Can objective criteria for poor tolerance of proximal humerus malunion be identified?

BACKGROUND: Malunion of the proximal humerus is common and variably tolerated. Classifications developed for proximal humerus malunion (PHM) rely on standard radiographs, which underestimate bone fragment displacement and lack accuracy. The clinical tolerance of PHM is subjective, and revision surgery is not always necessary. The primary objective of this study was to assess the reproducibility and relevance of four CT angle measurements for objectively quantifying the morphological disharmony caused by PHM in a control population then in a population with PHM. The secondary objectives were to identify angle cut-offs and to assess the correlations between angle values and the clinical tolerance of PHM. HYPOTHESIS: Objective criteria for assessing proximal humerus malunion can be identified using CT scans. MATERIALS AND METHODS: Four angles were chosen to quantify proximal humerus disharmony: the angles between the humeral head and the glenoid in the coronal plane (HGCo) and axial plane (HGAx), the angle of tuberosity divergence in the axial plane (TDAx), and the centrum collum diaphyseal angle (CCD). The reproducibility of measurements of the four angles on computed tomography (CT) views was evaluated in a control population and in 46 patients with PHM. To this end, the reproducibility of reference slice selection was determined and intra- and interobserver reproducibility of the angle measurements was then assessed. Patients with PHM were divided into two groups based on clinical tolerance to allow testing for disharmony parameters associated with poor clinical tolerance, which was defined as functional impairment and surgical revision. RESULTS: Slice selection was found to be reproducible. The Bland-Altman plot indicated that the angle measurements in both the controls and the patients were reproducible within ±2 SDs. Intraclass correlation coefficient values ranged from fair to excellent for all angles in both the controls and the patients. The mean TDAx was higher in the patients than in the controls (72.0° vs. 56.1°, P<0.05) and, within the PHM group, was higher in the subgroup with good vs. poor clinical tolerance (75.8° vs. 69.5°, P<0.05). The CCD angle was greater in the controls than in the patients (129.8° [range, 128.3°-131.3°] vs. 125.9° [range, 122.9°-128.9], respectively) and was significantly greater in the PHM subgroup with good vs poor clinical tolerance (131.4° vs. 122.3°, respectively; P=0.007). The HGCo and HGAx angles were significantly greater in the patients than in the controls (HGCo: 66.6° vs. 52.2°, respectively; HGAx: 17.5° vs. 13.3°, respectively, P=0.55). DISCUSSION: The measurement method described here provides a quantitative assessment of postfracture disharmony based on four angles, the HGCo, HGAx, and TDAx. Measurement of these four angles on CT images was found to have good intra- and interobserver reproducibility. The angle values were significantly greater in the patients with PHM than in the controls. Within the patient group, the subgroup with poor clinical tolerance had smaller values of the TDAx, CCD, and HGAx angles and a greater value of the HGCo angle. LEVEL OF EVIDENCE: IV, retrospective observational study.

Functional and socioprofessional outcome of surgery for Volkmann's contracture.

OBJECTIVES: Volkmann's ischemic contracture is rare and surgical treatment remains a challenge. The goal of treatment is to obtain permanent recovery of joint range of motion and strength. The goal of this study was to evaluate the functional and socioprofessional outcome of surgical treatment of Volkmann's ischemic contracture. METHODS: This retrospective study was performed in two centers with one surgeon. Seven patients were included; mean age 23.6 years old. The Quick-Dash score, Patient Rated Wrist Questionnaire (PRWE) scores were obtained. Grip strength was compared to the contralateral side. Satisfaction was evaluated by the question: would you have surgery again? The surgical technique included 7 muscle slide procedures. RESULTS: Wrist and finger range of motion was good at least 6.1years in all cases according to the system by Buck-Gramcko. Grip strength on the operated side was 72.3% of the contralateral side. The mean PRWE was 14.64/100, mean QUICK-DASH score was 7.9/100. Patients returned to their professional activities in all cases. Patients who were questioned were all satisfied with surgery. CONCLUSIONS: Once the contracture is established in Volkmann's contracture Page-Scaglieti-Gosset muscle slide procedure can be used with good results allowing a return to socioprofessional activities. LEVEL OF EVIDENCE: IV, retrospective study.

Arthroscopic arthrodesis of the shoulder in brachial plexus palsy.

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.