0.013) than those with Viegas type II. However, three cases of complex regional pain syndrome (CRPS) were reported in the Viegas type II group vs. zero in the Viegas type I group. There were no differences between the two groups in terms of strength, functional scores or VAS pain. The outcome of radiocapitate osteoarthritis was similar in both groups. Considering the number of CRPS cases in the Viegas type II group and similar functional results in both groups, the worse outcomes of the Viegas type II patients in terms of ROM cannot be considered as clinically relevant. This comparative study does not provide a reasonable basis for concluding that Viegas type I patients are better candidates for PRC than Viegas type II patients.

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.

Background Radioscapholunate (RSL) fusion is a surgical option to manage radiocarpal osteoarthritis. Many authors upgrade the procedure by adding distal scaphoid excision with or without excision of the triquetrum. Our objective was to identify the prognostic factors for good clinical and radiographic outcomes of RSL arthrodesis. Purpose Distal scaphoid excision improves both scaphotrapeziotrapezoidal osteoarthritis and radiocarpal fusion, and excision of the triquetrum is not critical to achieving satisfactory outcomes. Methods In this retrospective and bicentric investigation, all wrists were managed with RSL fusion for posttraumatic radiocarpal osteoarthritis. A total of 85 patients were included and evaluated at the revision by clinical (pain, wrist motion, and strength), functional (Disabilities of the Arm, Shoulder, and Hand questionnaire, Patient-Related Wrist Evaluation score, and Modified Mayo Wrist Score), and radiological (scaphotrapeziotrapezoidal, midcarpal osteoarthritis, and radiocarpal nonunion) examinations. We assessed prognostic factors for clinical and radiographic (osteoarthritis and nonunions) outcomes. Results The average follow-up was 9.1 years (1–21.4). Work-related accidents adversely impacted the clinical outcomes, and distal scaphoid excision significantly improved them and decreased scaphotrapeziotrapezoidal osteoarthritis and nonunion. Neither distal scaphoid excision nor excision of the triquetrum influenced midcarpal osteoarthritis. Radiocarpal fusion was significantly promoted by memory staples and bone grafting. Discussion Distal scaphoid excision should be preferred to improve the functional results while decreasing scaphotrapeziotrapezoidal osteoarthritis and radiocarpal nonunion rates. Excision of the triquetrum appears to be an alternative to radioulnar resection–arthroplasty to solve ulnocarpal impaction syndrome. Strict surgical procedure must be observed to promote RSL fusion combining solid bone fixation and the use of bone graft. Level of evidence This is a level IV, case series, retrospective series.

International audience; Total trapeziometacarpal (TMC) joint replacement is increasingly being performed for the treatment of basal joint arthritis. However, complications such as instability or loosening are also frequent with TMC ball-and-socket joint replacement. Management of these complications lacks consensus. The purpose of this study was to report the results of 12 cases of failed TMC joint replacement that were treated by trapeziectomy with ligament reconstruction and tendon interposition (LRTI) arthroplasty. The follow-up consisted of functional (numerical scale, DASH score, satisfaction), physical (range of motion, strength) and radiological (Barron and Eaton ratio measurement) assessments. At a mean follow-up of 21 months, 11 patients were satisfied or very satisfied after surgery. The mean pain score was 2/10 and the mean DASH score 30/100. Mean thumb palmar and radial abduction was 40°. Thumb opposition measured by the Kapandji technique was 9/10. The height ratio was slightly increased. Trapeziectomy with LRTI after TMC joint replacement appears to be an attractive salvage procedure.

Background Advanced proximal carpal row damage is common in rheumatoid arthritis (RA). Proximal row carpectomy (PRC) simplifies total wrist arthrodesis, obviating the need for an iliac bone graft. In theory, PRC also improves the chances of healing, as fusion of a single joint space is needed for the procedure to be successful. Potential effects of the loss of carpal height related to PRC are unknown. Hypothesis We hypothesised that PRC performed concomitantly with total wrist arthrodesis in patients with RA produces good clinical and radiological outcomes, without inducing loss of strength or digital deformities. Material and methods In 38 total arthrodeses of rheumatoid wrists, a clinical evaluation was performed, including a visual analogue scale (VAS) pain score, the Patient-Rated Wrist Evaluation (PRWE), grip strength, digital deformities, and patient satisfaction. A standard radiographic workup was obtained to assess healing and carpal height indices. Results After a mean follow-up of 50 months, the mean VAS pain score was 0.4 (range: 0–7), the mean PRWE score was 21 (range: 0–80.5), and grip strength as a percentage of the contralateral limb was 76%. The healing rate was 92% (35/38 wrists), and 34 (90%) patients reported being satisfied or very satisfied. No effects of carpal height loss on clinical or radiographic parameters was detected. Discussion Total wrist arthrodesis combined with PRC provides reliable and reproducible benefits. This study found no evidence of adverse effects related to the loss of carpal height. Level of evidence IV, retrospective study.

Background Restoring the axis of rotation is often considered crucial to achieving good functional outcomes of total elbow arthroplasty. The objective of this work was to evaluate whether variations in implant positioning correlated with clinical outcomes. Hypothesis Clinical outcomes are dictated by the quality of implant positioning. Material and methods A retrospective review was conducted of data from 25 patients (26 elbows). Function was assessed using a pain score, the Disabilities of the Arm, Shoulder, and Hand (DASH) Score, and the Mayo Elbow Performance Score (MEPS). The patients also underwent a clinical evaluation for measurements of motion range and flexion/extension strength. Position of the humeral and ulnar implants was assessed by computed tomography with reconstruction using OsiriX software. Indices reflecting anterior offset, lateral offset, valgus, height, and rotation were computed by subtracting the ulnar value of each of these variables from the corresponding humeral value. These indices provided a quantitative assessment of whether position errors for the two components had additive effects or, on the contrary, counterbalanced each other. Elbows with prosthetic loosening or extensive epiphyseal destruction were excluded. Results Of the 26 elbows, 5 were excluded. In the remaining 21 elbows, the discrepancy between the humeral and ulnar lateral offsets was significantly associated with pain intensity ( P ≤ 0.05) and the MEPS ( P ≤ 0.05). Anterior position of the ulna relative to the humerus was associated with decreased extension strength ( P ≤ 0.05) and worse results for all functional parameters ( P ≤ 0.05). Discussion In the absence of loosening, positioning errors seem to adversely affect functional outcomes, probably by placing inappropriate stress on the soft tissues. Level of evidence III.

Thumb carpometacarpal osteoarthritis affects many post-menopausal women. If medical treatment fails, the most common options are trapeziectomy and trapezio-metacarpal arthroplasty. The purpose of this study was to evaluate the survival rate of trapezio-metacarpal prostheses in surgical treatment of thumb carpometacarpal osteoarthritis, and to highlight potential risk factors of unfavorable outcome. We performed a retrospective study involving 294 trapezio-metacarpal prostheses in 245 patients, who underwent surgery between 2001 and 2016. Clinical assessment was performed by self-questionnaire including pain, satisfaction, recovery time, QuickDASH Score, and opposition according to Kapandji score. Thumb X-rays were used to evaluate implant loosening sign, periprosthetic remodeling, and arthrosis of over and underlying joints. Implants survival rate at the final follow-up of 17.3 years was 90.8 % (95 % CI [85.8–96.1]). Median pain was 1 on 10 on VAS scale (0–8). Median QuickDASH Score was 20 (0–82), median opposition according to Kapandji was 9 on 10 (3–10). Median return to work time was 2 months (1–12). We identified 7.8 % of major complications, including 3.4 % of dislocations, 3.1 % of implants loosening, and 1 % of fractures. All dislocations involved surgical revision. Only few publications show results with more than 100 trapezio-metacarpal prostheses. Our results are consistent with existing studies. Trapeziectomy represents currently the gold standard in surgical treatment of thumb carpometacarpal osteoarthritis. Long-term superiority has not been proven in recent meta-analysis. Two recent studies found superiority of arthroplasty at short term concerning pain, strength, mobility, satisfaction, and recovery time, with similar complication rates. Trapezio-metacarpal arthroplasty is a long-term reliable solution for surgical treatment of thumb carpometacarpal osteoarthritis, with a limited complication rate.

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.

Ulnar paralysis has multiple clinical presentations, which are due to partial recovery or to anatomical variations between the ulnar and median nerves. The main sequelae of ulnar nerve paralysis are the loss of hand strength with impairment of all intrinsic functions of the fingers and some of the thumb's functions. Weakness of the adductor pollicis and flexor pollicis brevis muscles may manifest as weak key pinch with automatic flexion of the thumb interphalangeal joint when gripping. Indications for palliative surgery have decreased due to advances in peripheral nerve surgery. However, palliative surgery still has a significant role to play when nerve repair techniques are not indicated or do not provide satisfactory results. The principle is to reinforce metacarpophalangeal flexion while stabilizing the thumb's interphalangeal joint, thus supplementing the action of the flexor pollicis brevis. This is generally done by transferring the flexor digitorum superficialis tendon of the fourth finger to the distal insertion of the superficial thenar muscles and the extensor pollicis longus. Restoration of the first dorsal interosseous is more rarely indicated.

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.

We report a unique and previously unreported case of motor paralysis of the posterior interosseous nerve of rapid onset in a context of hypertrophy of the short supinator muscle, occurring 2 years after a distal rupture of the biceps in a 62 year-old man. The ruptured tendon had received functional treatment due to the patient's age and low functional requirements. Operatively, the deep branch of the radial nerve was released within the arcade of Frohse with complete recovery from symptoms at 5 months. The unrepaired rupture of the distal portion of the biceps could be a risk factor for posterior interosseous nerve compression in active subjects.

Background Shoulder arthroscopic arthrodesis is an uncommon and non-standardized procedure. Results are poorly evaluated. We describe the findings in 8 patients who underwent shoulder arthroscopic arthrodesis for brachial plexus injury. Methods The humeral head and glenoid were excised through standard arthroscopic portals. A Hoffmann external fixator and cannulated screws were used to stabilize the shoulder. Standard clinical assessment and radiographic evaluation were performed each month until bony fusion occurred. With a mean follow-up of 28 months, functional evaluation included pain level (on a 0- to 10-mm visual analog scale); American Shoulder and Elbow Surgeons index; Disabilities of the Arm, Shoulder and Hand score; and Simple Shoulder Test score. Mobility was systematically investigated. Blood loss was assessed by measuring hematocrit proportion. Results Glenohumeral fusion was achieved in all 8 patients. The mean time to arthrodesis was 3 months (range, 2-8 months). At last follow-up, the mean pain level was 1 (range, 0-4); the mean American Shoulder and Elbow Surgeons score was 69; the mean Disabilities of the Arm, Shoulder and Hand score was 36; and the mean Simple Shoulder Test score was 4. Mean active flexion and abduction were 80° (range, 60°-90°) and 59° (range, 40°-80°), respectively. Mean blood loss during the perioperative period was 432 mL (range, 246-792 mL). We observed one superficial wound infection and one migration of an acromiohumeral screw. These complications did not compromise the final results. Conclusions Arthroscopic arthrodesis of the shoulder can be a reliable procedure and associated with a low rate of complications.

Determining and accurately restoring the flexion-extension axis of the elbow is essential for functional recovery after total elbow arthroplasty (TEA). We evaluated the effect of morphological features of the elbow on variations of alignment of the components at TEA. Morphological and positioning variables were compared by systematic CT scans of 22 elbows in 21 patients after TEA. There were five men and 16 women, and the mean age was 63 years (38 to 80). The mean follow-up was 22 months (11 to 44). The anterior offset and version of the humeral components were significantly affected by the anterior angulation of the humerus (p = 0.052 and p = 0.004, respectively). The anterior offset and version of the ulnar components were strongly significantly affected by the anterior angulation of the ulna (p < 0.001 and p < 0.001). The closer the anterior angulation of the ulna was to the joint, the lower the ulnar anterior offset (p = 0.030) and version of the ulnar component (p = 0.010). The distance from the joint to the varus angulation also affected the lateral offset of the ulnar component (p = 0.046). Anatomical variations at the distal humerus and proximal ulna affect the alignment of the components at TEA. This is explained by abutment of the stems of the components and is particularly severe when there are substantial deformities or the deformities are close to the joint. Cite this article: Bone Joint J 2015;97-B:1539–45.

International audience; Background Combined thumb basal and wrist joint arthritis (excluding scaphotrapeziotrapezoid arthritis) is rare considering the frequency of arthritis of either joint alone. Combined surgical treatment has never been described in the literature. Furthermore, the scaphoidectomy common to all interventions for Watson stage 2 or 3 wrist arthritis theoretically makes it impossible to perform a trapeziectomy for thumb basal joint arthritis. Question/Purpose The aim of this study was to present and analyze the results of two types of surgical treatment when both wrist and thumb arthritis was present. Materials and Methods Our retrospective series included 11 patients suffering from Eaton Stage III thumb basal joint arthritis and scapholunate advanced collapse (SLAC) II and III-type wrist arthritis. Five patients (group A) underwent trapeziectomy and palliative surgery for their wrist with conservation of the distal pole of the scaphoid (one proximal row carpectomy [PRC] and four four-corner fusions), and six (group B) patients had a trapeziometacarpal arthroplasty either with PRC (two cases) or four-corner arthrodesis (four cases) including total scaphoidectomy. Results The mean follow-up was 57 months. The overall visual analog scale (VAS) score for pain was 1.5 at rest, with no difference between the trapeziectomy and arthroplasty groups. The average Kapandji score was 9.3 (9 in group A and 9.5 in group B). The flexion/extension range of motion for the wrist was 64° following four-corner arthrodesis and 75° following PRC. Only one case of algodystrophy was observed. The radiological analysis revealed no complications. Discussion This study shows that thumb basal joint arthritis and SLAC type wrist arthritis may be treated by combined treatment during the same intervention without any complications. The results of palliative surgery for the wrist, either with trapeziectomy or with a trapeziometacarpal arthroplasty, are comparable. With a trapeziectomy, the distal pole of the scaphoid must be fused to the capitate to help stabilize the thumb column. Level of Evidence Level IV.

Purpose Restoring active elbow flexion is essential in the surgical management of C5-C6 ± C7 brachial plexus palsies. This study compares the clinical results of 2 techniques to restore elbow flexion: the partial ulnar nerve transfer and the intercostal nerve transfer. Methods Partial ulnar nerve transfer was performed in 23 patients, and intercostal nerve transfer was performed in 17 patients. For both techniques, the transfer to the musculocutaneous nerve was made at the same anatomical point. Age and preoperative delay were comparable between groups of patients. Results Biceps reinnervation time was significantly earlier (p = .001) in the ulnar nerve technique (mean, 5.1 mo) than the intercostal nerve technique (mean 9.9 mo). Ten of 17 patients recovered useful elbow flexion force (British Medical Research Council grade >M3) in the intercostal nerve transfer group, compared with 20 of 23 patients in the ulnar nerve transfer group. No patient who had surgery more than 6 months after the injury recovered useful elbow flexion force in the intercostal nerve transfer. Elbow flexion strength was better in patients less than 30 years old in the intercostal nerve group. No complications were observed in either group. Conclusions This study shows that transferring fascicles of the ulnar nerve yields better results than intercostals nerve transfer for restoring elbow flexion. Moreover, preoperative delay and age are important preoperative prognostic factors for the intercostal nerves transfers. Type of study/level of evidence Therapeutic III.

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2 degrees pronation (-70 degrees to 80 degrees ) to 95.8 degrees supination (80 degrees to 140 degrees ). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6 degrees (60 degrees to 90 degrees ) in pronation and 50.4 degrees (0 degrees to 90 degrees ) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.

Introduction To assess correlations between new sonographic features at different biceps tendon levels compared to tendinitis arthroscopy. Material and methods A total of 47 patients in our Upper Limb Orthopedic Surgery Department were prospectively included over a 5-month period. Arthroscopy was performed to assess the macroscopic appearance of the horizontal intra-articular portion of the tendon. The horizontal part of the biceps tendon was divided into 3 parts in order to assess inflammation by grade. The tendon was considered inflammatory in case of grade 2 and 3. Biceps tendon criteria were analyzed at five ultrasound levels, i.e. area, tendon flattening ratio, presence of fluid, Doppler inflammation assessment and intra-tendon ROI on a dynamic film to assess the maximum, minimum signal and heterogeneity. Results No significant correlations were found between arthroscopy-detected inflammation and the surface. On the dynamic film, the maximum tendon signal was significantly lower when the biceps tendon was classified by the surgeon as inflammatory ( p = 0.030), and remained significant after logistic regression adjustment for age and gender ( p = 0.048). The 114 threshold resulted in the best differentiation, with 91% sensitivity, 48% specificity, 86% NPV and 61% PPV. Discussion The maximum biceps tendon signal measured on a dynamic film made when tilting the probe was significantly lower when the tendon was detected as inflammatory via arthroscopy. None of the other quantitative or qualitative measurements had any correlation. Level of evidence IV.

Introduction Painful gleno-humeral subluxation (GHS) may develop in hemiplegic patients. The objectives of this study were, to report our outcomes with the use of biceps suspension procedure for the treatment of shoulder pain associated with GHS in hemiplegic patient and to present our arthroscopic technique. Methods This study is a retrospective case series of six consecutive patients with hemiplegia with painful gleno-humeral subluxation. Two patients had open surgery procedure and four procedures were realized under arthroscopy. The surgical procedure consisted of practicing a distal tenotomy of the long head of the biceps tendon, and passing it through an intra-osseous tunnel created in the humerus. The tendon was pulled through the tunnel proximally to distally and then fix on the humeral diaphysis by a Blount staple under maximal traction while a manual reduction of the subluxation was maintained. An evaluation was conducted before and after surgery for pain, physical examination, radiographs findings and patient satisfaction with the outcome of the surgery. Results Average patient age was 59 (range 36 to 78 years). The mean duration of the patient follow-up was 18,6 months (range 6 to 37 months). Four patients were wearing a sling permanently preoperatively, one intermittently and one was wearing an orthosis. All patients had permanently quit their sling at the time of evaluation, except for the one with preoperative orthosis who was using a simple sling. There was a statistically significant decrease of the pain (p = 0.002) with a mean preoperative score on the numeric pain rating scale of 6,6 (range, 5 to 9) and 2,6 (range 1 to 5) postoperatively. The mean Ashworth postoperative score was lower compared with preoperative score (2 from 2,6) but the difference was not statistically significant (p = 0.06). Three patients considered that the result of the surgery was very good, two good, one fair. Three patients had complete reduction of the glenohumeral joint at the last radiographic control, two had a partial reduction and one had a recurrent of inferior subluxation. The results were similar for the pain reduction between the two open procedures and the arthroscopic procedure. There was one complication recorded which was an anchor migration that did not require additional surgery. Conclusion This study confirm the good results in pain relief and patient satisfaction with a biceps suspension procedure for painful inferior glenohumeral subluxation in hemiplegic patients and report for the first time the possibility to perform the procedure under arthroscopy.

International audience; We previously showed that transfer of adult myoblasts (MB) into cardiotoxin-damaged muscle improved the properties of reinnervated tibialis anterior muscle of rabbits. However, this cell therapy protocol cannot be applied to humans because of the hazardous effects of the myotoxin. To circumvent this approach, we used the recently developed high-density injection technique to autotransplant cultured cells 1 mm from each other into the tibialis anterior muscle without previous cardiotoxin-induced damage. Two months after transection and immediate suture of the common peroneal nerve, we transferred by this technique two types of precursor cells, MB or cells isolated from the adipose tissue stromal vascular fraction. In contrast to our previous results, muscles studied at 4 months showed no benefits in terms of function or morphology, whatever the transferred cells. These results, together with the results of earlier studies, emphasize the importance of delivery methods and the muscle environment in supporting cell integration into host tissues.

Objective Assessment of the feasibility and efficacy of percutaneous needle tenotomy in patients with neuro-orthopedic disorders secondary to impairment of the central nervous system. Material and method Fourteen patients were followed in the Physical medicine and rehabilitation Department from September 2014 to March 2015. The average age was 58.7 years (29–86 y). The origin of neuro-orthopedic disorder was stroke (n = 7), parkinsonism (n = 2), head trauma (n = 2), cerebral palsy (n = 1), Little's disease (n = 1) and Alzheimer's disease (n = 1). The indication of percutaneous needle tenotomy was selected during a medical-surgical consultation. Twenty-one goals were identified: hygiene (n = 6), pain (n = 4), sitting (n = 3), standing (n = 4), transfers (n = 1), walking (n = 2), grasping (n = 1). A total of 31 sites were covered: the finger flexors (n = 9), the semitendinosus, biceps femoris and tensor fascia lata (n = 7), the Achilles tendon (n = 5), the biceps and brachioradialis (N = 3), the wrist flexors (n = 2), flexor digitorum longus (7 claw toes) and hip adductors (n = 1). In 10 patients the treatment involved several sites. Tenotomy was performed with a 18G needle (1,2 × 40 mm), under local or regional anesthesia. A plaster cast was associated with hamstring tenotomy if the objective was functional. A cast was always associated with Achilles tendon, elbow flexor and wrist flexor tenotomy. The Goal Attainment Scale (GAS) was used to assess the effectiveness of treatment. Results The targets were achieved in all cases (GAS ≥ 0). No side effects were noted. Discussion Percutaneous needle tenotomy is a technique which can be used as treatment of some neuro-orthopedic disorders in brain-damaged patients. Percutaneous tenotomy of the Achilles’ tendon has already been described by Minkowitz. Our study shows the feasibility and effectiveness of needle tenotomy, sometimes multi-site, performed in this type of patient.

Introduction Progress in microsurgical techniques for the last 40 years revealed a new population of patients: those with replanted hand. Observation We present the case of a 63-year-old patient with a complete traumatic radio carpal amputation. His amputated hand was successfully replanted in emergency on December 8, 2014; we will detail the issues in post-operative rehabilitation treatment and the need to solve multiple problems. We will discuss about vascular question, risk of infection, skin appearance, bone, tendon, neurological, and psychological component, some objectives having to take in consideration different factors involved in the recovery. Discussion The replantation of a hand in a 63-year-old patient requires specialized care, long and difficult labor with an uncertain future for reinnervation. On the other side, the myoelectric prosthesis allows to the patient a rapid return to social life.

Introduction Dystonic and dyskinetic syndromes produce musculotendinous retractions, subluxations and hip or shoulder dislocations. Most of the time, deep brain stimulation and pallidotomy cannot be used in secondary syndromes as they are in primitive forms. Drug treatments have frequent side effects. Very often these treatments are inadequate to prevent musculoskeletal deformities, which have an impact on pain, nursing, positioning and quality of life. Observation We followed a 45-year-old man with a spastic tetraparesia and a generalised dystonic and dyskinetic syndrome residual of a cerebral anoxia due to a heart arrest. His initial treatment was oral baclofen, anticholinergics and secondary intratechal baclofen. His symptoms increased progressively: pain, communication and nursing difficulties, mispositioning, elbow crease mycosis, as a consequence of musculoskeletal deformities. The patient had triple flexion of his upper limbs, antero inferior irreducible left shoulder dislocation, bilateral flessum of the knees. Multidisciplinary management has been provided, initially surgical then medical. Surgery included rotator cuff desinsertion of the left shoulder, needle percutaneous tenotomies of left elbow flexors, biceps femoris and semitendinus and plaster cast immobilisation. The medical treatment included twice-daily bolus of intratechal baclofen with dose-increase, botulinum toxin injection (left semimembranosus, right shoulder retractor muscles), phenolyc neurolysis (bilateral ansa pectoralis, left musculocutaneous nerve), physiotherapy and occupational therapy. The pain relief allowed a progressive morphinic doses decrease. Both armchair and bed positioning have been improved. Dyskinetic movements disappeared and verbal communication became easier. Discussion Neuro-orthopedic deformities management in patients with dystonia and dyskinesia may allow a decrease of dyskinetic movements and improve their comfort. It consists of multidisciplinary medicosurgical approach with tenotomies in association with oral or intratechal baclofen, botulinum toxin, chemical neurolysis and rehabilitation.

International audience; Tendon transfers are carried out to restore functional deficits by rerouting the remaining intact muscles. Transfers are highly attractive in the context of hand surgery because of the possibility of restoring the patient's ability to grip. In palsy cases, tendon transfers are only used when a neurological procedure is contraindicated or has failed. The strategy used to restore function follows a common set of principles, no matter the nature of the deficit. The first step is to clearly distinguish between deficient muscles and muscles that could be transferred. Next, the type of palsy will dictate the scope of the program and the complexity of the gripping movements that can be restored. Based on this reasoning, a surgical strategy that matches the means (transferable muscles) with the objectives (functions to restore) will be established and clearly explained to the patient. Every paralyzed hand can be described using three parameters. 1) Deficient segments: wrist, thumb and long fingers; 2) mechanical performance of muscles groups being revived: high energy-wrist extension and finger flexion that require strong transfers with long excursion; low energy-wrist flexion and finger extension movements that are less demanding mechanically, because they can be accomplished through gravity alone in some cases; 3) condition of the two primary motors in the hand: extrinsics (flexors and extensors) and intrinsics (facilitator). No matter the type of palsy, the transfer surgery follows the same technical principles: exposure, release, fixation, tensioning and rehabilitation. By performing an in-depth analysis of each case and by following strict technical principles, tendon transfer surgery leads to reproducible results; this allows the surgeon to establish clear objectives for the patient preoperatively.

Background Sarcoma rarely involves the hand or wrist. Extensive surgical excision is the current standard of care. At the extremities, such as the hand and wrist, limb-sparing surgery with reconstruction to provide optimal function is increasingly performed. A descriptive case-series study of 16 patients with sarcoma of the hand and wrist managed using limb-sparing surgery is reported here. Material and methods Of 19 patients with sarcoma of the hand or wrist treated between 1999 and 2012, 16 were managed using limb-sparing surgery. These were consecutive patients managed at a single-centre and studied retrospectively. The tumour involved the hand in 7 patients and the wrist in 9 patients. The procedure was primary in 6 patients, whereas 10 patients underwent secondary revision surgery. In 12 patients, reconstruction was performed for one or more of the following structures: nerves (n = 2), tendons (n = 3), bone (n = 3), and/or skin (n = 8). After surgical excision, the margins were R0 in 15 patients and R1 in 1 patient. At last follow-up, survival, pain, and function as reflected by the DASH and MSTS scores were assessed. Results After the median follow-up of 4.5 years [1–13], 15 patients were alive with no local recurrence and 1 patient had lung metastases. Mean values were 18 [0–49] for the DASH score and 88.8% [53–100] for the MSTS score. Discussion Limb-sparing surgery reconciles the need to achieve complete tumour excision with the need to restore function. No limits should be placed on tumour excision, given the availability of effective reconstructive methods. The functional outcome depends on the tolerance of adjuvant treatments, most notably radiotherapy. Level of evidence IV, retrospective study.

Purpose To evaluate whether the congruency between the joint surfaces of the lunate fossa of the distal radius and the proximal capitate might be a prognostic factor for functional, clinical, or radiographic results after proximal row carpectomy (PRC). Methods After reconstructing the computed tomographic arthrogram of patients with PRC, we evaluated the shape of the proximal capitate by measuring the radius of curvature of the tip of the capitate. The congruency of the future radiocapitate joint was then evaluated by the radiocapitate index in the frontal and sagittal planes. This was calculated by dividing the radius of curvature of the tip of the capitate by the mean radius of curvature of the lunate fossa. We determined the relationship between these morphological results and the functional (Disabilities of the Arm, Shoulder, and Hand [DASH] score, Mayo Wrist score, and pain relief), clinical (mobility and strength) and x-ray results (radiocapitate arthrosis). Results A total of 27 patients were reviewed at a mean follow-up of 59 months. The shape of the proximal capitate did not affect outcomes. In the frontal plane, a better radiocapitate congruency was significantly associated with an increase in wrist flexion and better functional results for the DASH. There was a non-significant relationship between congruency and improvement of Mayo Wrist score and pain relief. In the sagittal plane, the DASH score tended to improve when congruency was better. Conclusions The shape of the capitate was not a prognostic factor for functional outcome after PRC. The radiocapitate index seems more relevant in predicting results at last follow-up. Type of study/level of evidence Prognostic II.

Skeletal muscle demonstrates a force deficit after repair of injured peripheral nerves. We tested the hypothesis that transplantation of satellite cells into reinnervated rabbit tibialis anterior (TA) muscles improves their properties. Adult rabbits underwent transection and immediate suture of the common peroneal nerve. In order to provide an environment favorable for cell transplantation, TA were then made to degenerate by cardiotoxin injection, either immediately or after a 2-month delay, which is sufficient for muscle reinnervation. In both cases, the injured TA were transplanted with cultured satellite cells 5 days after induction of muscle degeneration. When cells were transferred immediately after nerve repair, drastic morphological and functional muscle alterations were observed. However, when the muscles were allowed to become reinnervated before cell transplantation, muscles were heavier and developed a significantly higher maximal force compared to denervated-reinnervated muscles. Thus, application of the cell therapy protocol improved properties of denervated muscles only when they were allowed to become innervated. These results, which represent the application of cell therapy to improve force recovery of reinnervated muscles, will be of significant interest in certain clinical contexts, particularly after immediate or delayed muscle reinnervation.

Background Giant cell tumor (GCT) of bone is rare in the carpus and only 11 cases have been reported in the capitate bone. The problem with this location is the high recurrence rate due to easy extension to the adjacent joint spaces and bones. Case description The case report concerns a 48 years old woman, with a GCT of the capitate diagnosed on curettage. The treatment consisted of large resection with lunatum-third metacarpal arthrodesis, with a successful union at 2 years follow-up, no recurrence and an acceptable function of the wrist. Literature review When treated by curettage (alone or with adjuvant procedures), the GCT of the capitate recurred in 4/5 cases. All tumors treated with large resection did not recur. Clinical relevance Recommended treatment of GCT of the capitate is resection with carpo-metacarpal arthrodesis.

Introduction The hand of the brain damaged patient combines motor deficit, abnormal muscle tone causing spasticity, and sensory defect. The purpose of surgical program could be functional by restoring grasp or non-functional by resolving hygienic problems, and improving cosmetic appearance due to the clenched fist deformity. The superficialis-to-profundus tendon transfer, first described by Braun and al., allows the opening of non-functional hands. The aim of our study was to confirm the efficacy of this technique to correct vicious attitudes, to highlight a possible functional gain and finally to identify any complications. Materials and methods Patients (9 women and 17 men, aged 36–79 years) were evaluated by a team of rehabilitation physicians and orthopeadic surgeons. Palliative transfer of the flexor digitorum superficialis tendons to the flexor digitorum profundus tendons has been achieved. Pictures were taken both preoperatively and during follow-up consultations. The hands were classified according to their appearance: the position of the wrist and fingers (Keenan and al.). Surgery complications were sought. Results Mean follow-up was 47 months. Preoperatively all hands were classified type 5 (closed hand: no distance between palm and pulp). Postoperatively 38% of patients have type 1 hand (wrist in neutral position, metacarpophalangeal joints [MCP] and proximal interphalangeal [PIP] at 20° of flexion) and 46% type 2 hand (fingers are more flexed [MCP and PIP at 40° of flexion]), with good cosmetic appearance. None of them have hygienic problems. Mean House score increased from 0 to 0.9, with 7 patients improved. Four patients had an attitude of supination of the forearm, 10 had an intrinsic-plus deformity and 6 had swan neck deformity of the finger. Secondary procedures had to be made. Conclusion This transfer gives satisfactory results on the opening of the hand but with significant complications. Intrinsic spasticity may be unmasked. Accessories pronator muscles release, while the biceps is spastic, can lead to an attitude of supination of the forearm, which causes functional and esthetic problems.

Objective The musculotendinous retractions are common complications of central neurological damage with consequences for comfort and function. Treatment of uncomfortable retractions is often surgical, mainly based on tendon gestures. The objective of this study was to evaluate the efficiency of percutaneous needle tenotomy in these indications. Material/patients and methods The indication was accepted at a medical-surgical consultation. Tenotomy was performed using an 18 Gauge needle. The patients were older than 18 years, had a history of central neurological disease, and had a musculotendinous retraction regarding a superficial tendon of upper limb. The primary endpoint was the Goal Attainment Scale (GAS). Secondary outcomes were pain, the pulp-palm distance and range of motion gain. The evaluation was conducted in pre-tenotomy, immediately post-tenotomy, 3 months and 6 months. Results Twelve patients (8 women) were included in our study. The mean age was 62.91 years (28–87). Neuro-orthopedic disorders were related to a stroke ( n = 4), head trauma ( n = 2), to Parkinsonian syndrome ( n = 3) at a cerebral palsy ( n = 3). The objectives identified were nursing ( n = 12), pain ( n = 11), the skin condition ( n = 5), gripping ( n = 2), posture ( n = 1) and dressing ( n = 1). The targets were achieved in all cases. The average score GAS per patient ranged from 0 to 2. GAS score was unchanged at 3 months and 6 months. Discussion–conclusion Our experience confirms the locations already described for percutaneous needle tenotomy of the flexor of the fingers. We also report the effectiveness of percutaneous tenotomy in the wrist and elbow flexors without vascular and nerve injury elbow.

Introduction The hand of the spastic patient combines motor deficit, abnormal muscle tone causing spasticity, and sensory defect. The purpose of the surgical program could be functional by restoring grasp or nonfunctional by resolving hygienic problems and improving cosmetic appearance due to the clenched fist deformity. The superficialis-to-profundus tendon transfer, first described by Braun et al., allows the opening of nonfunctional hands. The aim of our study was to confirm the efficacy of this technique to correct vicious attitudes, to highlight a possible functional gain and finally to identify any complications. Materials and methods Patients (9 women and 17 men, aged 36–79 years) were evaluated by a team of rehabilitation physicians and orthopedic surgeons. Palliative transfer of the flexor digitorum superficialis tendons to the flexor digitorum profundus tendons has been achieved. Pictures were taken both preoperatively and during follow-up consultations. The hands were classified according to their appearance- the position of the wrist and fingers (Keenan et al.). Surgery complications were sought. Results Mean follow-up was 47 months. Preoperatively, all hands were classified type 5 (closed hand no distance between palm and pulp). Postoperatively, 38% of patients have type 1 hand (wrist in neutral position, metacarpophalangeal joints (MCP) and proximal interphalangeal (PIP) at 20° of flexion) and 46% type 2 hand (fingers are more flexed [MCP and PIP at 40° of flexion]), with good cosmetic appearance. None of them have hygienic problems. Mean House score increased from 0 to 0.9, with 7 patients improved. Four patients had an attitude of supination of the forearm, 10 had an intrinsic-plus deformity and 6 had swan neck deformity of the finger. Secondary procedures had to be made. Conclusion This transfer gives satisfactory results on the opening of the hand but with significant complications. Intrinsic spasticity may be unmasked. Accessories pronator muscles release, while the biceps is spastic, can lead to an attitude of supination of the forearm, which causes functional and esthetic problems.

The authors report a case of calcified glomus tumor of the shoulder in a 54-year-old woman. The nonspecific clinical findings and the noncharacteristic imaging results made diagnosis of this tumor impossible before surgery. The diagnosis was confirmed by a biopsy. The outcome after surgical resection was excellent.

Reprint author: Bacou F. bacou@supagro.inra.fr; International audience; Skeletal muscle demonstrates a force deficit after repair of injured peripheral nerves. Data from the literature indicate that myoblast transfer enhances recovery of muscle function. Thus, we tested the hypothesis that transfer of adult myoblasts improves the properties of reinnervated rabbit tibialis anterior (TA) muscles in both the short term (4 months) and long term (14 months). Two months after transection and immediate suture of the common peroneal nerve, TA muscles were made to degenerate by cardiotoxin injection and then transplanted with adult myoblasts cultured for 13 days. Under these conditions, muscles studied at 4 months were heavier, contained larger fibers, and developed a significantly higher maximal force than muscles that had only been denervated-reinnervated. In the long term, although muscles made to degenerate were heavier and developed a significantly higher maximal force than denervated-reinnervated muscles, myoblast transfer failed to improve these parameters. However, the overall characteristics of long-term operated muscles tended clearly to approach those of the controls. Taken together, these results may have significant implications in certain orthopedic contexts, particularly after immediate or delayed muscle reinnervation.

The size of injured metamere (IM) in tetraplegia exhibits a high variability that explains the different clinical presentations in patients who have the same neurologic level. Even when functional electrical stimulation is not planned, the lower motor neuron (LMN) integrity of paralyzed muscles must be evaluated, especially in patients with high-level tetraplegia. During the acute phase, detecting the size of the IM is important to prevent supination contracture and stiffness of the thumb and finger joints. When planning functional surgery, the LMN integrity of intrinsic muscles helps the surgeon adapt his surgical procedures. Assessing IM size must be integrated systematically into the evaluation of tetraplegic patients.

Cross-reinnervation, in cases of nerve repair or nerve transfer, can be the consequence of wrong connections which are surgically induced between the different types of motoneurons (fast and slow). A slow muscle nerve is able to convert a fast muscle virtually completely to the slow fibre type, whereas a fast muscle nerve exerts an incomplete control over the properties of a slow muscle. Our experiments show that following delayed cross-reinnervation, a statistically significant slow-to-fast transformation of the soleus muscle was observed, with a maximum when nerve repair was performed 6 weeks following nerve section in the rat model. Thus, the negative consequences on nerve and muscle relationship due to cross-reinnervation in the case of wrong connections between slow and fast motoneurons after conventional nerve suture or in the case of nerve transfer could be minimised by imposing a delay before nerve repair.