Results of isolated ulnar shaft shortening osteotomy in the treatment of idiopathic ulnocarpal impaction syndrome.

The objective of this study was to evaluate the results of isolated ulnar shaft shortening osteotomy (USSO) in the treatment of idiopathic ulnocarpal impingement syndrome. This was a two-center retrospective study. All patients older than 18 years who underwent isolated USSO for idiopathic ulnocarpal impingement syndrome between 2006 and 2016 were included. The outcome measures were: patient satisfaction, decrease in pain intensity, change in occupation, QuickDASH and PRWE functional scores, secondary palliative surgery suggesting failure of the ulnar shaft shortening osteotomy, and postoperative ulnar variance. The main complications were analyzed. Thirty-one patients were included. Twenty-six (84%) were satisfied with the procedure. At an average follow-up of 62 months, there was no secondary palliative surgery. Mean pain intensity on VAS was 7/10 (range, 2-10) and 1.7/10 (range, 0-6) preoperatively and postoperatively, respectively, for a mean decrease of 5.3 ± 2.6 points; this decrease was statistically significant (p < 0.001). None of the manual workers had to alter their work. Mean postoperative QuickDASH score was 19.6/100 (range, 0-79.55) and mean postoperative PRWE score was 23/100 (range, 1-85). Mean postoperative ulnar variance was -0.5 mm. As for complications, 61% of patients (n = 19/31) had discomfort related to the plate; 9.7% (n = 3/31) had distal radioulnar osteoarthritis; 4% (n = 1/19) had a fracture after hardware removal; 13% (n = 4/31) had non-union. Despite a high rate of complications, the study confirmed the effectiveness, in terms of pain, of isolated USSO in the treatment of idiopathic ulnocarpal impingement syndrome. LEVEL OF EVIDENCE: IV; retrospective cohort.

Double tendon transfer for correction of drop-foot.

Many conditions can cause foot drop, which makes walking difficult because the foot easily bumps into obstacles, or the knee must be kept more flexed than usual during the swing phase of gait, especially when going up stairs. Several techniques that have been described to correct foot drop rely on bone procedures or tendon transfer, with or without bone fixation. In this article, we describe a simple technique that is heavily used in leprosy-endemic countries and provides long-lasting results. It requires a double tendon transfer through the interosseous membrane of leg; the tibialis posterior and flexor digitorum longus are sutured to the tibialis anterior, and extensor hallucis longus and extensor digitorum longus, respectively, proximally to the extensor retinaculum.

Wrist arthrodesis with intercalated iliac crest graft in mutilans rheumatoid arthritis.

In mutilans rheumatoid arthritis (RA) patients with major wrist destruction, wrist arthrodesis is recommended. This type of arthrodesis needs carpal reconstruction and stable fixation. The goal of this study was to assess the functional and anatomical outcomes of an iliac crest graft and internal fixation with two medullary pins. Six wrists in three patients suffering from RA were reviewed clinically and radiologically at an average follow-up of 25 months. We assessed the fusion of the iliac graft with the radius and the metacarpus, the preoperative and postoperative carpal height, and the bone stock in front of the thumb. All the patients had improved functionally. The iliac graft fused with the radius in all cases and fused with the metacarpus in 5 out of 6 cases; the non-union occurred in the wrist where only one pin was used. Restoration of carpal height was associated with improvements in hand function. The bone stock was sufficient to allow implantation of a trapezial cup during a total arthroplasty of the thumb trapeziometacarpal (TMC) joint. No major complications occurred. An iliac graft and two pins through the 2nd and 3rd metacarpals were used to reconstruct the carpal height and to obtain wrist fusion. Internal fixation with only one pin is not recommended. Functional improvement can be attributed to the normal tension within the extrinsic flexors and extensors of fingers and thumb being restored because the carpal height was restored. A secondary TMC arthroplasty is theoretically possible.

Is cemented metal-polyethylene 22.2mm hip arthroplasty a gold standard? Results of a series of 105 primary arthroplasties at a minimum of ten years follow-up.

INTRODUCTION: Although Charnley-Kerboull metal-on-polyethylene 22.2mm cemented total hip arthroplasty (THA) is considered to be the gold standard in France, results with this prosthesis are conflicting, in particular in relation to Scandinavian registers. The goal of this retrospective study was to confirm the validity of this prosthesis at a minimum of 10years follow-up. HYPOTHESIS: Survival of this type of THA would fulfill NICE conditions (survival at 10 years of at least 90%). MATERIALS AND METHODS: One hundred and five primary THA were performed in 93 patients (30 men and 63 women) mean age 72.6 years old (60-86) between January 1998 and March 2001. After a mean follow-up of 10.6 years (10-13 years), 21 patients (23 THA) were lost to follow-up and 32 (35 THA) had died leaving 40 patients (47 THA) for clinical analysis (Merle d'Aubigné and Oxford scores) and X-ray assessment. Survival was calculated with revision for any cause and radiological loosening with or without revision as end-points. RESULTS: The mean Oxford score at the final follow-up was 22/60 (13-45), the PMA score was 14.2 (11-17). Eight patients underwent revision surgery after a mean 7.5 years (2-11) (1 early dislocation and 7 acetabular cup loosenings). Survival at 10 years was 89.4% (CI95%: 78-95) for all causes of revision and 78% (CI95%: 61-91) for loosening with (n=7) or without (n=3) revision. No cases of septic or femoral loosening were observed. Twelve of the 47 revised hip replacements (25.5%) presented wear≥2mm. DISCUSSION: Although functional results were acceptable for this elderly population, survival did not reach the NICE value and was lower than results in the literature for this type of implant. Cup loosening and wear were the main causes of revision. LEVEL OF EVIDENCE IV: retrospective.

[Arthroscopic treatment of lateral epicondylitis: a prospective study on 14 cases]. / Traitement arthroscopique de l'épicondylite latérale : étude prospective à propos de 14 cas.

Lateral epicondylitis of the elbow is a relatively common pathology and would involve 1-3% of the overall population. Lack of consensus on surgical techniques reflects the difficulty of understanding and treating this disease. Our prospective study reports the results of its arthroscopic treatment on 14 patients operated on between 2009 and 2012. The mean follow-up was 7.15 months. All patients underwent a well conducted medical treatment for an average of 32.5 months. The operation was carried out under regional anesthesia in an outpatient. The technique included a time of joint exploration, joint capsulotomy and a transverse division of the pathological tendon of extensor carpi radialis brevis (ECRB) and extensor digitorum communis (EDC). The value on the visual analogic scale (VAS) at rest and during exercise increased from 2.85 to 0.43 and from 7.71 to 2.43, respectively, then remained stable over time. Professional activity was resumed on average at 9.1 weeks. Neither intraoperative nor postoperative complications were found. No laxity was observed. The Mayo Clinic and DASH scores were significantly improved from 52.14 to 92.5 and from 54.11 to 9.7, respectively. Overall, we observed 11 very good and three good results. Although our prospective series has a few patients and limited follow-up, our results are better or similar than those reported in the literature on pain relief and functional recovery. In contrast, the average recovery of professional activity was longer. Elbow arthroscopy, less invasive than open procedures, and allowing further joint exploration, seems an excellent alternative technique in this indication.

Imaging of the nerves of the knee region.

Peripheral neuropathies are a frequent, but often underdiagnosed, cause of pain and functional impairment. The clinical symptoms can be subtle, and other neurologic or non neurologic clinical entities are often evoked. MRI and ultrasonography are the imaging modalities of choice for depicting nerves and assessing neuropathies. Common neuropathies in the knee area involve the saphenous, the tibial, the common peroneal and the sural nerves. The most frequent mechanisms of nerve injury in this area are nerve entrapment and nerve stretching. A perfect knowledge of the normal imaging anatomy is essential for accurate assessment of neuropathies. In this article, we will review the anatomy of the nerves around the knee, and their normal and pathological appearance.

[Pathology of wrist ligaments. 32 lesions of the carpal triangular fibrocartilage complex (TFCC). Prognostic significance of associated luno-triquetral lesions]. / La pathologie ligamentaire du poignet. À propos de 32 lésions du complexe fibro-cartilagineux triangulaire du carpe (TFCC). Intérêt pronostique des lésions luno-triquetrales associées.

Trauma of the wrist is often responsible for multiple ligament injuries. We wanted to know if the association of a luno-triquetral ligament lesion and a triangular fibrocartilage disc lesion has a poor prognosis. We reviewed 32 patients with a traumatic injury of the triangular ligament, with a mean age of 35 years, and 32 months of follow up. The functional scores used were the Modified Mayo Wrist score, the Quick DASH score, and the Herzberg score. Patients were classified according to the severity of luno-triquetral lesions, in conformity with the Geissler's classification. Ten patients had a healthy ligament, 11 a stable lesion stage 1 and 11 an unstable lesion stage 2, 3 or 4. The joint mobility averages were 59.5° in flexion, 64.2° in extension, a pronation of 71.3°, a supination of 74.1°, an ulnar inclination of 33.8° and a radial inclination of 16.8°. The Modified Mayo Wrist score average was 75/100, the Herzberg score average was 81.5/100 and the average of the Quick DASH 8/100. The patients were all very satisfied or satisfied with their intervention. There was no statistically significant difference between the three groups studied regarding mobility and functional scores. In this study, an associated luno-triquetral ligament injury does not seem to worsen the functional outcome after surgery, provided appropriate treatment had been performed. However, a larger patient sample is needed to verify these findings.

[Treatment of rheumatoid swan neck deformity by tenodesis of proximal interphalangeal joint with a half flexor digitorum superficialis tendon. About 23 fingers at 61 months follow-up]. / Traitement des déformations des doigts longs en col-de-cygne dans les affections rhumatismales par ténodèse de l'articulation interphalangienne proximale à l'aide d'un hémi-tendon fléchisseur superficiel. À propos de 23 doigts à 61 mois de recul.

OBJECTIVES: Surgical treatment of finger swan neck deformities is versatile. We aimed to assess the outcome of PIP tenodesis on unfixed deformities, in patients suffering from rheumatoid arthritis. METHODS: Twenty-three PIP tenodeses were performed on eight patients, using half of a superficialis flexor digitorum tendon sutured to A2 pulley through a volar approach. Postoperative splinting, in 20° of PIP flexion, was maintained for 4 weeks. The patients were assessed retrospectively, at a mean period of 61 months. RESULTS: The PIP flexion gained 26°. On the other hand, a 4°-flexion contraction was induced. The mean postoperative flexion reached 65°. The PIP hyperextension was corrected by 33°. In one same patient, the correction was insufficient for the four fingers. The DIP lack of extension was totally corrected in 70% of the cases and partially in 30%. Each patient had functional improvement. Nineteen good and excellent, and four fair results were reported. No major complication was observed. CONCLUSION: This tenodesis seems to be reliable and to give good long-term results. It is our intervention of choice for rheumatoid flexible swan-neck deformity.

[Histologic risk factors of basal cell carcinoma of the face, about 184 cases]. / Facteurs de risques histologiques des carcinomes basocellulaires de la face : à propos d'une série de 184 cas.

BACKGROUND: Basal cell carcinoma is the most common type of skin cancer in humans. OBJECTIVES: The aim of our study was to determine the histologic risk factors involved in recurrence of basal cell carcinomas of the face. PATIENTS AND METHODS: We conducted a retrospective study of patients with primary basal cell carcinoma (BCC) of the face treated between March 2003 and December 2005. We analyzed the size of lateral and deep margins of tumor, histologic subtype, perineural invasion, and ulcerations. Clinical follow-up was observed until June 2011. RESULTS: We note that 184 cases of BCC were included. Eleven recurrences occurred during the follow-up, i.e. 6%. The population was divided into two groups according to histologic safety margins (1 mm for all basal cell carcinomas, 0.8 mm for nodular and 2 mm for aggressive-growth (AG-BCC) subtypes). There was a significant difference between groups in regards to cancer recurrence. Tumor size above 2 cm and presence of perineural invasion increased the risk of recurrence. DISCUSSION: Low histological safety margins appear to be critical on tumor recurrence. Depending on the tumor characteristics, and the patient, we advocate a re-excision in cases of histological safety margins inferior to 0.8 mm for the nodular subtypes and 2 mm for aggressive subtypes. Tumor size, and perineural invasion should be taken into consideration so as to make a well-informed decision between re-excision and a watching strategy in critical cases.

Femoral head to neck offset after hip resurfacing is critical for range of motion.

BACKGROUND: Range of motion after hip arthroplasty may be limited by soft tissues around the hip, extra-articular contact and femoral stem-neck contact with the acetabular articular surface. Femoral head-neck diameter ratio is recognized as a major factor influencing hip range of motion. In hip resurfacing, range of motion is constrained by "cup component to femoral neck" contact. To avoid cup-to-bone contact or to increase the degree of flexion at which it occurs, anterior translation of the femoral component relative to the central femoral neck axis may improve anterior head-neck offset and hip flexion. We questioned whether low or high anterior femoral head to neck offset, cup inclination, stem anteversion, and component size influenced postoperative range of motion and hip flexion in patients who had undergone hip resurfacing. METHODS: We prospectively followed 66 patients (68 hips) who underwent hip resurfacing at a mean age at operation of 46.4 years (range, 19-60 years). Mean follow-up was 37.5 months (range, 33-41 months). No patient was lost to follow-up. All patients were evaluated clinically and range of motion was precised. Radiological measurement evaluated the anterior femoral head-neck offset. FINDINGS: Mean anterior neck-head offset was 7.5mm (range, 5-12 mm). We found significant linear regression correlation between anterior offset and flexion (R=0.66) and between anterior offset and global range of motion (R=0.51). One millimeter of anterior offset increased hip range of motion by 5° in flexion. No significant correlations were found between global range of motion or flexion arc of motion and component size, stem anteversion, cup inclination, gender ratio, preoperative arc of flexion or global range of motion. INTERPRETATION: Restoring or improving deficient anterior femoral head-neck offset appears important for restoring postoperative range of motion and specifically hip flexion.

Total hip arthroplasty revision in case of intra-pelvic cup migration: designing a surgical strategy.

Intrapelvic acetabular cup migration is a rare but serious complication, which can occur after cup loosening following total hip arthroplasty. To make safe intrapelvic implant removal, several principles must be respected: identification of potential risks with a thorough preoperative workup, preoperative planing of a surgical strategy for removing protruding hardware without injuring noble anatomical structures, preserving muscle and bone stock, pelvic anatomy reconstruction (including, as needed, osteosynthesis of the pelvis), and prosthetic components selection correcting any length discrepancy. Preoperative assessment is based on a complete radiological workup, angio-CT, as well as studies searching for signs of inflammation (blood workup and joint aspiration). All cases of intrapelvic migration of an acetabular component do not systematically command a subperitoneal approach. The presence of some residual bone shell, an intrapelvic foreign body, or a path deviation from normal in a vascular bundle or an ureter must be analyzed before deciding on the approach. The potential problems managing this mode of loosening event are a reminder for the need of periodical total hip arthroplasty follow-up. This regular monitoring helps preventing complications sometimes life threatening.

Stem subsidence after total hip revision: 183 cases at 5.9 years follow-up.

INTRODUCTION: Secondary subsidence of a revision femoral stem is often a negative predictive sign for successful osseointegration and perfect long-term stability. MATERIALS AND METHODS: We performed a retrospective study in a series of 183 revision total hip replacements between 1996 and 2000 to evaluate the importance and risk factors of secondary subsidence with a cementless press-fit design femoral stem as well as this subsidence's consequences to osseointegration. RESULTS: Secondary subsidence did not occur in 80 cases (53%), was between 0 and 4mm in 41 cases (27%); between 5 and 10mm in 17 cases (12%) and was greater than 10mm in 12 cases (8%). Mean subsidence of all patients was 3mm (0-30). There was a statistically significant negative correlation between subsidence and the quality of osseointegration (P=0.03). There was no significant relationship between component diameter and stem subsidence (P=0.9). The presence of preoperative bone deficiencies did not increase the risk of secondary subsidence (P=0.2). CONCLUSION: In the case of revision with press-fit stems, the importance of secondary subsidence should not be overestimated, because it usually does not negatively affect satisfactory osseointegration.

[Osseous vascular anatomy in the hand and wrist]. / Anatomie vasculaire osseuse à la main et au poignet.

The design and the realization of vascularized osseous grafts at the hand and the wrist require a precise knowledge of the general and regional anatomy. This article gives first a progress report on current knowledge about the general organization of arterial and venous vascularization, of the long bones (number and localization of the nutrient foramina, communication between the epiphyseo-metaphyseal and diaphyseal networks) and of the short bones, in the adult and the child, before the closing of the growth plate. The general organization of arterial vascularization of the hand and the wrist is pointed out, with the current nomenclature and the contribution of the recent publications, in particular in these, which relate to the distal extremity of the radius. The vascularization of each bone (radius and ulna, carpal bones, metacarpals and phalanges) is then described; making way, the anatomical bases of each vascularized bone graft, which can be harvested there, are described. The last technical projections are included, in particular the realization of the reverse flow vascularized bone grafts harvested from the metacarpals. This article still gives a progress report on the osseous vascularization of the short bones, in particular of those which are exposed the most to the osteonecrosis (scaphoid, lunatum). It has the ambition to light the reader and to prepare him (her) with the reading of the following chapters.

Swanson-type silastic arthroplasties of the PIP joint for rheumatoid arthritis. Results of 19 implants at 5.3 years of follow-up.

This retrospective study reports the results from 19 PIP Silastic spacers in 11 female patients suffering from inflammatory diseases at a mean of 2.2 and 5.3 years after surgery. The improvement in range of movement decreased with time, evolving from a gain of 18̊ at 2.2 years to only a 4-gain at subsequent follow-up. The fracture rate was high (30%). Objective analysis by physicians reported poor or mild improvements in 75% of cases. Subjective analysis (assessing aesthetics, function and pain) by patients, showed an average score of 5.6/10. At final follow-up, eight out of nine patients did not regret having had surgery. As patients actually hope for pain relief and improved function and quality of life, rather than anatomical recovery, this explains the high acceptability and interest in this rudimentary surgical procedure.

[Central-medullary nailing of proximal humerus fractures using T2 nails. A retrospective study of 38 cases]. / Enclouage centromédullaire des fractures de l'extrémité proximale de l'humérus par clou T2. Etude rétrospective de 38 cas.

The intramedullary nailing of humerus has emerged as one of the treatments of reference for proximal fractures. We have reviewed 38 patients aged 64.2 on average with a mean follow of 18 months. The functional scores used were the Constant and Murley's score as well as the DASH self-administered quality of life questionnaire. Radiological criteria have been analyzed, namely the cephalic angle noted alphaF and the presence of any osteolysis of the major tuberosity. Patients were grouped by type of fracture, according to Neer's classification, with nine cases in Neer 2 group, 19 in Neer 3 group, and ten in Neer 4 group. The unrefined Constant score was 53.4 points on average, balanced to 71.6%. The joint mobilities were an average forward elevation of 108 degrees, an average abduction of 100 degrees and an external rotation of 27 degrees. These scores were even worse than the fracture was comminuted. It was not found a radioclinical correlation between value of the angle alphaF and clinical outcome, but the presence of osteolysis of the major tuberosity was significantly associated with poor late functional results. Five cases of osteonecrosis have been counted, divided with 10.5% in the Neer stage 3, and 30% in the Neer stage 4. The average unrefined Constant score from these patients was 38.5 points on average, balanced to 57.7%. Intramedullary nailing allows fixation of comminuted fractures with three or four fragments, but control of fixing and strength of assembly were not always practiced. In young patients, where tuberosities consolidation is essential, screwed plates seem to be a favorable alternative. Moreover, total reverse prosthesis seems to have more and more arguments to impose itself like the preferred treatment towards fractures in four fragments in people aged over 75 years.

[A rare cause of pseudoclubbing (pseudohippocratic finger): the acrometastasis. A case report]. / Une cause rare de pseudohippocratisme digital : l'acrométastase. A propos d'un cas.

The authors report a case of acrometastasis in a patient with breast carcinoma who, after nine years of remission, developed multiple osseous metastases including one in the distal phalanx of her right little finger. The patient who was aged 48, presented with a painful swelling of the distal end of the right little finger. Three weeks previously, she had been diagnosed with multiple osseous metastases. A distal interphalangeal disarticulation was advised and was performed without complications. Histological examination confirmed the diagnosis of metastasis of adenocarcinoma. The clinical picture of acrometastasis is generally dominated by pain, but a presentation similar to a whitlow is also possible. When the lesion is distal, amputation is preferred except possibly in the case of the thumb. Clubbing must be differentiated from pseudoclubbing. Clubbing is a nail deformation affecting all digital rays of one or both hands. It belongs to the syndrome of hypertrophic osteoarthropathy whose systemic etiologies are numerous. Pseudoclubbing is an atypical deformation, concerning one or more rays, and is asymmetrical; its causes are different and can be local. The normal angle of Lovibond is approximately 160 degrees, it is greater than 180 degrees in clubbing and less than 180 degrees in pseudoclubbing. Clinical examination makes it possible to differentiate these two signs and must be supplemented by radiographic examination.

Second generation GUEPAR total arthroplasty of the thumb basal joint: 50 months follow-up in 84 cases.

BACKGROUND: Osteoarthritis of the thumb basal joint is the most common location for hand degenerative joint disease. First, carpometacarpal (CMC) joint arthroplasty is one treatment option. The purpose of this article is to present the outcome of the GUEPAR II prosthesis, a total trapeziometacarpal cemented implant of the retaining ball-and-socket design type. Numerous other advantageous features of this implant, second generation of an earlier version are explored. HYPOTHESIS: Clinical and radiological results confirm the GUEPAR II trapeziometacarpal arthroplasty as a reliable and efficient evolution of earlier prosthetic designs. MATERIALS AND METHODS: Eighty-four GUEPAR II prostheses were implanted to treat advanced and severely incapacitating first CMC osteoarthritis. The average follow-up time in this collaborative series (from 2 centers) was 50 months. RESULTS: There were no intraoperative complications and no dislocations at the final follow-up evaluation, 92% of patients were satisfied or very satisfied with their results with objective improvement of their Kapandji score. Strength was closely comparable to the nonaffected side. Radiographic studies at the final follow-up evaluations did not show (except in one socket revision instance) signs of implant loosening. On occasion, non-progressive radiolucent lines were observed. More than 80% of the patients remained pain free. CONCLUSIONS: In our series, GUEPAR II total joint arthroplasty of the thumb CMC joint has proven to be efficacious, improving motion, strength, and achieving a high degree of pain relief. Successful outcome appears in our experience contingent upon strict compliance with numerous surgical technique details. Current research focuses on improving bipolar fixation by developing press-fit cementless implants.