Elbow coverage by the descending superficial radial artery flap: a clinical series and literature review.

PURPOSE: Soft tissue coverage of the posterior aspect of the elbow requires thin and flexible flaps to adapt to movements without constraining them. The authors report a clinical series of reconstruction by the descending superficial radial artery (DSRA) flap, a proximal forearm perforator flap which use is rarely reported in the literature. METHODS: Seven patients with a mean age of 50 years (range 24-88 years) were treated for a posterior elbow defect using the DSRA flap with an adipofascial pedicle. The flap was tunneled to the defect in the subcutaneous tissue or raised using the racket-like technique to avoid any pedicle compression. RESULTS: The mean follow-up was 3.3 months (range 1-12 months). A partial necrosis of the skin paddle occurred in an 88-year-old patient. In the other cases, the flap evolution was straightforward. At the last follow-up, the appearance of the flaps was satisfactory in terms of color, texture, and thickness. No complications were observed at the donor site. CONCLUSION: The DSRA flap with an adipofascial pedicle is a simple, reliable, and reproducible method for reconstruction of small to moderate-sized defect on the posterior aspect of the elbow. Its use is easier for defects on the posterolateral side, but it can reach the medial olecranon.

Influence of the anatomy of the proximal articular surface of the trapezium (PAST) and the trapezoidal articular surface of the trapezium (TRAST) in cup placement during trapeziometacarpal arthroplasty.

The influence of the anatomy of the proximal articular surface of the trapezium (PAST) and the trapezoidal articular surface of the trapezium (TRAST) on cup placement during trapeziometacarpal arthroplasty was retrospectively evaluated on 56 preoperative anteroposterior radiographs of patients who underwent surgery for trapeziometacarpal osteoarthritis. The percentage coverage of the prosthetic cup by the PAST and the available height of the trapezium were calculated. In 39% of cases, there was a significant difference (up to a mean 4.5 mm, p < 0.001) between the radial height of the trapezium (which is usually considered) and the available height of the trapezium. The anatomy of the PAST and the TRAST has an impact on the placement of the prosthetic cup when trapezium height is low. The results of the present study suggest that these considerations must be known by all operators performing trapeziometacarpal arthroplasty; that lateralization, implant suspension, or surgical alternatives should be considered to prevent several intra- and postoperative surgical complications. Level of evidence: IV.

Recommendations for radiographic assessment of hand wounds.

A retrospective study of 945 hand patients was conducted to determine the relevance of systematic radiographic assessment. An osteoarticular lesion or a radiopaque foreign body was found in 34% of cases. The indications for radiographic assessment should be related to the mechanism of injury.

31 years survival rate of ARPE® single-mobility prosthesis in trapeziometacarpal osteoarthritis.

A retrospective study of 41 trapeziometacarpal prostheses showed that the implant survival rate decreased linearly over time with a critical period in the first years; ranging from 83% after 5 years to 50% after 30 years.Level of evidence: IV.

Trapeziometacarpal osteoarthritis: do not forget other disorders.

A retrospective study of patients with symptomatic trapeziometacarpal osteoarthritis was conducted to assess the prevalence of other disorders of the hand. Another disorder of the hand was associated in 49% of cases. A systematic clinical examination of the whole hand must be performed preoperatively.

Long-term patient-reported outcome measures of fingertip coverage with a homodigital unipedicle neurovascular island flap.

We report the long-term patient-reported outcomes and objective outcomes of a homodigital neurovascular island flap for distal phalangeal amputations in the fingers (with the thumb excluded) for 20 patients at a median follow-up of 4.4 years (IQR 2.2 to 12.3). We assessed the global subjective and aesthetic outcomes, range of motion, sensitivity and strength. The patient-reported median subjective global score was 7.5/10 points (IQR 7 to 9) and the aesthetic score was 8/10 points (IQR 8 to 9). Range of motion, sensitivity and strength were similar to the uninjured side. Stiffness was present in more than half of the cases; 14 patients had a hook nail deformity and seven patients reported symptomatic cold intolerance. At a long-term follow-up, the patient-reported outcome measures and objective outcomes of this flap are satisfactory and it is a safe and reliable flap.Level of evidence: IV.

Role of middle glenohumeral ligament in external shoulder rotation.

Background: The middle glenohumeral ligament (MGHL) is one of the three ligaments that stabilize the anterior capsule of the shoulder. Recent work suggests that it inserts distally into the deep layer of the subscapularis tendon. The role of the MGHL remains debated. The hypothesis of this study was that the MGHL plays a significant functional role in limiting external rotation of the shoulder while allowing a wide range of motion through its distal insertion into the subscapularis rather than directly onto the humerus. Methods: In a cadaveric study performed on 20 shoulders (10 subjects), the MGHL and the other anterior structures of the shoulder were successively cut according to a standardized protocol. At each stage, the external rotation range of the shoulder was measured with the arm at the side (ER 1) and in 90° abduction (ER 2) using a goniometer. After dissection, the structure of the MGHL and its distal insertion were analyzed. Results: Cutting the MGHL led to significant increases in ER 1 but not in ER 2. Shoulder range of motion in ER 1 increased on average by 15 ± 5° (P < .001) after cutting the MGHL and by 21 ± 11° (P < .001) after subscapularis peel. The range of motion in ER 2 increased by 3 ± 4° (P = .048) after cutting the MGHL, by 4 ± 6° (P = .02) after subscapularis peel and by 25 ± 8° (P < .001) after cutting the inferior glenohumeral ligament. The MGHL was present in all dissected shoulders. It was leaf-like in 12 cases, cord-like in 6 cases and had a vestigial appearance in 2 cases. The distal insertion was in all cases in the deep layer of the subscapularis in a thickening of the anterior capsule in the superior part of the muscle, except for two cases in which the tendinous part of the subscapularis was also involved. Conclusion: The MGHL limited shoulder external rotation by a similar amount as the subscapularis muscle. Further studies are required to understand the clinical relevance of these findings, notably for the treatment of shoulder stiffness.

Reverse Perilunate Injuries-The "Extended Scaphoid" Sign.

Background Reverse perilunate injuries (REPLI) are rare variants of the classic radial-sided perilunate injuries (PLI) whose mechanism was described by Mayfield in 1980. Classic radial-sided nontranscaphoid dorsal PLI invariably display a flexed, foreshortened position of the scaphoid on their initial posteroanterior (PA) and lateral radiographs. We observed that some dorsal perilunate dislocations displayed an extended position of the scaphoid on their initial radiographs. Our hypothesis is that this extended position of the scaphoid was associated with a REPLI pattern. Methods The PA and lateral initial emergency radiographs of our specialized wrist surgery series of 114 dorsal pure ligamentous PLI (within a 186 cases series of PLI treated between 2004 and 2020) were reviewed as well as the available figures of the current REPLI literature. Results A total of seven cases of cases within our dorsal PLI series displayed an extended position of the scaphoid on their initial PA and lateral radiographs, while 107 cases displayed a flexed, foreshortened position. The PA and lateral radiographs available in the REPLI literature displayed an extended position of the scaphoid, a lunotriquetral dissociation, and a dorsal dislocation of the capitate with respect to the lunate. Discussion This study confirms our hypothesis. By contrast to the dorsal classic radial-sided pure ligamentous PLI pattern of scaphoid displacement (scaphoid flexed and foreshortened with scapholunate gap), the dorsal REPLI pattern displays an extended position of the scaphoid with scapholunate step-off and overlap rather than a gap. The combination of a lunotriquetral dissociation with a dorsal dislocation of the capitate from the lunate yet an extended position of the scaphoid with almost normal radioscaphoid relationships should raise a high suspicion for REPLI.

Evaluation of containment measures' effect on orthopaedic trauma surgery during the COVID-19 pandemic: a retrospective comparison between 2019 and 2020.

BACKGROUND: There is no available information about the effect of containment measures on trauma surgery activity. The aim of this study was to analyse and report the containment measures' impact on trauma surgery activity during the COVID-19 pandemic in order to quickly react and adjust in case of a new sanitary crisis and containment. METHODS: An original epidemiological study was performed in our trauma centre in France. Data from trauma surgeries performed during the pre-containment (from March 1 to March 16, 2020), containment (from March 17 to April 17, 2020) and reference (from March 1 to April 17, 2019) periods were compared. The primary outcome was the number of patients operated on daily and the daily operating room time. Clinical data, delay for surgery, mechanism of injury and injury pattern were also reviewed. RESULTS: There was a statistically significant decrease in the number of patients operated upon daily (- 39,8%, p value < 0.001) and daily operating room time (- 35.5%, p value < 0.001) between the reference and containment periods and between the pre-containment and containment periods (respectively, - 35.0%, p value < 0.001 and - 28.7%, p value 0.002). No differences were reported between the reference and pre-containment periods for daily-operated patients (p value 0.359). CONCLUSION: Containment measures had a direct impact on trauma surgery activity with a decrease of a third of trauma surgery activity. Those results could be useful if a new containment occurred.