Normative values of the DASH questionnaire in healthy individuals over 50 years of age.

This study aimed to define the normative values of the DASH score in healthy individuals over 50 years of age. One hundred and twenty subjects equally representing both genders and six age categories (50-54, 55-59, 60-64, 65-69, 70-74 and 75-80 years), with no past medical history affecting the upper limb, were asked to complete the DASH questionnaire. A visual analogue scale for pain and an HAQ-DI questionnaire were also completed to confirm the absence of symptomatic untreated upper limb pathologies. In this series of a priori normal subjects, most had a DASH score greater than 0. Moreover, the DASH score was found to rise with age, with a statistically significant difference between women and men. The DASH questionnaire is widely accepted in the everyday medical practice as a tool to evaluate upper limb function. However, age adjustment of the DASH questionnaire is necessary to correctly evaluate the clinical status and progression of individuals over the age of 50.

Lunate biomechanics: application to Kienböck's disease and its treatment.

Kienböck's disease was initially considered as lunate osteomalacia due to lesions of its nutrient arteries during carpal ligament tears. It has also been suggested following primary fractures, or because of repeated microtrauma. It is only in the past 20 or 30 years that it has appeared as aseptic necrosis. Based on Hultén's hypothesis that a negative radioulnar index was the cause of Kienböck's disease, equalization osteotomies (shortening of the radius or lengthening of the ulna) were developed. The observation of Kienböck's disease in subjects with a positive index and the risk of ulnar abutment after osteotomy led to the introduction of new osteotomies to get around these difficulties, still in the hope of treating the cause of Kienböck's disease. While it has been confirmed that a negative radioulnar index promotes lunate fracture, it clearly does not induce the pathology in the form of necrosis. In this scenario, perilunar osteotomies produce durable decompression, limiting the risk of lunate fracture in case of necrosis by removing the compressive constraints. After comparing the different osteotomies used to treat Kienböck's disease, it seems that the Camembert osteotomy for radius shortening, combined with selective shortening of the ulnar head as described by Sennwald, decompresses the lunate maximally, and protects it long enough for potential natural revascularization to occur.

Microvascular reconstructive techniques in orthopaedic traumatology.

Great evolution has taken place in Orthopaedic Traumatology, regarding techniques, surgical means and equipment. However, we still encounter complicated cases of limb trauma that necessitate microvascular reconstruction. Through three different illustrative cases (one emergency foot revascularization by a free flap, covering an ankle arthrodesis and bridging the anterior tibial artery, one cure of a complex infected tibial non-union with extensive skeletal defect by double barrel fibular transfer and one osteo-chondral reconstruction of the scaphoid proximal pole using a vascularized graft harvested from the femoral medial condyle), the authors remind the Orthopaedic community about the benefits of microsurgery, especially if used in proper indication and timing. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology.

Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know.

OBJECTIVES: The aim of this study was to review the impact of smoking tobacco on the musculoskeletal system, and on bone fractures in particular. METHODS: English-language publications of human and animal studies categorizing subjects into smokers and nonsmokers were sourced from MEDLINE, The Cochrane Library, and SCOPUS. This review specifically focused on the risk, surgical treatment, and prevention of fracture complications in smokers. RESULTS: Smokers have an increased risk of fracture and experience more complications with delayed bone healing, even if they have already stopped smoking, because some adverse effects persist for a prolonged period. Some risks can be reduced during and after surgery by local and general prevention, and smoking cessation is an important factor in lessening this risk. However, if a patient wants to stop smoking at the time of a fracture, the cessation strategies in reducing tobacco use are not easy to implement. The patient should also be warned that using e-cigarettes or other tobaccos does not appear to reduce adverse effects on health. CONCLUSION: The evidence reviewed in this study shows that smoking has a negative effect in terms of the risk and treatment of fractures.Cite this article: J. Hernigou, F. Schuind. Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know. Bone Joint Res 2019;8:255-265. DOI: 10.1302/2046-3758.86.BJR-2018-0344.R1.

Direct Nerve Sutures in (Extended) Upper Obstetric Brachial Plexus Repair.

Background In rare, selected cases of severe (extended) upper obstetric brachial plexus palsy (OBPP), after supraclavicular exposure and distal mobilization of the traumatized trunks and careful neuroma excision, we decided to perform direct nerve coaptation with tolerable tension and immobilized the affected arm positioned in adduction and 90-degree elbow flexion for three weeks. Objectives We present our surgical technique and preliminary results in a prospective open patient series, including 22 patients (14 right and 8 left side affected) between 2009 and 2016, operated at a mean age of 8.4 months. Methods Analysis of functional results after a minimum of 18 months was conducted using the British Medical Research Council (BMRC) scale. Results All children reached 60-90° of elbow flexion and 75° of shoulder abduction at already six months after surgery. For those patients having already passed one year post surgery, the mean active shoulder abduction reached 92°, and for those who past the 18 months 124°. We discuss the actual knowledge about nerve coaptation under "reasonable" tension including its advantages and drawbacks. Conclusion This technique may be indicated in preoperatively selected cases of (extended) upper OBPP and may give good functional results.

Prognostic factors in the treatment of carpal scaphoid non-unions.

In this literature review, the authors analyse the prognostic factors in the curative treatment of scaphoid non-unions. The main negative prognostic factors are smoking, the time elapsed since the fracture, and avascular necrosis of the proximal fragment. If the latter is present, the revascularization by a pedicle or microsurgical bone autograft is probably the treatment of choice. In non-unions without evidence of osteonecrosis, vascularized bone grafts are probably not superior to conventional bone grafts, which can presently be performed under arthroscopic control, with minimal morbidity.

[Mono-arthritis of the hand: case report of osteoid osteoma]. / Mono-arthrite de la main: un cas rapporté d'ostéome ostéïode.

Osteoid osteoma is a rare occurrence at the hand. There is often a long delay before the diagnosis because the clinical signs mimic other frequent affections of the hand. We report the case of a 24-year old female patient suffering from an osteoid osteoma in the first phalanx of a finger. The diagnosis was made four years after the first symptoms. We started by a curettage-biopsy, followed in a second operative step by cauterization and filling up the defect by a bone autograft. Six months after the surgery, the patient was no longer experiencing any symptom. This rare case demonstrates that osteoid osteoma remains a possible diagnosis in chronic pain affecting the hand.

Which approach is best for subungual glomus tumors? Transungual with microsurgical dissection of the nail bed or periungual?

Glomus tumors are rare, accounting for 1% to 5% of all hand tumors. The treatment of subungual glomus tumors consists of complete surgical excision, either by the periungual or transungual approach. Tumor recurrence and nail dystrophy are the main complications. The purpose of this study was to evaluate the outcome as a function of the surgical approach used - transungual or periungual. Fifty-three patients presenting with a subungual glomus tumor underwent surgical excision through the periungual approach if the tumor was peripheral, or the transungual approach if the tumor was centrally located. These patients were followed for an average of 2years. Pain relief was always obtained the day following surgery. Wound healing was achieved on average after 2weeks with the periungual approach and 5weeks with the transungual approach. Other than some longitudinal striations in 10 patients (18.9%) who had been operated through the transungual approach, there were no complications or tumor recurrence. We recommend a periungual approach for a peripheral tumor and a transungual approach for a central tumor. The latter approach, which carries some risks of nail-related sequelae--always minor in our experience--allows for better exposure if the tumor is centrally located.

[Volar dislocation of the fifth carpometacarpal joint: a case report]. / Luxation carpo-métacarpienne palmaire du cinquième doigt : à propos d'un cas.

Pure carpo-metacarpal dislocations without any fracture are rare, their volar component is exceptional. Untreated injuries can result in instability and early articular degeneration. We report a 72-year-old female patient who underwent an isolated closed volar dislocation of her fifth finger carpo-metacarpal joint after a fall. The clinical examination showed a 10°-defect in rotation with limited adduction (radial deviation). The X-rays showed a gap between the base of the fourth and the fifth metacarpal bones with volar dislocation of the base of the fifth carpometacarpal joint. The dislocation was successfully treated by closed reduction maintained with two K-wires. Immobilisation of the joint was applied for 6 weeks. At 2 years follow-up evaluation, the patient was pain free with no clinico-radiological evidence of instability and had returned to her previous level of activity.

Trapeziometacarpal osteoarthrosis: clinical results and sonographic evaluation of the interposed tissue after trapeziectomy and first metacarpal suspension by external minifixation at a minimal two-year follow-up.

Among the surgical options to treat trapeziometacarpal osteoarthrosis, trapeziectomy has been criticized as unable to prevent postoperative collapse of the thumb, causing painful scapho-metacarpal impingement. The implantation of an external minifixator between the first and the second metacarpals for sufficient time has been proposed to maintain the postoperative space created by the bone resection to allow the development of a resistant interposed fibrous tissue. Nineteen patients (16 women, 3 men, mean age 64.5 years) were evaluated at 3.3 years of follow-up after an unilateral trapeziectomy and first metacarpal suspension by external minifixation. Eighty-four percent of the patients were very satisfied with the operation. The mean DASH score was 27.7%, the pain 1.7/10 (Visual Analogue Scale), the opening angle of the first web 58.3° and the Kapandji opposition score 9.5/10. Sonography demonstrated the existence of a strong fibrotic interposed tissue, preventing scapho-metacarpal impingement. The mean height of the trapeziectomy space (8.4mm) was maintained upon active pinch and maximal traction on the thumb. A significant atrophy of thenar muscles was also demonstrated, except for the Abductor pollicis brevis. In conclusion, total trapeziectomy with external minifixation provides acceptable clinical results, stabilizes the base of the thumb and prevents scapho-metacarpal impingement. The study brings also important new information about the nature of the interposed tissue in the trapezial space and about the state of the thenar muscles after trapeziectomy.

Percutaneous humeral derotational osteotomy in obstetrical brachial plexus palsy: a new technique.

Thirty three per cent of children with obstetrical brachial plexus palsy with incomplete neurological recovery develop shoulder internal contracture associated with osseous deformity. Some of the older children are treated by humeral derotational osteotomy. The classical technique of open approach to the humeral diaphysis and plate fixation imposes a longitudinal scar and carries significant risks (nonunion, nerve palsy); a secondary procedure for plate removal is necessary in a significant proportion of patients. The authors report a new technique of percutaneous humeral osteotomy with osteosynthesis by Hoffmann external fixator. In six cases bone healing was obtained at an average of 45 days, without adverse complication. The postoperative results showed improved shoulder function. This new technique is simple and safe; it represents a new option for the treatment of sequelae of obstetrical brachial plexus palsy.

Secondary displacement of distal radius fractures treated by bridging external fixation.

Loss of reduction remains an important problem after treatment of distal radius fractures, whatever the type of bone fixation. We assessed retrospectively the rate of secondary displacement after external fixation of distal radius fractures in order to identify possible risk factors for instability. We reviewed the pre-operative and serial post-operative radiographs of a retrospective series of 35 distal radius fractures treated by bridging external fixation. When classified according to the Société Française d'Orthopédie et Traumatologie (SOFCOT) criteria, the rate of secondary displacement was 48.5%. At final follow up, the reduction was anatomical in 12% and acceptable in 83%. There was malunion in 5%. The loss of reduction concerned primarily the distal radius palmar tilt and was moderate. No correlation was found with age, gender, type of fracture, degree of initial displacement, associated ulnar fracture, or seniority of the treating surgeon.

Dislocation of the elbow with ipsilateral forearm fracture. Six particular cases.

Elbow dislocation associated with ipsilateral radial shaft fracture is an infrequent injury (nine cases reported in the literature). We present six new cases observed between 2006 and 2012, with an average age of 31 years and a mean follow-up of 18 months. The forearm fracture and ipsilateral dislocation of the elbow were probably caused by forearm hypersupination with extension of the elbow. The dislocation was reduced by manipulation before open reduction and osteosynthesis of the forearm fracture. Four elbows were stable after reduction; two markedly unstable elbows necessitated temporary humero-ulnar external fixation; one case needed a ligamentoplasty several months later. Despite the complexity of the traumatic lesion, the clinical and radiological outcomes were acceptable.

Value of Gilliatt's pneumatic tourniquet test for diagnosis of carpal tunnel syndrome.

OBJECTIVES: In 1953, Gilliatt and Wilson described the pneumatic-tourniquet test to diagnose the carpal tunnel syndrome (CTS). It was originally carried out by inflating a brachial cuff at suprasystolic pressure, looking for the appearance of dysesthesiae; several authors later proposed to perform it at infrasystolic pressure, arguing that it would better reflect the elevated venous pressure supposed to be present in CTS. The purpose of this study was to compare both methods. METHODS: This prospective randomized controlled study included 49 patients and compared both methods to perform Gilliatt's test with more commonly used provocative tests (Tinel, Phalen, Durkan, and Weber). The following end-points were considered: typical clinical presentation, altered neurophysiological tests, abnormal ultrasound findings and early resolution of symptoms after surgical decompression. RESULTS: For all these end-points, no significant difference was observed in sensibility nor specificity, whether Gilliatt's test was performed supra- or infra-systolic. In addition, Gilliatt's test proved to have less diagnostic value than Phalen and Durkan tests for sensibility. CONCLUSION: This study did not permit to distinguish the two versions of Gilliatt's test but to open a discussion about the utility of such a test to diagnose the CTS.

Arthrodesis of the wrist with bone autograft and Hoffmann external fixation.

We report a series of 29 cases of wrist arthrodesis using a radiometacarpal half-frame or triangular Hoffmann configuration, bone autograft, and relocation of a retinacular rectangular flap under the extensor tendons to prevent adhesions. No splint or plaster cast has been used. Early active motion of the fingers was encouraged. The average duration of follow-up was 4 years. Bone healing was obtained in 27 patients after 104 days on average. All patients regained full finger movements and rotation of the forearm. Nine patients were reassessed on average 7.2 years after the arthrodesis: the VAS for pain at rest was 2.4/10, the DASH score 33/100, the grip strength 75% of the contralateral side on average.

Tolerance and effects of FK506 (tacrolimus) on nerve regeneration: a pilot study.

In adults, the outcome of nerve suture and nerve autograft remains generally unsatisfactory. FK506 (tacrolimus), an immunosuppressant drug used in transplantation, has been reported in animal studies to enhance nerve regeneration. In hand transplantation patients, nerve regeneration was unexpectedly good and rapid, and this observation has been attributed to FK506. The present Phase II experiment investigated the tolerance to FK506 after nerve suture or autograft, and the potential effects of the drug on axonal regeneration. Following strict criteria, five patients were included in this study. Within 7 days of nerve repair (median, ulnar and sciatic transections), patients received FK506 (aiming for blood concentrations between 5 and 8 ng/ml) for a total duration of 60 days. The patients were carefully followed with clinical and biological monitoring in order to detect side-effects. A clinical and electrophysiological assessment of the effect of FK506 on nerve regeneration was conducted. No undesirable side-effect was observed during or after FK506 treatment, but one non-compliant patient discontinued treatment. There was no evident improvement of sensory, motor or functional recovery at the end of the follow-up period (average duration 39.8 months), as compared to the expected clinical result without treatment. Although statistically non-significant, FK506 seemed to accelerate the progression of the Hoffmann-Tinel sign, but without impact on the final result.

[The Department of Orthopaedics and Traumatology of the University Clinics of Brussels, Erasme Hospital]. / Le Service d'Orthopédie-Traumatologie des Cliniques Universitaires de Bruxelles, hôpital Erasme.

On the occasion of the thirty years since its inauguration, the Department of Orthopaedics and Traumatology of the University Hospital Erasme reviews the milestones of its development. Various original new techniques have been implemented: monitoring of implants using strain gauges, external fixation of the limbs, external minifixation, miniinvasive anterior approach in hip arthroplasty, knee ligamentoplasties, orthopaedic microsurgery and composite tissue allotransplantation. The care of aged patients takes place in close collaboration with the Department of Geriatrics. Two new clinical units have been created, the Unit of Hand and Peripheral Nerve Surgery, and the Centre for Sports. The Department has organized an efficient Bone Bank. The new day care hospital improves the possibilities of ambulatory surgery. The article details as well the activities of teaching and research of the members of the Department.

[The Orthopaedic and Traumatology Research Laboratory]. / Le Laboratoire de Recherche en Orthopédie Traumatologie - LROT.

The history of the Orthopaedics and Traumatology Research Laboratory (LROT) is summarized during the last thirty years. The approach, initially focused on bone biomechanics and strength of materials, underwent a rapid diversification as expressed by the list of research topics: monitoring of bone healing; bone strains measurements for different level of activities including microgravity and prevention of disuse osteoporosis; biological effects of electromagnetic fields; evolution of the viscoelastic properties of the callus during bone healing; improvement of the osteoinductive properties of bone substitutes produced by the Tissues Bank of the University Hospital Erasme; Kashin-Beck disease; SICOT telediagnostic, and biomechanics of threaded implants. Those topics, event the most fundamental ones, have immediate significant clinical applications allowing a decrease of the morbidity and an acceleration of the rehabilitation of the patients. The results show the need of multidisciplinary collaborations coordinated around one autonomous laboratory, able to handle specific protocols requiring a dedicate environment.