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Scapular stress fracture (sSF) is a difficult complication to treat after reverse total shoulder arthroplasty (RSA). The aim of this study was to identify the prevalence and possible risk factors in a large population. A total of 2165 RSAs that were implanted between January 2006 and October 2017 in five hospitals were evaluated. Within this cohort, sSF was radiologically confirmed. Age, gender, surgical indication and hospital of treatment were determined for the entire cohort. A matched 3:1 case-control study was then performed to investigate several clinical and surgical variables. sSF occurred in 3.1% (63 patients), with a median time interval of five months post-operative [IQR = 9, range: (1–79)]. Within the entire cohort, females (OR = 2.99) and rotator cuff arthropathy (RCA) (OR = 2.79) were more prone to this complication. Age had little influence (OR = 1.03). After exclusion, fifty-five eligible cases were matched to 165 controls based on hospital, gender, age and surgical indication. After univariable analysis, significance was obtained for osteopenia (P = 0.037), osteoporosis (P = 0.032), surgical approach (P = 0.002) and peri-operative acromioclavicular (AC) joint surgery (P = 0.035). Multivariate analysis demonstrated that osteopenia (OR = 3.94), osteoporosis (OR = 2.85) and a deltopectoral approach (OR = 3.70) were independent risk factors. According to our findings, older women with poor bone quality and a history of RCA suffered more frequently from sSF. Anterolateral approach during surgery was a surgical protective factor, possibly due to the mobilization of the acromioclavicular joint. Although this study indicates who is at risk for sSF, further investigation for prevention of sSF in these patients is necessary.

Bennett's fractures are the most common fractures around the trapeziometacarpal joint but require specialized radiographs to be correctly diagnosed. If a fracture is missed at initial presentation, it may heal with an intra-articular gap, leading to joint incongruency and a painful trapeziometacarpal joint. We present a new technique to correct the intra-articular gap and restore joint congruency in the event of a symptomatic Bennett malunion with a gap of at least 2 mm. The joint is exposed through an anterolateral approach, and the malunion is marked with K-wires under fluoroscopic control. A closing wedge osteotomy with excision of the malunion site is then performed to restore joint congruency. The osteotomy is fixed with 3 interfragmentary screws, and the joint is immobilized for 2 weeks before passive mobilization is initiated. Hardware can be removed between 3 and 6 months postoperatively after consolidation of the osteotomy. We recommend this technique in active patients without trapeziometacarpal osteoarthritis who present with a painful Bennett malunion. Restoration of the joint congruency reduces pain and may prevent the development of posttraumatic osteoarthritis.

Background Glenoid rim fractures are uncommon and generally associated with high complication rates. The most common treatment techniques include screw or anchor fixation. Here, we introduce a new fixation method to treat Ideberg type 1 A fractures. Methods A retrospective analysis was performed on patients treated with open reduction and plate fixation for Ideberg type 1 A fractures. The active range of motion capacity of both shoulders was recorded postoperatively. Constant-Murley score and Oxford disability index scores were used as outcome tools. Results Five patients (three men and two women) were evaluated; their mean age was 56 years (standard deviation (SD), 10 years). The mean follow-up period was 25 months (range, 6–69 months); all fractures healed radiologically during the follow-up period. The mean Constant-Murley score was 80.36 (SD 11.01); the mean Oxford disability index was 37 (SD 9). The subsequent flexion and external rotation of the injured shoulders were similar to those of the uninjured side (injured vs. uninjured side: flexion, 176 ± 5.4 vs. 178 ± 4.4; external rotation, 48 ± 10.9 vs. 60 ± 0). No patient showed signs of osteoarthritis, stiffness, instability, or chronic pain at the last follow-up. Discussion Open reduction and internal fixation with a plate is suitable for Ideberg type 1A glenoid fractures.

The Latarjet procedure alters scapulothoracic motion by releasing the pectoralis minor insertion to the coracoid process and by changing the vector of the conjoint tendon. The purpose of this study is to evaluate the feasibility of retaining the pectoralis minor insertion and a part of the conjoint tendon on to the remainder of the coracoid, and to evaluate the efficiency of the procedure in avoiding scapular dyskinesis, without concessions to glenohumeral stability. Since June 2017, a modification to the Latarjet procedure has been used in the treatment of posttraumatic anterior shoulder instability. The pectoralis minor insertion and a part of the conjoint tendon is retained on its anatomical position, by harvesting only the lateral part of the coracoid. We retrospectively enrolled the first 9 consecutively treated shoulders with a minimum of 6 months follow up and recorded scapulothoracic position and scapulothoracic motion, patient satisfaction, Oxford score, and Short Form (SF)-36. All patients underwent a radiographic review at final follow up. No scapular dyskinesis was observed at final follow- up. Radiographies consistently showed a bony spur at the original osteotomy site, suggesting a functional attachment of the pectoralis minor tendon to the scapula. Harvesting only the lateral part of the coracoid is technically feasible, efficient in treating anterior shoulder instability and avoids scapular dyskinesis. Level of evidence : Level IV, Retrospective Cohort study, Treatment study.

Closed reduction and fixation with elastic intramedullary nails is a popular technique to treat displaced pediatric forearm fractures and has yielded good functional results. Postoperative neurological symptoms can be due to neuropraxia and expectative treatment has been advised for 3 months until further investigation is necessary. We present a case of an 11-year-old boy that presented with median nerve palsy 2 months after a displaced forearm fracture treated with elastic intramedullary nails. Ultrasound and nerve conduction study confirmed the presence of a median nerve entrapped in the callus of the radial fracture. Surgical exploration demonstrated that the nerve was twisted around the intramedullary device. After neurolysis and surgical repair the patient finally recovered 2 years after the operation. This case highlights the possibility of median nerve entrapment after reduction with elastic intramedullary nails. Symptoms should be recognized early, and urgent surgical exploration is needed to prevent irreversible damage.

Background Surgical management of de Quervain's tenosynovitis is based on decompression of the first extensor compartment. A simple release of the first compartment can cause instability of the extensor pollicis brevis (EPB) and abductor pollicis longus (APL) tendons in zone seven of the extensors. The WHAT test (wrist hyperflexion and abduction of the thumb) is very effective in diagnosing this instability. Patients and Methods In this retrospective monocentric study, we analyzed a case series of 10 patients all of whom underwent a reconstruction of the first extensor compartment using a retinacular graft because of symptomatic instability after decompression surgery. The reconstruction was a modified technique of the sixth compartment. Functional outcome and characteristics of the newly reconstructed pulley were examined by physical examination with the aid of ultrasound and internationally validated questionnaires. Results Four patients had a good-to-excellent functional outcome, all of those had a maximum of two surgical procedures performed on the first extensor compartment. Six patients presented poor functional outcome. In four of them, more than two surgical procedures were performed. Minor residual instability was noted in six cases, found in both the groups. Conclusion The reconstruction procedures on the first compartment seemed to be satisfactory in treating instability of the EPB and APL tendons after primary surgical release for de Quervain's disease. Level of Evidence Level IV, observational study without controls.

Background Ulnocarpal abutment is a common condition following distal radius fractures. There are different surgical methods of treatment for this pathology: open and arthroscopic wafer procedure or an ulnar shortening osteotomy. We describe an oblique metaphyseal shortening osteotomy of the distal ulna using two cannulated headless compression screws. We report the results of 10 patients treated with this method. Materials and Methods Out of 17 patients, 10 could be reviewed retrospectively for this study. Patient-rated outcomes were measured using the VAS (visual analogue scale) for pain, PRWHE (patient-rated wrist and hand evaluation) survey, and Quick-DASH (disability of arm, shoulder and hand) survey for functional outcomes. At the review we measured the range of motion (ROM) of the wrist (extension and flexion, ulnar and radial deviation, pronation and supination). Grip strength, pronation, and supination strength of the forearm was measured using a calibrated hydraulic dynamometer. ROM and strength of the affected wrist was compared with ROM and strength of the unaffected wrist. Surgical Procedure Oblique long metaphyseal osteotomy of the distal ulna (from proximal-ulnar to distal-radial), fixed with two cannulated headless compression screws. Results The average postoperative VAS score for pain was 23.71 (standard deviation [SD] of 30.41). The average postoperative PRWHE score was 32.55 (SD of 26.28). The average postoperative Quick-DASH score was 28.65 (SD of 27.21). The majority of patients had a comparable ROM and strength between the operated side and the non-operated side. Conclusion This surgical technique has the advantage of reducing the amount of hardware and to decrease the potential hinder caused by it on medium term. Moreover, the incision remains smaller, and the anatomic metaphyseal localization of the osteotomy potentially allows a better and rapid healing.

Background The treatment of glenoid bone deficiencies in primary or revision total shoulder arthroplasty is challenging. This retrospective study evaluated the short-term clinical and radiologic results of a new custom-made patient-specific glenoid implant. Methods We treated 10 patients with severe glenoid deficiencies with the Glenius Glenoid Reconstruction System (Materialise NV, Leuven, Belgium). Outcome data included a patient-derived Constant-Murley score, a visual analog score (VAS), a satisfaction score, the 11-item version of the Disabilities of the Arm, Shoulder and Hand score, and the Simple Shoulder Test. We compared the postoperative position of the implant with the preoperative planned position on computed tomography scans. Results At an average follow-up period of 30.5 months, the mean patient-derived Constant-Murley score was 41.3 ± 17.5 points (range, 18-76 points) with a visual analog scale of 3.3 ± 2.5 points (range, 0-7 points). The mean 11-item version of the Disabilities of the Arm, Shoulder and Hand score was 35.8 ± 18.4 (range, 2-71), and the mean Simple Shoulder Test was 47.5% ± 25.3% (range, 8%-92%). Eight patients reported the result as better (n = 3) or much better (n = 5). One patient had an elongation of the brachial plexus, and 1 patient had a period of instability. The average preoperative glenoid defect size was 9 ± 4 cm3 (range, 1-14 cm3). The mean deviation between the preoperative planned and the postoperative version and inclination was 6° ± 4° (range 1°-16°) and 4° ± 4° (range 0°-11°), respectively. Conclusion Early results of the Glenius Glenoid Reconstruction System are encouraging. Adequate pain relief, a reasonable functionality, and good patient satisfaction can be obtained in these difficult cases. Further follow-up will determine the bony ingrowth and subsequent longevity of this patient-specific glenoid component.

Background Simple decompression of the first extensor compartment is commonly used for treating de Quervain disease, with the possible complication of subluxation of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) over the radial styloid. To prevent this painful subluxation of the tendons, several methods of reconstructing the pulley have been proposed. Questions/Purposes The purpose of our study was to evaluate a new technique for reconstructing the first extensor compartment following a release for de Quervain disease. Patients and Methods A retrospective study (mean length 40.4 months) was performed in 45 patients. The outcome assessment involved two different questionnaires and ultrasound evaluation of any tendon subluxation. Results None of the patients required reoperation for tendon instability or incomplete decompression of the first extensor compartment. Two patients experienced clicking around the radial styloid after surgery. This was not related to the amount of volar migration of the tendons. Conclusions We believe the reconstruction proposed here is an effective method of preventing painful subluxation of the APL and EPB following a release of the first extensor compartment.

Background One of the surgical treatment options for trapeziometacarpal (TMC) joint arthritis is a prosthetic ball-and-socket replacement. One of the complications in the postoperative setting is de Quervain tendinopathy. Purposes Although this complication has been reported following a resection athroplasty, we questioned whether lengthening of the thumb following the Ivory (Memometal, Stryker Corporate, Kalamazoo, MI, USA) ball-and-socket arthroplasty could be a causal factor. Methods In a prospective study regarding the overall outcome of the Ivory prosthesis, we analyzed 96 cases (83 patients; 69 female, 12 male, 8 bilateral) of primary implanted Ivory prosthesis and the incidence of de Quervain disease during the first year following surgery. We found a particularly high incidence (17%) of de Quervain tendinopathy the first year following this ball-and-socket arthroplasty. We measured the lengthening of the thumb radiographically in the group presenting de Quervain and the asymptomatic group and compared this measure between the two groups. Results We did not find any measurable or statistically significant difference between the groups regarding lengthening. Discussion These findings suggest that lengthening of the thumb following ball-and-socket arthroplasty is not a causal factor in the development of de Quervain tendinopathy within one year after surgery.

De Quervain’s disease has different clinical features. Different tests have been described in the past, the most popular test being the Eichhoff’s test, often wrongly named as the Finkelstein’s test. Over the years, a misinterpretation has occurred between these two tests, the latter being confused with the first. To compare the Eichhoff’s test with a new test, the wrist hyperflexion and abduction of the thumb test, we set up a prospective study over a period of three years for a cohort of 100 patients (88 women, 12 men) presenting spontaneous pain over the radial side of the styloid of the radius (de Quervain tendinopathy). The purpose of the study was to compare the accuracy of the Eichhoff’s test and wrist hyperflexion and abduction of the thumb test to diagnose correctly de Quervain’s disease by comparing clinical findings using those tests with the results on ultrasound. The wrist hyperflexion and abduction of the thumb test revealed greater sensitivity (0.99) and an improved specificity (0.29) together with a slightly better positive predictive value (0.95) and an improved negative predictive value (0.67). Moreover, the study showed us that the wrist hyperflexion and abduction of the thumb test is very valuable in diagnosing dynamic instability after successful decompression of the first extensor compartment. Our results support that the wrist hyperflexion and abduction of the thumb test is a more precise tool for the diagnosis of de Quervain’s disease than the Eichhoff’s test and thus could be adopted to guide clinical diagnosis in the early stages of de Quervain’s tendinopathy.

Introduction: There is a lack of organization in existing studies on the outcome and complications of total shoulder arthroplasty. As a result, it is difficult to gain substantial evidence regarding the rate and risk factors for the occurrence of glenoid loosening which remains the most common cause of prosthetic failure. To improve the quality of future studies, an agreement should exist on definitions of glenoid loosening and on the potential risk factors.Areas covered: Reviewing the literature, loosening can be defined as the appearance of radiolucent lines, radiological loosening, clinical loosening and revision as the end stage. Three different categories of influencing parameters can be distinguished: implant related, patient related and surgeon related.Expert commentary: The aim of this review is to organize the available knowledge on glenoid failure, as well as to describe the gaps so that it will constructively contribute to the debate on how to prevent glenoid failure in the anatomic tot...

Osteotomy of the lesser tuberosity in shoulder arthroplasty allows bony healing of the subscapularis tendon but does not prevent fatty degeneration in its muscle. Occurrence or increase in fatty degeneration may depend on the surgical technique.We (1) assessed fatty degeneration in the subscapularis muscle and its cross-sectional area after a C-block osteotomy of the lesser tuberosity with minimal mobilization of the subscapularis muscle, and (2) determined whether this technique had any adverse effect on function, fatty degeneration, and cross-sectional area of the subscapularis muscle.We retrospectively examined 36 patients with shoulder replacements who had C-block osteotomies. Constant-Murley scores and clinical signs of subscapularis insufficiency were recorded. We radiographically assessed prosthetic placement. On CT scans, lesser tuberosity healing, fatty degeneration, and cross-sectional area of the subscapularis muscle were determined. The minimum followup was 13 months (mean, 18 months; range, 13-33 months).The mean absolute Constant-Murley score was 71.2. Two patients had weakness of the subscapularis muscle without loss of active motion. All tuberosities healed anatomically. A normal glenohumeral relationship was found in all cases. Fatty degeneration was Grade 0 in 44%, Grade 1 in 39%, Grade 2 in 14%, and Grade 3 in 3%. The subscapularis muscular cross-sectional area decreased from 16.7 cm(2) preoperatively to 14.5 cm(2) postoperatively (13%).The C-block osteotomy with minimal dissection of the subscapularis is associated with a low incidence of fatty degeneration in the subscapularis muscle after shoulder arthroplasty although the muscular cross-sectional area of the subscapularis decreased.Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

En 1927, Mauclaire, puis en 1932, Dieterich, furent les premiers a faire un rapport sur une condition de necrose aseptique des tetes metacarpiennes. Depuis lors, la condition se nomme comme maladie de Dieterich – Mauclaire (ou vice-versa). La plupart des articles qui sont apparus dans la litterature recente, rapportent leurs succes chirurgicaux, tandis que d’autres auteurs decrivent le traitement conservateur. Dans cette categorie, le suivi depasse rarement 1 an. Nous vous rapportons l’evolution naturelle de cette condition avec un suivi systematique pendant une periode de 8 ans. Ce patient a ete victime d’un traumatisme au niveau de sa main droite a l’âge 10 ans. Suite a cet evenement, il developpe une douleur persistante. Quatre ans apres, il se presente a notre service de chirurgie de la main pour un deuxieme avis. Nous l’avons suivi pendant 4 annees avec des radiographies et tomodensitometries serielles. Le traitement a consiste, d’une part, du port d’une attelle de repos (nocturne) de type palette palmaire de support metacarpo-phalangien, ainsi que de la prise d’anti inflammatoires. Par ailleurs, tout travail trop lourd, trop repetitif et intense doit etre evite lors des ses activites comme etudiant en a l’ecole horticole. Cette strategie a amenuise rapidement et de facon considerable ses douleurs. A l’examen radiographique et tomodensitometrique evalues annuellement, on a pu apprecier un remodellation etonnante de la surface articulaire ainsi que d’un maintien de l’espace articulaire. Suite a l’analyse de la litterature, notre cas presente le plus long suivi. Les articles sur les traitements chirurgicaux, rapportent un traitement conservateur de 3 mois maximum avant de preferer le parcours chirurgical. Apres, les patients sont suivis pendant 6 mois a 4 annees. Les articles rapportant le resultat du traitement conservateur, rapportent un suivi moyen variant de 3 mois a 33 mois. Notre cas demontre qu’un traitement conservateur de cette maladie peut donner d’excellents resultats. Il est tres important de se rendre compte que dans un monde ou les implants et les traitements chirurgicaux les uns plus complexes que les autres se succedent, que nous ne pouvons oublier l’interet du traitement conservateur et un suivi regulier des patients porteurs de cette maladie. Ce cas prouve qu’une attitude conservatrice vis-a-vis de la maladie Dietrich – Mauclaire peut donner des resultats tout a fait satisfaisants.

This study investigated the long term functional outcome after total replacement of the trapeziometacarpal joint with the Ivory prosthesis (Stryker Corporate, Michigan, USA) for trapeziometcarpal joint osteoarthritis in male patients. In this prospective study, range of motion, overall function, pain and radiologic outcome of the trapeziometacarpal arthroplasty were analysed in male patients after a minimum of 5 years of follow-up. The opening of the first web space and metacarpophalangeal flexion and extension were graded. Opposition and retropulsion were graded by Kapandji scores. Key pinch, precision pinch and grip strength were measured using a calibrated hydraulic pinch gauge and a calibrated hydraulic hand dynamometer. To assess overall function, the Quick Disabilities of the Arm, Shoulder and Hand score was used. Pain score was assessed with the Visual Analogue Scale. Radiologic outcome was evaluated using frontal and profile views as described by Kapandji and Eaton views with and without stress. A total of 17 Ivory arthroplasties was evaluated. Out of the 21 male patients eligible, 14 were included in the study. Three had bilateral arthroplasties. The mean age was 63 (range 52–84) years. The mean follow up period was 95 (range 62–125) months. Patient's satisfaction was high in 65 % of the patients, with 35 % of the patients not willingly to repeat surgery. We found no significant improvement in key pinch, precision pinch and grip strength after surgery, nor when comparing preoperative with postoperative strength. Considering thumb mobility, similar conclusions can be drawn. Overall function, according to the Quick Disabilities of the Arm, Shoulder and Hand score had been improved by 37 %. Pain decreased by 83 % with a mean Visual Analogue Scale score of 11/100 at a minimum of 5 years follow-up. Radiologic evaluation revealed collapse of the trapezium in 2 patients. In two other patients, a broken implant was detected. None of these patients needed surgical revision. They are followed in our outpatient clinic. Three patients had a failure of the prosthesis (overall survival of 82 %) and were converted to a trapiezectomy. Cantilever bending loads at the thumb base are larger in males than females. This might explain the high complication rate in the male subgroup. The Ivory arthroplasty for treating advanced trapeziometacarpal osteoarthritis, is associated with an high incidence of complications in the male patient. Nevertheless, there is an improvement in overall function and pain reduction and not every complication requires surgical revision.

Hypothesis The tuberosities of the proximal humerus relate geometrically to the humeral head in an anteroposterior symmetry. Material and methods Twenty-eight cadaveric shoulders were scanned with computed tomography and reconstructed digitally in 3 dimensions. On both tuberosities, 5 facets were identified. An orthogonal planar system using the center of the humeral head as its origin was created to calculate the coordinates of the centre of each facet. The angular position of the center of each facet was measured with reference to the sagittal plane. The inclination of each facet was measured to the axial plane. Results The presence of 5 distinct facets with a different inclination was confirmed (lesser tuberosity: inferior facet: 77.8° [sd 7.8°]; superior facet: 50.3° [sd 9.3°] – greater tuberosity: superior facet: 20.4° (sd 5.6°); middle facet: 48.6° (sd 5.2°); inferior facet: 92.7° [sd 7.7°]). The angular position of the centers of the facets was less variable (lesser tuberosity: inferior facet: 22.6° [sd 4.3°]; superior facet: 39.2° [sd 4.4°] – greater tuberosity: superior facet: 89.9° [sd 5.9°]; middle facet: 131.6° [sd 6.1°]; inferior facet: 155.1° [sd 6.8°]). Conclusion Our study contributes to the knowledge of the anatomy of the proximal humerus, more specifically of the position of the rotator cuff insertion in relation to the humeral head. These insights are useful in the development of shoulder trauma prostheses.

Posterior shoulder instability has been difficult to diagnose and even more challenging to manage. However, it is being diagnosed and treated more frequently, particularly after sports injuries. The purpose of this article is to review literature concerning the management of these pathologies. A literature review was carried out in the main medical databases to evaluate the several studies concerning the open and arthroscopic treatment of posterior shoulder instability. Because of better awareness of the pathology, better technical investigations, and a better understanding of shoulder biomechanics, more and more mechanical factors that can cause posterior instability have been described. Structural abnormalities can be divided into bony abnormalities and soft-tissue abnormalities. Each group can also be divided into abnormalities caused by trauma (macro- or microtrauma) or congenital. These abnormalities can be treated with non-anatomic and anatomic stability procedures. During the last decades, the latter have been described more frequently, most of them arthroscopically. For surgical treatment to be successful, the instability must be attributable to mechanical factors that can be modified by surgery. Because of better knowledge of the pathology, a more specific surgery can be performed. This lesion-specific surgery has improved clinical results compared to non-anatomic stability procedures, particularly when that surgery has been performed arthroscopically.

We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance. A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved.

Background: The treatment of rotator cuff tears has evolved from open surgical repairs to complete arthroscopic repairs over the past two decades. In this study, we reviewed the results of arthroscopic rotator cuff repairs with the so-called double-row, or footprint, reconstruction technique. Methods: Between 1998 and 2002, 264 patients underwent an arthroscopic rotator cuff repair with double-row fixation. The average age at the time of the operation was fifty-nine years. Two hundred and thirty-eight patients (242 shoulders) were available for follow-up; 210 were evaluated with a full clinical examination and thirty-two, with a questionnaire only. Preoperative and postoperative examinations consisted of determination of a Constant score and a visual analogue score for pain as well as a full physical examination of the shoulder. Ultrasonography was done at a minimum of twelve months postoperatively to assess the integrity of the cuff. Results: The average score for pain improved from 7.4 points (range, 3 to 10 points) preoperatively to 0.7 point (range, 0 to 3 points) postoperatively. The subjective outcome was excellent or good in 220 (90.9%) of the 242 shoulders. The average increase in the Constant score after the operation was 25.4 points (range, 0 to 57 points). Ultrasonography demonstrated an intact rotator cuff in 83% (174) of the shoulders overall, 47% (fifteen) of the thirty-two with a repair of a massive tear, 78% (thirty-two) of the forty-one with a repair of a large tear, 93% (113) of the 121 with a repair of a medium tear, and 88% (fourteen) of the sixteen with a repair of a small tear. Strength and active elevation increased significantly more in the group with an intact repair at the time of follow-up than in the group with a failed repair; however, there was no difference in the pain scores. Conclusions: Arthroscopic rotator cuff repair with double-row fixation can achieve a high percentage of excellent subjective and objective results. Integrity of the repair can be expected in the majority of shoulders treated for a large, medium, or small tear, and the strength and range of motion provided by an intact repair are significantly better than those following a failed repair. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Resume Introduction L'instabilite de l'articulation trapezometacarpienne en presence de dysplasie trapezienne est une affection invalidante bien avant la survenue des changements radiologiques. La plupart des patients sont jeunes et exigeants sur le plan fonctionnel. Le traitement est souvent conservateur. Les options chirurgicales qui preservent l'articulation sont classiques : ligamentoplasties de la base du premier metacarpien [2] , [7] , [15] ou tenotomie des bandelettes transarticulaires accessoires du long abducteur [19]. D'autres options sont moins validees (arthrodese, Pelligrini Burton, Weilby, prothese [4] , [5] , [6] ). Il nous est venu l'idee de combiner deux techniques decrites au prealable ajoutant a cela une ligamentoplastie. Methode En 1973, Wilson [8] publia sa technique d'osteotomie d'abduction de la base du premier metacarpien comme traitement de la rhizarthrose. En 2002, Kapandji et Heim [3] ont publie leur osteotomie en coin du trapeze afin de corriger la pente (l'angle de devers) [3] d'un trapeze dysplasique. Combiner ces deux techniques offre l'avantage de ne pas fermer la premiere commissure en realisant une osteotomie d'abduction du premier metacarpien. Par ailleurs, l'osteotomie d'ouverture du trapeze corrige le bord radial dysplasique du trapeze en corrigeant l'angle de devers. Resultats Nous avons realise cette technique chez six patients entre 2001 et 2005. Les resultats preliminaires sont encourageants. Discussion La technique decrite offre l'avantage de preserver l'articulation trapezometacarpienne. Elle est relativement facile de realisation. Par ailleurs, elle preserve l'acces a d'autres techniques en cas d'echec a moyen ou long terme.

Reconstruction of a normal glenohumeral relationship is desirable for a successful arthroplasty. Double-contrast computed tomography was performed on 49 healthy shoulders in young volunteers. For creation of a uniform spatial reference system, the subjects were positioned in a thoracobrachial orthosis with the arm adducted in the coronal plane and the forearm flexed in the sagittal plane, and they were examined in dorsal recumbency. The classical anatomic angles were measured, and the anatomic axes were determined and quantified as angles to the coronal plane. When the axis of the glenoid was correlated to the axis of the humeral head, a mean of 8.5 degrees divergence in a clear Gaussian distribution was found. This contrasts with the variability of the version of the humeral head and of the glenoid and offers a useful guideline in difficult prosthetic surgery of the shoulder in which normal anatomic landmarks are lost because of arthritic or traumatic deformity.

This study investigated the long-term functional outcome after total replacement of the trapeziometacarpal joint with the Ivory prosthesis (Stryker Corporate, Kalamazoo, Michigan, USA) for trapeziometcarpal joint osteoarthritis. In this prospective study, range of motion, overall function, pain and radiologic outcome of the trapeziometacarpal arthroplasty were analysed after a minimum of 10 years of follow-up. The opening of the first web space and metacarpophalangeal flexion and extension were graded. Opposition and retropulsion were graded by Kapandji scores. Key pinch, precision pinch and grip strength were measured using a calibrated hydraulic pinch gauge and a calibrated hydraulic hand dynamometer. To assess the overall function, the Quick Disabilities of the Arm, Shoulder and Hand score was used. Pain score was assessed with the Visual Analogue Scale. Radiologic outcome was evaluated using frontal and profile views as described by Kapandji and Eaton views with and without stress. A total of 26 Ivory arthroplasties was evaluated. Out of the 32 patients eligible, 24 patients were included in the study. Two patients had bilateral arthroplasties. The female to male ratio was 22–2 and the mean age was 71 (range 57–83) years. The mean follow-up period was 130 (range 120–142) months. Patient satisfaction was high, with 85 % of the patients willingly to repeat surgery. The mobility of the operated thumb was improved compared to the contralateral thumb, except for metacarpophalangeal extension (78 % less than contralateral). Key pinch deteriorated with 7 % compared to preoperatively, grip strength improved with 3 %. The overall function, according to the Quick Disabilities of the Arm, Shoulder and Hand score improved by 54 %. Pain decreased by 81 % with a mean Visual Analogue Scale score of 13/100 at a minimum of 10 years follow-up. Radiologic evaluation revealed polythene wear with secondary joint instability that needed revision in two patients, and a broken implant that needed revision in another male patient. Three patients had asymptomatic polythene wear that required no revision but remain in follow up. One patient had a failure of the prosthesis and was converted to a trapiezectomy. The 10 year overall survival of the prosthesis was 85 %. These long term results suggest that the Ivory arthroplasty is a reliable option for treating advanced trapeziometacarpal osteoarthritis, since it gives an important improvement in overall function and pain reduction. However, revision of the implant within 10 years after surgery is needed in 15 % of the cases.

Le traitement de la maladie de Dupuytren est en pleine evolution ces dernieres annees. Les traitements proposes sont divers : la fasciectomie totale, fasciectomie serielle et l’aponeurotomie a l’aiguille se font petit a petit remplacer par le traitement par collagenose. En Belgique, ce produit est rembourse pour des contractures de 20° au minimum, comportant au maximum deux articulations. La firme pharmaceutique propose pour l’articulation metacarpo-phalangienne d’utiliser 0,58 mg d’enzyme dans un volume de 0,25 mL. Pour l’articulation interphalangienne, il faut prevoir 0,58 mg d’enzyme actif dans un volume de 0,20 mL. Plusieurs etudes ont prouve que le rapport couts-avantages de Xiapex® est favorable compare aux traitements chirurgicaux. On a voulu augmenter ce rapport couts-resultats davantage en utilisant tout l’enzyme disponible dans un flacon (0,9 mg), en le diluant dans un volume de 0,6 mL. Ainsi, il devient possible de traiter des contractures pour lesquelles ont utiliserait 2 flacons. Quarante-deux mains chez 36 patients qui avaient au moins 2 articulations atteintes par la maladie de Dupuytren ont ete injectes avec la dose decrite precedemment. On les a suivi pendant un periode moyenne de 26 mois (12–39 mois). Le taux de contracture (en degres) a ete repertorie avant le traitement, apres trois mois et au suivi final. Le taux de recidive, de satisfaction et de force sont rapportes. Parmi les 42 mains traitees, 21 ont maintenu la correction (avec une progression de moins de 20°) obtenu a 3 mois, tandis que 2742 ont progresse vers une recidive de contracture de plus de 20°. Sur ces 27 recidives de contracture, 10 se presentent au niveau de l’articulation interphalangienne proximale du cinquieme doigt, et 4 comportent de surcroit une contracture d’une autre articulation des doigts longs. Nous deplorons 9 corrections incompletes, tous parmi des articulations interphalangiennes proximales. Huit de ces corrections incompletes de la contracture sont restes stables au suivi final. Le traitement par la collagenase a pris beaucoup d’ampleur et merite d’etre retenu comme traitement valable pour la maladie de Dupuytren. La dilution jusqu’a 0,6 cm3 permet un resultat comparable pour plus d’articulations dans 50 % des cas. Cela est comparable aux resultats obtenus avec deux flacons, tous en etant moins couteux. L’articulation interphalangienne proximale de l’auriculaire reste neanmoins difficile a corriger completement.

Les cals vicieux articulaires des phalanges sont, de par leur taille et l’entourage tissulaire, un defi delicat par rapport a toute chirurgie correctrice. Les moyens de calculs mis a disposition pour preparer la strategie de correction ont neanmoins evolue. La societe Materialise ® developpe depuis plus de 25 ans des gabarits de correction 3D pour simplifier la preparation et ainsi le deroulement de la chirurgie. Nous illustrons la technologie proposee au moyen d’un cas precis qui s’est presente suite a un accident de travail. Cette patiente, inspecteur de police, âgee de 44 ans, droitiere, a ete victime lors de l’arrestation d’un individu, d’un traumatisme par prehension de son annulaire gauche et hyperextension forcee de la metacarpophalangienne de son doigt. Le diagnostic de fracture par impaction de la surface articulaire du tiers dorsal de la base de la phalange proximale a ete retarde compte tenu de la rarite de ce type de lesion. Suite a l’echec du traitement conservateur ainsi que de la persistance des douleurs que suscitait ce cal vicieux intra-articulaire, nous avons propose un osteotomie (intra-articulaire) de correction de l’impaction en utilisant la preparation par impression 3D de la societe Materialise ®. La lesion, la preparation et le planning preoperatoire en 3D virtuels sont illustres. Le deroulement chirurgical et l’osteotomie au moyen des gabarits dedies est filmee. Le tout est synthese par plaque et vis a angle stable 1,5 mm (Synthes®). Une allogreffe lyophilisee est utilisee pour combler l’ouverture cree par l’osteotomie. Le resultat fonctionnel et radiologique est illustre en postoperatoire immediat et a 1 an. Cette patiente a recupere des amplitudes normales. La douleur qu’elle presentait avant l’osteotomie a totalement disparu. La force de prehension est passee de 2 kg en preoperatoire a 25 kg au dynamometre de Jamar a 6 mois. Cette technique offre au chirurgien des possibilites de correction intra-articulaire precises permettant un deroulement chirurgical beaucoup plus previsible grâce au gabarits prevus pour ces petites articulations. Neanmoins, le cout actuel (2500 € TVA incluse) est un frein important a l’utilisation systematique de cet instrument. Toutefois, le resultat permet une baisse substantielle du taux d’invalidite de l’individu, ce qui compense facilement ce cout supplementaire lors d’accidents du travail.

Introduction La coalition ulnocarpienne est une pathologie bien connue. Il existe de differentes techniques chirurgicales pour cette pathologie – la technique dite de « Wafer » a ciel ouvert ou sous arthroscopie, ainsi que le racourcissement (diaphysaire) de l’ulna. Nous decrivons une technique modifiee d’une osteotomie metaphysaire oblique de l’ulna fixee au moyen de deux vis canullees. Nous rapportons les resultats de 10 patients traites de cette facon. Materiel et methodes Les resultats rapportes par les patients ont ete mesures en utilisant l’echelle visuelle analogique (EVA - VAS) en ce qui concerne la douleur, le score Patient-Rated Wrist and Hand Evaluation (PRWHE) ainsi que le QuickDASH (Disability of Arm, Shoulder and Hand) quant au resultats fonctionnels. Au dernier controle Clinique nous avons evalue les amplitudes du poignet et de l’avant-bras (extension, flexion, deviation ulnaire et radiale, prono-supination). Le force de poigne, la force en prono-supination ont ete evaluees utilisant des dynamometres calibres en compression et en rotation. Les mobilites et la force evalues ont ete compares au poignet oppose. Technique chirurgicale Osteotomie oblique metaphysaire de l’ulna de distal radiale en proximal ulnaire, l’avant-bras positionne en prono-supination neutre fixee au moyen de deux vis sans tete a compression. Resultats L’EVA postoperatoire moyen pour la douleur etait de 23,71 (DS de 30,41). Le PRWHE postoperatoire moyen etait de 32,55 (DS de 26,28). Le QuickDASH postoperatoire moyen etait de 28,65 (SD de 27,21). Les mobilites postoperatoires moyennes ainsi que la force de poigne etaient comparables au cote non atteint. Conclusion Les avantages potentiels de notre technique se situent au niveau de la quantite de materiel d’osteosynthese et l’incision plus reduite. L’obliquite de l’osteotomie et la localisation metaphysaire distale de l’ulna permettent potentiellement un delai de consolidation plus court.

Introduction Le traitement chirurgical de la maladie de de Quervain consiste dans la majorite des cas en une liberation singuliere de la premiere loge des extenseurs. Une liberation simple sans reconstruction de la poulie peut amener une instabilite des tendons a ce niveau. Dans notre service nous avons repertorie une serie de 10 patients aupres desquels il persistait une instabilite postoperatoire douloureuse des tendons du long abducteur ainsi que celui du court extenseur du pouce en zone 7. Cependant, peu de cas de cette complication furent rapportes dans la litterature. La definition de cette instabilite a ete verifiee ainsi que la meilleure methode de diagnostic. Analyse d’une cohorte de 10 patients qui presentaient une instabilite symptomatique des tendons suite a une decompression chirurgicale pour la maladie de de Quervain et qui ont eu une reprise comportant une reconstruction de la loge par la technique modifiee d’Eckhart. Materiel d’etude Etude retrospective monocentrique. Analyse de 10 patients qui ont beneficie d’une plastie d’Eckhart au niveau du premier compartiment des extenseurs entre 2000 et 2015. Methodes Chaque patient a ete invite a remplir le QuickDASH, le questionnaire MHOQ et le PRWE afin d’objectiver leur etat de fonctionnement. Tous les patients ont subi un examen clinique, une radiographie et une echographie dynamique pour quantifier la migration des tendons. Par la suite, une analyse avec comparaison des resultats de l’echographie, la clinique et les scores des differents questionnaires a ete realisee. Resultats Dans 50 % des cas, une migration residuelle des tendons persiste. Dans un suivi postoperatoire d’un minimum de deux ans, les scores moyens du QuickDASH et le PRWE du groupe avec migration residuelle sont respectivement 44,4 % et 49,5 % contre 27 % et 46,1 % dans le groupe sans instabilite. Le score moyen de MHOQ concernant la satisfaction de la main affectee est 41,7 % dans le groupe avec migration residuelle contre 49 % dans le groupe sans instabilite. Discussion L’instabilite de la premiere loge des extenseurs apres une decompression est un diagnostic difficile compte tenu de l’absence de synovite et de tendinose. Dans cette etude le WHAT-test est le test le plus precis et adapte pour le diagnostic. La technique decrite par Eckhart, modifiee est une option valide dans le traitement de cette entite difficile a prendre en charge chirurgicalement. Cette etude illustre l’importance d’un testing peroperatoire dynamique pendant une procedure de decompression afin d’effectuer une stabilisation initiale.

Background Symptomatic atrophic nonunion after multiple clavicle osteosynthesis can be difficult to treat. The aim of this study was to evaluate the results of a transfer of the clavicular part of the pectoralis major muscle as augmentation of osteosynthesis of these nonunions. Materials and methods A retrospective study included all patients who were treated between 2001 and 2010 (minimum 2-year follow-up). The indications for primary surgery, the number of operations, and the indication for a pectoralis major transfer were evaluated. Time of radiologic consolidation and postoperative complications were assessed. Clinical evaluation was performed with preoperative and postoperative satisfaction ratings and Constant-Murley scores. Results The study included 11 patients. The indications for a primary osteosynthesis were acute displaced fractures (7), delayed union (2), nonunion (1), and malunion (1). On average, 3.7 procedures were performed (range, 2-6) before the tendon transfer. At revision, there were 2 patients with infection and 9 without infection. Of the 11 clavicles, 10 showed radiologic consolidation after a mean time of 10 weeks (6-20 weeks). The mean follow-up was 62 months (24-132 months). The mean Constant-Murley score increased from 37 (24-55) preoperatively to 59 (43-98), and the satisfaction rating increased from 2 (1-3) to 7 (2-10). Complications included nonunion (1), hardware removal (2), hardware irritation (4), and donor site pain (1). Conclusion The use of the clavicular part of the pectoralis major transfer as an augmentation in revision for symptomatic atrophic nonunion after multiple clavicle osteosynthesis showed good radiologic and acceptable clinical results.

We present the results of a 5 year prospective follow-up study on the functional outcome after total replacement of the trapeziometacarpal joint with the Ivory prosthesis (Memometal, Stryker Corporate, Kalamazoo, Michigan, USA) in 22 patients. The female to male ratio was 21:1 and the mean age was 66 (range 54–78) years. The mean follow-up period was 67 (range 60–77) months after operation. Patient satisfaction was high. The mobility of the operated thumb was restored to a range of motion comparable to the contralateral thumb. Key pinch and grip strength improved by 13% and 31%, respectively. Overall function, according to Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, improved by 59%. Pain decreased by 85% according to the numerical rating scale. Radiological evaluation revealed no loosening of the implant after 5 years except in one patient who required revision due to polythene wear with secondary joint instability. Another patient had asymptomatic polythene wear that required no revision but remains in follow-up. The 5 year overall survival of the prosthesis was 95%. These medium-term results suggest that the Ivory arthroplasty is a reliable option for treating advanced trapeziometacarpal arthritis, because it appears to give a very good functional outcome and has the potential for long-term survival rates.

Hand injuries in sports are usually traumatic in nature and may occur from falls, axial loading of digits, or rotational traumatic injuries with forced gripping.

In 1984, Faithfull and Timothy Herbert described the use of the Herbert screw for small joint fusion of the hand in the Journal of Hand Surgery [4]. It was their way to illustrate the quality of a wonderful headless compression screw, which would mark the end of the century in interfragmentary screwing of small bones. It was the first time that internal splinting of the small bones was described and more specifically scapholunate synostosis – syndesmosis – with a headless compression screw.

Injuries of the scapholunate ligament are often underestimated. In the acute phase, radiographs are often misleading. Initially, patients have quite sharp pains which tend to decrease over a couple of weeks with rest, immobilization and painkillers.The described technique is useful in treating chronic unstable Scapholunate tears

We report on a displaced surgical scapular neck fracture with an ipsilateral undisplaced distal clavicle fracture of the dominant shoulder in a professional athlete. Although directives for determining the treatment of choice, whether conservative or operative, can be found in the literature, confusion still exists.1,6,14-16 Our management adds a treatment alternative, which has not yet been reported to our knowledge.

La contracture en flexion des doigts longs n’a pas seulement une repercussion sur la fonction des doigts longs, elle diminue la fonction de toute la main. Les patients sont incapables de porter des gants, de mettre leur main dans des espaces etroits et sont souvent embetes par des accrochages involontaires d’objets. Nous avons revu les resultats d’une technique chirurgicale proposee par Guy Raimbeau, qui consiste en la resection de la phalange moyenne (P2) suivi d’une arthrodese de la phalange distale (P3) a la phalange proximale (P1) dans le traitement des contractures inveterees des doigts longs. Dix patients furent retenus pour cette etude. Chaque patient ayant subi cette intervention chirurgicale les 7 annees precedent l’etude a ete invite pour un interview ainsi qu’un examen clinique et controle radiographique. La fonction postoperatoire de la main a ete evaluee utilisant les questionnaires PRWE et Quick Dash, l’echelle visuelle analogique, intolerance au froid et satisfaction personnelle. Les patients ont ete examines sur le plan clinique par rapport a leurs mobilites de l’articulation metacarpo-phalangienne (MCP), force de poigne (Jamar) et force pollicidigale, test de Weber pour la sensibilite pulpaire ainsi qu’une radiographie. Nos resultats demontrent que l’integrite pulpaire et sa capacite discriminatoire (Weber) sont preservee. Les mobilites des MCP sont preservees. Les memes resultats sont retrouves pour la force de poigne (Jamar) ainsi que la force de pince. Nous avons retrouve une difference significative entre le score PRWHE preoperatoire et celui en postoperatoire contrairement au Quick Dash. En comparant la situation preoperatoire, 87,5 % des patients s’estimaient satisfait, ou tres satisfait concernant le resultat de cette intervention chirurgicale. L’intolerance au froid a ete documentee dans 37,5 % des patients. Seul un patient etait toutefois decu par le resultat esthetique, tous les autres etaient satisfaits. Mitz V et al. ont demontre la valeur de la preservation de la pulpe pour les doigts longs en crochet. Ces deformations sont souvent traitees en resequant tout le rayon ou par amputation. Les benefices de cette procedure sont la preservation de la pulpe et sa sensibilite, ainsi qu’un resultat esthetique apres la regression du volume de la peau palmaire comprimee. Par ailleurs, des nevromes douloureux, complication possible aux amputations digitales sont evites. Cette intervention donne un resultat fiable pour des contractions irreparables des doigts longs sur le versant ulnaire.

Combined pectoralis major disruption and proximal humeral fractures are uncommon. A simple radiologic diagnostic tool which consists of the measurement of the displacement from the humeral shaft to the lateral side of the humeral head (lateral to the outer proximal cortex) can help to diagnose this combined lesion.

Treatment of fractures of the proximal phalanx of the long fingers remains difficult and challenging ; several options have been used. We report our experience with an isometric traction splint, modified from the Southampton design. A cohort of 32 patients with displaced fractures of a proximal phalanx was treated and assessed retrospectively after a short term (9 weeks after splint application). Traction splint was applied to realign the fracture and to control rotation. This construct was used for approximatively 5 weeks (mean: 36 days; range: 21-44 days), considering the usual progression of fracture healing in closed phalangeal fractures and patient tolerance to the splint. Three weeks after splint removal, almost full range of motion was regained in the metacarpophalangeal and interphalangeal joints in all patients, except in 3 cases. Two of these three patients had a displaced fracture of the proximal phalanx as a result of a compression trauma. The combination of the trauma type with static traction splint led to a tenodesis effect with a severe active flexion deficit in the metacarpophalangeal and interphalangeal joints. Our results suggest that isometric traction splint is a valid treatment option for displaced fractures of the proximal phalanx, however compression type fractures should be excluded.

Trapeziometacarpal joint pain is often associated with a dynamic adduction deformity of the thumb metacarpal, combined with radial subluxation at the base of the thumb metacarpal, due to trapeziometacarpal dysplasia. Addition-subtraction osteotomy is a surgical option to correct the bony deformity when conservative treatment fails. Eight patients who underwent surgery with this technique were prospectively evaluated. All patients were female and mean age was 42 (range 2759) years. Mean follow-up period was 23 (range 1042) months postoperatively. Seven patients (87.5%) were very satisfied. Joint mobility and strength of the operated thumb was restored to a degree comparable to the contralateral thumb. Overal l function according to the QuickDASH score improved by 75.5% and pain according to the Visual Analogue Scale decreased by 65%. Radiological evaluation showed a decrease of the trapezial slope. Mean angle between the articular surface of the trapezium and the long axis of the second metacarpal measured 142° preoperatively 129° and postoperatively. In the present study results of addition-subtraction osteotomy without ligamentoplasty were promising, especially for function and pain. The technique may be a valuable treatment option for trapeziometa carpal dysplasia with metacarpal instability.

Few studies have investigated the vascular anatomy of the trapeziometacarpal (TM) joint of the thumb. The aim of our study was to describe the supplying arteries of the trapezium and the TM joint since this knowledge is essential for trapezium osteotomies. Ten anatomical dissections in ten different cadavers using two different techniques (four macerations, six classic dissections) were performed. The arteries of the TM joint originated from the radial artery and the princeps pollicis artery. Four important branches were identified. The arteries formed a vascular network around the joint. The dorsoradial surface of the joint contained the richest arterial network. These findings present an important consideration when performing an osteotomy of the trapezium.

The purpose of this study was to evaluate a reduction method that is based on the theory of Evans to reduce angulated greenstick fractures of the distal forearm with a rotation manoeuvre, to evaluate an immobilisation technique and to evaluate a brief survey on surgeon practice for treatment of these fractures. A retrospective study was performed on 21 patients. Fractures were reduced with a pronation or supination manoeuvre depending on the angulation of the fracture and were immobilised in pronation or supination. A good reduction was achieved in all patients. Six weeks after manipulation a loss of reduction was seen in 6 out of 21 patients, but with a reangulation of less than 15 degrees. There was no significant difference between fractures immobilized in pronation or in supination. There was no need for remanipulation. At the 2008 Osteosynthesis and Trauma Care Foundation (OTC) meeting, a brief informal survey was performed concerning the reduction method and the use of K-wires after reduction. No surgeons indicated they would perform only a rotation manoeuvre.

In the elderly, there is no guideline for the treatment of irreparable rotator cuff lesions. The results of open or arthroscopic repair are variable. We hypothesized that the use of a reversed arthroscopic subacromial decompression (RASD) would yield comparable results.Between January 2004 and December 2006, thirty-eight patients underwent a RASD for irreparable cuff tears in 39 shoulders. The surgical procedure consisted of a tenotomy of the long head of the biceps tendon, a debridement of the torn rotator cuff and a tuberoplasty, without violation of the coracoacromial arch and the acromion.Thirty-three patients (age 69.9 +/- 7.3 years) were available for clinical and radiological evaluation of 34 shoulders (male/female ratio: 11/22), at a mean follow-up of 38 months (range: 21 months-52 months). Two of 33 patients had required revision surgery, and were excluded from further statistical analysis. In the remaining 31 patients (32 shoulders), the modified Constant-Murley score (CMS) improved from 34.9% +/- 11.6 to 84.0% +/- 11.6 (p0.0001). The preoperative mobility did not correlate with the final result. Preoperative pain was found to correlate negatively to the modified CMS at follow-up (p= 0.0038). Although the acromiohumeral height decreased with 2.58 mm +/- 1.68 and the severity of glenohumeral osteoarthritis increased with one grade (Samilson-Prieto classification), there was no correlation with the functional outcome.We conclude that for irreparable rotator cuff tears in the elderly, excellent mid-term results can be achieved with a RASD.

Purpose: Successful total shoulder arthroplasty (TSA) requires a correct position of the glenoid component. This study compares the accuracy of the positioning with a new developed glenoid aiming device and virtual three-dimensional computed tomography (3D-CT) scan positioning. Materials and Methods: On 39 scapulas from cadavers, a K-wire (KDev) was positioned using the glenoid aiming device. It consists of glenoid components connected to the aiming device, which cover 150 degrees of the inferior glenoid circle, has a fixed version and inclination and is available with several different radii. The aiming device is stabilized at the most medial scapular point. The K-wire is drilled from the center of the glenoid component to this most medial point. All scapulas were also scanned with CT and 3D reconstructed. A virtual K-wire (Kct) was positioned in the center of the glenoid and in the scapular plane. Several parameters were compared. Radius of the chosen glenoid component (rDev) and the virtual radius of the glenoid circle (rCT), spinal scapular length with the device (SSLdev) and virtual (SSLct), version and inclination between KDev and Kct, difference between entry point and exit point ("Matsen"-point). Results: Mean rDev: 14 mm +/- 1.7 mm and mean rCT: 13.5 mm +/- 1.6 mm. There was no significant difference between SSLdev (110.6 mm +/- 7.5 mm) and SSLct (108 mm +/- 7.5 mm). The version of KDev and Kct was -2.53 degrees and -2.17 degrees and the inclination 111.29 degrees and 111.66 degrees, respectively. The distance between the "Matsen-point" device and CT was 1.8 mm. Conclusion: This glenoid aiming device can position the K-wire on the glenoid with great accuracy and can, therefore, be helpful to position the glenoid component in TSA. The level of evidence: II.

A new shoulder prosthesis design for proximal humeral fractures has been developed. The rim of the articular component of this prosthesis has several holes to which the bone-tendon junction of the rotator cuff is fixed, to allow an anatomic reconstruction of the glenohumeral unit. The strength of the tuberosity fixation to this prosthesis is investigated in a cadaveric study. Artificial 4-part fractures were created in 18 human, fresh-frozen, paired shoulder joints with intact rotator cuffs. Two methods of tuberosity fixation were used in a matched-pair fashion. In group I the tuberosities were sutured to the rim of the prosthetic head, and in group II the tuberosities were circumferentially tension band–wired. Strength testing was performed on a material-testing machine, and displacement was recorded with an opto-electronic device. Both fixation methods proved to be equally reliable in the forces exerted during activities of daily living without significant displacement of the fracture fragments.

Twenty-five patients with primary adhesive capsulitis underwent an arthroscopic release of the capsule of the shoulder joint. They were reviewed after a mean of 14.8 months (range, 3-40 months). Night pain and awakening were a feature in all 25 patients preoperatively but were only found in 3 postoperatively. There was marked improvement in pain from a preoperative visual analog scale score of 3.1 to a postoperative visual analog scale score of 12.6 on a scale of 15. Passive movement of the joint improved significantly, with mean passive elevation changing from 73.7 degrees preoperatively to 163 degrees postoperatively, mean passive external rotation changing from 10.6 degrees preoperatively to 46.8 degrees postoperatively, and passive internal rotation improving by a mean of 9 levels. The mean preoperative Constant score of 25.3 improved to 75.5 postoperatively, and the Constant score adjusted for age and gender averaged 91%. All patients completed the Short Form-36 questionnaire at their review, revealing a norm-based physical summary score of 48.7, falling within 1 SD of a normal population sample. This arthroscopic surgical technique is derived from the open surgical release. It is founded upon an understanding of the pathology of this condition. It appears to yield rapid relief of pain and dramatic improvement in movement and function in this painful and otherwise protracted condition.

Painful cuff tear arthropathy (CTA) affects the independence of the elderly. Surgical treatment often consists of joint replacement, the functional outcome of which remains variable. Knowledge of the biomechanical properties of the different prosthetic designs can guide the orthopaedic surgeon in the choice of implant to predict its clinical result. A 3-D computer model of the glenohumeral joint is used to analyse the moment of the deltoid muscle in the scapular plane. A geometrical 3-D ball-and-socket model of the shoulder joint was used to calculate (1) the angle–force relationships, (2) the moment arm of the deltoid muscle and (3) the moment of the deltoid muscle components, for increasing degrees of arm elevation in the scapular plane. In this 3-D model, a clinical thoraco-scapular rhythm analysis was implemented, based on measurements in normal subjects, patients treated with an anatomical prosthesis and patients treated with an inversed delta III prosthesis®. These data were compared for 10 different prosthetic treatment options. Results. Muscle angle–force curves show a favourable slope in non-anatomical prosthetic designs, where the centre of rotation of the glenohumeral joint is medialized, the deltoid muscle is elongated and the humeral shaft is lateralized. On the contrary, anatomical prosthetic designs do not perform well in this computer analysis. Conclusions. From a biomechanical point of view, a shoulder prosthesis which medializes the centre of rotation, lengthens the deltoid muscle and increases the deltoid lever arm, results in a significantly more powerful abduction of the shoulder, despite complete loss of rotator cuff function. Relevance. This study explains why a successful functional outcome can be expected in CTA with a reversed prosthesis.

We modified the Hawkins impingement maneuver in order to develop a quantifiable and reproducible impingement test. The involved anatomic structures were examined with magnetic resonance imaging of 3 cadaveric shoulders. The reproducibility of the clinical sign was assessed with an interobserver and intraobserver reliability test, with calculation of the intraclass correlation coefficient (ICC). The quantified Hawkins maneuver appears to be a reproducible clinical test (median interobserver ICC, 0.9331; median intraobserver ICC, 0.9748) and creates bony contact between the greater tuberosity and the anterolateral acromion. This test enables the clinician to quantify the subacromial space.

Intraosseous epidermoid inclusion cysts of the phalanx of the finger are rare, and are regarded as reactive or post-traumatic pseudotumours. We describe a case of an epidermoid cyst in the distal phalanx of the fifth finger caused by chronic nail biting, which was successfully excised.

The morphology of the glenoid cavity is highly variable, and no consensus exists regarding how to classify the different forms. We examined 98 dry scapulae to identify a common morphological entity and to define reproducible bony references of the glenoid cavity. The glenoid cavities were photographed perpendicularly in a standardized fashion. The bony peripheral rim was studied on these two-dimensional images. defined by randomly chosen points in order to define one or more circles. This study, showed that only the peripheral rim of the inferior quadrants of the articular Surface was found to be located oil a circle (P = 0.926) with a radius of 12.8 mm (SD 1.3 mm). Defining the center of this circle appeared to be more reliable (ICC 0.98) than determining the middle point of the longitudinal axis (0,0) between the most cranial and most caudal points, defined as Saller's line (ICC 0.89). The distance of the center of this projected circle to the middle point of Saller's line had a unimodal distribution. Suggesting the existence of only one glenoid cavity morphotype. We then investigated the relationship between the center of the circle and the area of subchondral bone thickening under the bare spot, the so-called tubercle of Assaki. Ten phenolized cadaveric glenoid cavities were examined with computed tomography. A circle was projected on the first image showing the bony peripheral rim, and this circle was copied on the consecutive slices until the tubercle of Assaki came across. The center of the circle was located within the area of the tubercle of Assaki, in all but one specimen. To investigate the clinical implications of this finding, the cadaver specimens were used to compare the position of the center of the circle with the postulated center of implantation according to the literature, and to the reference guide for a commonly used total shoulder prosthesis. The center of the circle was consistently situated more distal than the postulated center of the guide (mean 5.5 mm, range 4-8 mm) and the middle point of the glenoid cavity (mean 2 mm, range 1-3 mm). These findings could offer a reproducible point of reference for the glenoid cavity in osseous anthropometry and a valuable reference in shoulder replacement surgery, and might help in the definition of osseous glenohumeral instability.

Erratum a « Traitement d’une dysplasie trapezienne symptomatique avec instabilite metacarpienne, consecutive a un allongement du premier metacarpien, par osteotomie d’addition-soustraction » [Chir. Main 32 (2013) 408-1] C.-K. Goorens , J.-F. Goubau *, P. Van Hoonacker , D. Kerckhove , B. Berghs a a Department of Orthopaedic Surgery, AZ Sint-Jan AV Brugge–Oostende, Campus Brugge, Ruddershove 10, 8000 Brugge, Belgium b Department of Orthopaedics and Traumatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium