Long-Term Follow-up of Modular Metallic Radial Head Replacement: Commentary on an article by Jonathan P. Marsh, MD, FRCSC, et al.: "Radial Head Fractures Treated with Modular Metallic Radial Head Replacement: Outcomes at a Mean Follow-up of Eight Years".

Radial head arthroplasty is used to stabilize the joint after a complex acute radial head fracture that is not amenable for fixation or to treat sequelae of radial head fractures. Most of the currently used radial head prostheses are metallic monoblock implants that are not consistently adaptable and raise technical challenges since their implantation requires lateral elbow subluxation. Metallic modular radial head arthroplasty implants available in various head and stem sizes have been developed to improve adaptability and facilitate implantation. Bipolar radial head arthroplasty implants were developed to improve articular tracking of the prosthesis on the capitellum

Entretien avec Pierre Mansat

Quaderni : Comment pouvez-vous résumer aujourd’hui le projet de Paris Métropole, sa dynamique, son inscription progressive dans l’agenda politique ? Il faut se souvenir que, jusqu’à ces deux ou trois dernières années, le terme même de métropole était inconnu du langage politique. De ce point de vue, l’inscription à l’agenda politique de la question de la métropole parisienne a pu sembler soudaine. En réalité, l’apparition du projet de Paris Métropole est le fruit d’un long travail d’influence..

Wave front migration of endothelial cells in a bone-implant interface

The neo-vascularization of the host site is crucial for the primary fixation and the long-term stability of the bone-implant interface. Our aim was to investigate the progression of endothelial cell population in the first weeks of healing. We proposed a theoretical reactive model to study the role of initial conditions, random motility, haptotaxis and chemotaxis in interactions with fibronectin factors and transforming angiogenic factors. The application of governing equations concerned a canine experimental implant and numerical experiments based upon statistical designs of experiments supported the discussion. We found that chemotaxis due to transforming angiogenic factors was attracting endothelial cells present into the host bone. Haptotaxis conditioned by fibronectin factors favored cells adhesion to the host bone. The combination of diffusive and reactive effects nourished the wave front migration of endothelial cells from the host bone towards the implant. Angiogenesis goes together with new-formed bone formation in clinics, so the similarity of distribution patterns of mineralized tissue observed in-vivo and the spatio-temporal concentration of endothelial cells predicted by the model, tended to support the reliability of our theoretical approach

Proximal row carpectomy on manual workers: 17 patients followed for an average of 6 years

Proximal row carpectomy (PRC) is indicated for the treatment of SNAC or SLAC wrist with preservation of the midcarpal joint. Our hypothesis was that PRC is not appropriate for treating advanced wrist osteoarthritis in patients who carry out heavy manual work. Twenty-three PRCs were performed on 21 patients, 5 women and 16 men with an average age of 54 years (33-77). All patients performed manual work; 11 of them performed heavy manual work. Etiologies were: SLAC wrist in 14 cases (2 stage III, 11 stage II, and 1 stage I) and SNAC wrist in 9 cases (6 stage IIIB and 3 stage IIB). At an average 75 months' follow-up (24-153), five patients were lost to follow-up. Radiocarpal arthrodesis was performed in one patient 10 years after the PRC. In the 17 remaining patients (18 wrists), pain (VAS) averaged 2.2, with residual pain of 5. Flexion-extension range was similar to preoperative levels (67% of contralateral wrist). Wrist strength was decreased by 34% compared to preoperative. The QuickDASH score averaged 26 points and the PRWE 20 points. Radiocapitate distance decreased by 0.3mm on average with joint line narrowing in 6 patients. The carpal translation index was 0.33mm, which was unchanged relative to preoperative values. Three patients had work-related limitations that required retraining and one patient had to be reassigned. PRC preserved the preoperative range of motion and reduced pain levels. However, significant loss of strength was observed, resulting in 23% of manual workers needing retraining or reassignment

Postoperative pain after arthroscopic versus open rotator cuff repair. A prospective study

Introduction: Although the arthroscopic technique is becoming the gold standard for rotator cuff tendon repair, there is no proof that this technique results in less postoperative pain compared to open repair. The aim of this study was to prospectively compare the postoperative pain level after arthroscopic or open rotator cuff repair and to define factors that could influence its course. Materials and methods: Between January 2012 and January 2013, 95 patients were operated for a rotator cuff tear: 45 using an arthroscopic technique and 50 an open technique. Daily analgesic use and self-evaluation of pain level using a visual analogic scale were recorded preoperatively and twice a day postoperatively during the first 6 weeks. These data were compared between the two groups and analyzed according to patients’ demographic data and preoperative evaluation of the tear. Results: The preoperative pain level was equivalent in the two groups (P = 0.22). Postoperatively, level-2 analgesic medication use was greater in the arthroscopic group after the 4th week (P = 0.01). A painfree shoulder was obtained before the 6th week in 75% and 66% of the patients after arthroscopic or open repair, respectively (P = 0.34). There was a positive correlation between the preoperative and postoperative pain level (r = 0.25; P = 0.02). Work compensation patients experienced more pain postoperatively (P = 0.08). Level-III analgesic medication use was greater for patients with massive rotator cuff tear (P = 0.001). Conclusion: No evidence was found on the superiority of arthroscopy versus open repair of rotator cuff tear concerning the postoperative pain level. The choice of the surgical technique should not be based on this argument

Is the Latarjet procedure risky? Analysis of complications and learning curve.

Purpose The purpose of this study was to analyse the learning curve and complication rate of the open Latarjet procedure. Methods The first 68 Latarjet procedures performed by a single surgeon for chronic anterior shoulder instability were reviewed retrospectively. The standard open surgical technique was followed faithfully during each procedure. Post-operative complications were taken from patient medical records. Post-operative evaluation consisted of clinical and radiological assessments. Results The rate of early (<3 months) clinical complications was 7.4 % (5.9 % haematoma, 1.5 % neurological deficit), and the delayed complication rate was 7.3 %. Early complication rate, duration of surgery (mean 65 min; 35–135) and hospital stay (mean 3 days; 1–4) were significantly reduced as experience increased (respectively; P = 0.03, ρ = − 0.3; P = 0.009, ρ = − 0.3; P < 0.0001, ρ = − 0.6). On the radiographs, the bone block was healed and in perfect position in 87 % of cases, with no effect of surgical experience (P = 0.3, ρ = 0.1). The rate of complications on radiographs was 17 %: 11 % partial lysis, 2 % complete lysis and 4 % non-union. No recurrence of instability was found after an average follow-up of 21 months

Complications and revisions after semi-constrained total elbow arthroplasty: a mono-centre analysis of one hundred cases.

Background The complication rate after total elbow arthroplasties is higher than for other arthroplasties. Purpose The purpose of this study was to evaluate the complications and revision rate after 100 semi-constrained total elbow arthroplasties from various types of aetiologies performed in our university hospital. Methods One hundred linked semiconstrained total elbow arthroplasties were performed and were reviewed with 24 months minimum follow-up. Indications were rheumatoid arthritis (45), trauma (33), revisions (16) and others (6). Results At five years average follow-up (range, 2–11), the complication rate was 37 %. Most frequent complications were ulnar nerve involvement (9 %) and triceps insufficiency (7 %). Five implants were aseptically loosed. The infection rate was 4 % with loosening of the implant in two. Four fract humerus proximal or distal to the stem. The radial nerve was injured in two cases. Failure of the locking system of the prosthesis was noted in one case and a fracture of the ulnar component was found in another patient. A revision surgery was performed in 13 cases (13 %). At follow-up 94 prostheses were still in place and the survival rate was 98 % at five years and 86 % at ten years. Conclusion Total elbow arthroplasty remains a difficult procedure with sometimes a high rate of complications necessitating revision procedures. Selection of the patients, a rigorous surgical technique, and a systematic follow-up are prerequisite to limit this incidence

Peri-lunate dislocation and fracture-dislocation of the wrist: Retrospective evaluation of 65 cases

INTRODUCTION: Peri-lunate wrist dislocations and fracture-dislocations are related to high-energy trauma. Prognosis is often compromised because of the complexity of the lesions. The purpose of this study was to assess outcomes of acute peri-lunate injuries and correlate them with the type of lesion and management. MATERIEL AND METHODS: A monocenter retrospective study has been conducted. Sixty-five patients (65 wrists) were reviewed. According to Herzberg's classification, there were 18 isolated peri-lunate dislocations and 47 peri-lunate fracture-dislocations - 27 with a scaphoid fracture and 20 with an intact scaphoid. The displacement was dorsal in 62 cases. All patients were treated surgically. RESULTS: At an average follow-up of 8 years (2-16) the average Cooney score was 66 points, quick-DASH score 21 points, and PRWE score 28 points. Pain score was 1.3 out of 10 points at rest and 4.3 out of 10 with effort. The flexion-extension arc was 96° with an average strength of 38kg (70±23% of opposite side). Radiographic analysis has shown decrease in carpal height, increase in ulnar translation, and DISI. Sign of wrist arthritis was found in 58.5% of the cases. The rate of osteonecrosis was 7.7%. Regional sympathetic painful syndrome was observed in 12%. In 26% of the cases a secondary surgery was needed. No influence has been found with the final results between fracture-dislocation and isolated dislocation, and delay of treatment. Osteochondral lesions observed at surgery (P=0.035), osteonecrosis at follow-up (P=0.017), and modification of the scapho-lunate angle (P=0.029) were correlated with the occurrence of osteoarthritis. DISCUSSION: Peri-lunate dislocation and fracture-dislocation represent severe wrist trauma with often numerous sequelae with follow-up: pain, stiffness, loss of strength, carpal instability and arthritis. Early diagnosis and anatomic reduction are prerequisite to a satisfactory functional result. Capsulo-ligamentous lesions must be repaired and fractures must be fixed

Distal radius fracture malunion: Importance of managing injuries of the distal radio-ulnar joint.

Background: Distal radius malunion is a major complication of distal radius fractures, reported in 0 to 33% of cases. Corrective osteotomy to restore normal anatomy usually provides improved function and significant pain relief. We report the outcomes in a case-series with special attention to the potential influence of the initial management. Material and methods: This single-centre retrospective study included 12 patients with a mean age of 35 years (range, 14–60 years) who were managed by different surgeons. There were 8 extra-articular fractures, including 3 with volar angulation, 2 anterior marginal fractures, and 2 intra-articular T-shaped fractures; the dominant side was involved in 7/12 patients. Initial fracture management was with an anterior plate in 2 patients, Kapandji intra-focal pinning in 5 patients, plate and pin fixation in 2 patients, and non-operative reduction in 3 patients. The malunion was anterior in 10 patients, including 2 with intra-articular malunion, and posterior in 2 patients. Corrective osteotomy of the radius was performed in all 12 patients between 2005 and 2012. In 11/12 patients, mean time from fracture to osteotomy was 168 days (range, 45–180 days). The defect was filled using an iliac bone graft in 7 patients and a bone substitute in 4 patients. No procedures on the distal radio-ulnar joint were performed. Results: All 12 patients were evaluated 24 months after the corrective osteotomy. They showed gains in ranges not only of flexion/extension, but also of pronation/supination. All patients reported improved wrist function. The flexion/extension arc increased by 40◦ (+21◦ of flexion and +19◦ of extension) and the pronation/supination arc by 46◦ (+13◦ of pronation and +15◦ of supination). Mean visual analogue scale score for pain was 1.7 (range, 0–3). Complications recorded within 2 years after corrective osteotomy were complex regional pain syndrome type I (n = 1), radio-carpal osteoarthritis (n = 3), and restricted supination due to incongruity of the distal radio-ulnar joint surfaces (n = 3). This last abnormality should therefore receive careful attention during the management of distal radius malunion. Discussion: In our case-series study, 3 (25%) patients required revision surgery for persistent loss of supination. The main error in these patients was failure to perform a complementary procedure on the distal radio-ulnar joint despite postoperative joint incongruity. This finding and data from a literature review warrant a high level of awareness that distal radio-ulnar joint congruity governs the outcome of corrective osteotomy for distal radius malunion

Posterior shoulder instability: prospective non-randomised comparison of operative and non-operative treatment in 51 patients

BACKGROUND: The management of posterior shoulder instability remains controversial. Consequently, for a symposium on this topic, the French Arthroscopy Society (SFA) conducted a prospective multicentre study comparing outcomes of operative and non-operative treatment. OBJECTIVE: To compare outcomes after operative versus non-operative treatment of posterior shoulder instability. HYPOTHESIS: The surgical treatment of posterior shoulder instability may achieve better clinical outcomes than non-operative treatment in selected patients. MATERIAL AND METHODS: Fifty-one patients were included prospectively then followed-up for 12months. Three groups were defined based on the clinical presentation: recurrent dislocation or subluxation, involuntary instability or voluntary instability that had become involuntary, and shoulder pain with instability. Of the 51 patients, 19 received non-operative therapy involving a three-step rehabilitation programme and 32 underwent surgery with a posterior bone block, labral repair and/orcapsule tightening, or bone defect filling. At inclusion and at last follow-up, the Subjective Shoulder Value (SSV), Rowe score, Walch-Duplay score, and Constant score were determined. RESULTS: The preliminary results after the first 12 months are reported here. In the non-operative and operative groups, the Constant score was 78 versus 87, the Rowe score 64 versus 88, and the Walch-Duplay score 69 versus 82, respectively. These differences were statistically significant (P<0.05). DISCUSSION: To our knowledge, this study is the first comparison of non-operative versus operative treatment in a cohort of patients with documented posterior shoulder instability. Outcomes were better with operative treatment. However, this finding remains preliminary given the short follow-up of only 1 year