Determining and accurately restoring the flexion-extension axis of the elbow is essential for functional recovery after total elbow arthroplasty (TEA). We evaluated the effect of morphological features of the elbow on variations of alignment of the components at TEA. Morphological and positioning variables were compared by systematic CT scans of 22 elbows in 21 patients after TEA.

There were five men and 16 women, and the mean age was 63 years (38 to 80). The mean follow-up was 22 months (11 to 44).

The anterior offset and version of the humeral components were significantly affected by the anterior angulation of the humerus (p = 0.052 and p = 0.004, respectively). The anterior offset and version of the ulnar components were strongly significantly affected by the anterior angulation of the ulna (p < 0.001 and p < 0.001).

The closer the anterior angulation of the ulna was to the joint, the lower the ulnar anterior offset (p = 0.030) and version of the ulnar component (p = 0.010). The distance from the joint to the varus angulation also affected the lateral offset of the ulnar component (p = 0.046).

Anatomical variations at the distal humerus and proximal ulna affect the alignment of the components at TEA. This is explained by abutment of the stems of the components and is particularly severe when there are substantial deformities or the deformities are close to the joint.

Cite this article: Bone Joint J 2015;97-B:1539–45.

Purpose of the study: We compared the reinnervation capacities of two nerve transfers onto the common trunk of the musculocutaneous nerve (MC), several bundles of the ulnar nerve (UN) and three intercostal nerves (IC) in patients with high brachial plexus palsy (C5C6 or C5C6C7).

Material and methods: Prospective consecutive study of two groups: group 1: 24 transfers and two to three UN bundles in 20 patients with C5C6 and four with C5C6C7, mean age at surgery 29.5 years; group 2: 15 neurotisations of the MC by CI in four C5C6 palsies and in 11 CC5C6C7 palsies, mean age at surgery 25.7 years. Mean time from accident to operation was 5.7 months, mean follow-up 29.4 months.

Results: The first contractions of the biceps were perceived clinically at 5.2 months after the surgery in group1 versus 9.9 months for group 2. Four patients in group 1 (17.0%) did not recover active flexion greater than M3 versus four (27%) in group 2. Mean force using the BMRC score was 3.6 in group 1 versus 3.2 in group 2. When elbow flexion was ≥3 (BMRC), force could be measured at 4.5kg in group 1 and 3.0 kg in group 2. For time to management up to seventh month, the two groups were comparable concerning pertinent results, but after that delay, none of the patients in group 2 achieved elbow flexion ≥3 versus 66% in group 1 up to one year. Up to the age of 40 years, results were comparable; no pertinent result was obtained after that age in group 2 versus 66% in group 1. C5C6C7 palsies had less favourable results irrespective of the technique.

Discussion: Our results show the superiority of UN transfer over CI transfer. In patients who undergo surgery before the seventh month, the rate of pertinent outcome was comparable although the flexion force was significantly greater in group 1. After seven months, only UN transfer offers hope of a useful result, up to the twelfth month. Before the age of 25 years, results are comparable, after 40, no pertinent result was observed after CI transfer while useful contraction could be obtained up to 45 years with UN transfer. C5C6C7 forms recover less well irrespective of the technique.

Purpose of the study: The slightest alteration of the antebrachial anatomic configuration, which constitutes a complex and precise biomechanical system, yields a limitation in pronosupination. Unlike the metaphysical region, little is known about rotational malunion involving the radial shaft. Kasten et all demonstrated in 30 cases that a rotational malunion of the radial shaft leads to significant loss in the pronosupination arc. If the proximal and distal radioulnar joints are intact, the interosseous membrane (IOM) probably plays an important role in this limitation.

Material and methods: The purpose of our study was to evaluate the impact of releasing the IOM on the pro-nosupination arc in an experimental model with a rotational malunion of the radial shaft inducing pronation.

Results: The study involved eight cadaver forearms free of all muscle structures and devoid of prior trauma. After stabilizing the elbow at 90°, the upper limb was fixed on a metal frame used as the reference to measure pronosupination. For each specimen, motion was measured initially, after osteotomy of the radius shaft to induce pronation then associated with longitudinal section of the IOM. A midshaft transverse osteotomy induced 78±7 pronation on average and was fixed with a DCP.

Discussion: The mean pronosupination arc was initially 175 in our population (81 pronation, 94 supination). After the creating the rotational malunion, this arc decreased significantly to 126 (SD. p> 0.05) (99 pronation, 27 supination). Release of the IOM increased this arc significantly from 27 to 153 (SD, p> 0.05) (105 pronation, 48supination)

Conclusion: Our study confirms the impact of rotational malunion on the pronosupination arc and shows the positive effect of releasing the IOM. Suppression of the IOM leads to a simpler biomechanics for the antebrachial system, allowing greater mobility of the bone one over the other. There are several clinical applications of this observation for the correction of shaft malunion of the antebrachial bones, but also certain corrective osteotomies for malpositions in the neurological patient.

Purpose of the study: Construction of a key grip is the final objective of programmed functional surgery of the upper limb in the tetraplegic. Three phases are necessary: activation of the grip, simplification of the poly-articular chain, and positioning the thumb column. For this operative phase, two techniques can be used, either fusion of the articulation with a trapezometacarpal arthrodesis (TMA) or a soft tissue procedure (tenodesis of the abductor pollicis longus). Our study compared analytically these two techniques, considering grip force and stability and the quality of the key grip opening.

Material and methods: This was a retrospective study of 38 key grips with a mean follow-up of 7.4 years in a population of tetraplegic patients (groups 1 – 5 in the International Classification of Giens. Seventeen active key grips including 11 with TMA and 21 passive key grips including 16 without TMA with regulation of the thumb position by soft tissue procedures. The active and passive grips according to the procedures were comparable statistically for their median ASIA motor scores.

Results: The force of the active key grips with TMA (mean 2.7± 1.3 kg) was significantly greater than that obtained after tenodesis (1.3±0.7 kg) (p=0.05). For passive key grips, the difference was not significant, 1.1±0.6 kg with TMA versus 1.0±0.9 kg without. Twenty-three percent of the grips were unstable after TMA versus 24% after tenodesis. Regarding grip opening, the mean distance between the pulp of the thumb and the index was 3.7 cm for active key grips after TMA by tenodesis effect and 5.4 cm for holding large objects while without TMA these values were 3.2 cm and 6.4 cm respectively. For passive grips, these same values were 2.2 and 3.4 cm after TMA versus 2.4 and 6.8 after tenodesis.

Discussion: For the active key grip, TMA enables a stronger grip but with loss of opening distance for large objects. Conversely, for the passive key grip, TMA does not enable a stronger grip but significantly limits passive opening. Globally TMA yields a more constant result. In patients with a limited motor potential, it is important to favour the creation of two different grips.

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures.

In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2° pronation (−70° to 80°) to 95.8° supination (80° to 140°). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine.

At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6° (60° to 90°) in pronation and 50.4° (0° to 90°) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading.

Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.

Purpose of the study: There is no satisfactory surgical solution for symptomatic osteoarthritis of the elbow joint with preserved functional motion if arthroplasty is not indicated (age, functional demand). The same is true for resistant epicondylalgia. The joint denervation techniques applied for the wrist and proximal inter-phalangeal joints have demonstrated their efficacy. We conducted an anatomic study of elbow innervation as a preliminary step to the development of a standardized surgical procedure for complete denervation of the elbow compartment.

Material and methods: The study was conducted on 15 right and left unprepared fresh cadaver specimens. A standardized dissection method was used. The terminal branches of the brachial plexus were dissected proximally to distally under magnification, from the root of the arm to the mid third of the forearm.

Results: Innervation of the medial compartment arose: anteriorly, from one of the two capsuloperiosteal branches arising from the medial nerve; in the epitrochleo-olecraneal gutter, from capsular branches issuing from the trunk of the radial nerve at the root of the arm and running with the ulnar nerve. The innervation of the lateral compartment arose: anteriorly, from an inconstant capsular branch issuing from the musculo-cutaneous nerve arising 4 to 7 cm downstream from the joint space and running between the bones. In the other cases, this zone was innervated by a nerve branch coming from the dorsal cutaneous nerve of the forearm issuing from the radial nerve. This branch innervated the apex of the laeral epicondyle in all cases. The posterior part of the lateral compartment was constantly innervated by a branch arising from the radial nerve in the proximal part of the arm, running between the deep hed of the triceps and the vastus lateralis, giving rise of nerves innervating the joint and terminating in the body of the anconeus muscle.

Discussion: Our study enabled the description of new sources of elbow innervation not reported by Wilhelm.

Conclusion: This systematization study of elbow joint innervation is a preliminary step to the development of a complete procedure for unicompartmental lateral or medial denervation of the elbow joint. The fields of application are the treatment of symptomatic osteoarthritis of the elbow joint in patients with preserved joint motion and resistant epicondylalgia.

Purpose: The approach chosen for total elbow arthrolysis is crucial. It should allow access to all lesions causing joint stiffness yet avoid excessive mutilation. We report our experience with the transhumeral approach respecting the lateral structures.

Material and methods: Thirteen transhumeral elbow arthrolyses were performed from 1996 to 2002 and reviewed retrospectively at mean 18 months (6–63). Mean age at surgery was 44 years. Stiffness resulted from trauma in five patients and degenerative disease in eight. The SOFCOT classification was severe in two, moderate in ten and minimal in one. Arthroysis was performed by the posterior transtricipital technique. After releasing the fossa and the olecranon beak, the coronoid process and the anterior capsule were released using a transhumeral bone window. Two patients also underwent ulnar nerve transposition. Rehabilitation was initiated early and continued for 17 weeks on average.

Results: At last follow-up, active elbow extension improved from −39±9° to 21±9° and flexion from 109±14° to 129±7°, corresponding to an increase in motion of 38±14° (70° preoperatively and 108° postoperatively). This gain in motion was the same in the trauma and degeneration groups. Pain, evaluated with a visual analogue scale from 0 to 10 improved from 3.2±1.3 to 2.4±2.0 for posttraumatic stiffness and from 7.4±1.3 to 4.1±2.0 for degenerative stiffness. There was on postoperative irritation of the ulnar nerve which regressed partially.

Discussion: Transhumeral arthrolysis allows posterior and anterior release while preserving the lateral structures. This technique has been very effective for olecranon bone blockage, posterior and anterior capsule retraction, and for coronoid anterior block. For degenerative elbows, pain relief was achieved in 70%.

Conclusion: Transhumeral elbow arthrolysis initially proposed for the degenerative elbow can be used for posttraumatic stiffness in patients with a moderate form without limiting pronosupination nor injuring the lateral ligaments. The best indication is fracture of the humeral plate.

Purpose: Functional outcome after shoulder arthrodesis was evaluated to assess indications for the treatment of posttraumatic partial and total brachial plexus paralysis in adults.

Material and methods: Twenty-seven patients who underwent glenohumeral arthrodesis for posttraumatic brachial plexus paralysis were reviewed. Eleven had radicular paralysis (C5, C6 and C5, C6, C7) and sixteen total paralysis. All patients recovered active elbow flexion. Shoulder reinnervation had failed in eleven patients. Before the arthrodesis, 22 patients could no use their paralysed limb. Mean time between direct neurological surgery and arthrodesis was 30 months for partial paralyses and 20 months for total paralyses. Glenohumeal screw fixation was used for the arthrodesis which was associated with an external fixation in 21.

Results: Mean postoperative follow-up was 70 months. There were two cases of non-union which fused after revision and three cases of humerus fracture which occurred during the first six months after surgery. Pain related to inferior subluxation improved in six patients. There was no significant difference between the two groups for position of the fusion, or postoperative active motion (60° flexion, 60° abduction, 45° internal rotation and 7 to −9° external rotation). There was a significant difference in force which was greater for superior paralyses (11 kgf versus 7 kgf in flexion, 12 kfg versus 7 kgf in abduction, 6 kgf versus 2 kgf in external rotation and 11 kgf versus 4 kgf in internal rotation). The same was true for hand movement. The differences were statistically correlated with force of the pectoralis major.

Conclusion: Glenohumeral arthrodesis provides significant improvement in function in patients with supraclavicular brachial plexus paralysis, even with a paralytic hand. Arthrodesis also allows reorienting surgical reinnervation to other functions such as hand movement. Shoulder force and hand movement are directly correlated with force of the pectoralis major.

Purpose: Blast injury of the hand generally occurs during manipulations of unstable explosives. The explosion greatly damages the first commissure. The aim of this study was to define a classification system useful for establishing therapeutic strategy.

Material and methods: From 1988 to 2002, we treated eight patients (nine hands, five dominant) with blast injury of the hand. Mean age was 24 years. Five hands were injured during manipulation of firecrackers and four during manipulation of munitions. The thumb was amputated on five hands, including three cases of index or medius amputation. Thumb revascularisation was successful in only one case. Two proximal thumb amputations were treated by twisted toe transfer. For one of these patients, the transfer was prepared by translocation of M2 on M1 using an inguinal flap. Two patients required a composite osteocutaneous reconstruction of M1 using the index as the bone source. In one final patient, lesions were limited to soft tissues.

Discussion: Blast injured hands present several types of lesions: extensive soft tissue damage, diffuse vessel damage making revascularisation difficult or impossible, combined thenar and joint lesions leading to secondary closure of the first commissure. We distinguished three stages. Stage 1 involves only muscle and skin damage. After opening the first commissure with M1-M2 pinning, cover is achieved with a posterior interosseous flap or a skin graft. Stage 2 involves osteoarticular damage. Bone loss of M1 and P1 is often associated with dislocation. Bone reconstruction is often achieved using the distally amputated or greatly damaged thumb. Stage 3 involves amputation or devascularisation of the thumb. Reconstruction of the thumb is particularly difficult in these cases. If the amputation is distal beyond MP, M1 lengthening or classical toe transfer can be used. If the amputation is proximal, prior M1 reconstruction is required with a skin envelope using M2 fashioned with an interosseous or inguinal flap, followed by twisted toe transfer of the second toe. Stage 3 translocations are difficult because of the often damaged index and scar formation.

We have compared the functional outcome after glenohumeral fusion for the sequelae of trauma to the brachial plexus between two groups of adult patients reviewed after a mean interval of 70 months. Group A (11 patients) had upper palsy with a functional hand and group B (16 patients) total palsy with a flail hand.

All 27 patients had recovered active elbow flexion against resistance before shoulder fusion. Both groups showed increased functional capabilities after glenohumeral arthrodesis and a flail hand did not influence the post-operative active range of movement. The strength of pectoralis major is a significant prognostic factor in terms of ultimate excursion of the hand and of shoulder strength. Glenohumeral arthrodesis improves function in patients who have recovered active elbow flexion after brachial plexus palsy even when the hand remains paralysed.

Purpose: We analysed outcome in a retrospective consecutive series of 30 Kapandju-Sauvé procedures performed between January 1993 and September 2000 for correction of antebrachial injuries (five patients) and distal radioulnar injuries (25 patients).

Material and methods: All patients (mean age 42 years) were reviewed by the same observer at a mean follow-up of 44 months. Mean time from initial trauma to surgery was 26 months.

Results: For the distal radio-ulnar injuries, the objectives were achieved (158° pronation-supination) with preservation of force (73% of healthy side). The Mayo Clinic functional score, as modified, was 72/100 at last follow-up and 24/25 patients were satisfied. For the ante-brachial injuries, outcome was slightly inferior: 110° pro-nation-supination, force 48% of healthy side, functional score 56/100, three out of five patients very satisfied or satisfied, resumed occupational activity in four out of five patients. There were however no cases with an unstable ulnar stump in this group.

Conclusion: This study confirmed the efficacy of the Kapandji-Sauvé procedure for the treatment of sequelae of distal radio-ulnar injuries, particularly in young patients. The novel indication for antebrachial injuries also provided satisfactory results after a simple procedure compared with shaft osteotomy of the two ante-brachial bones.

Purpose: Operative wounds are commonly washed with a more or less diluted antiseptic solution to prevent infection or to treated overt infection. Chlorhexidine is widely used. We report the cases of nine patients who developed joint destruction attributed to peroperative irrigation with a chlorhexidine solution.

Material and methods: Nine patients (three men and six women) who had undergone surgery in another facility were referred to our unit for unexplained postoperative chondrolysis. The joint localisations were: wrists (n=7) after surgery for a dorsal arthrosynovial cyst (mean age 37 years); elbow (n=1) after surgery for epicondylalgia (age 49 years); shoulder (n=1) after arthroscopy for sub-acromial impingement (age 51 years).

The time between surgery and the first consultation in our unit varied from three to nine years (mean five years four months). Persistent stiffness had been noted in the postoperative period with pain at joint mobilisation which worsened progressively. For the patients with chondrolysis of the wrist: the x-rays demonstrated destruction of the radius-first ray joint in one, the medio-carpal joint in four and overall destruction in two. Overall joint destruction was also observed in the elbow and shoulder patients. Search for other causes of joint destruction was negative; infection and inflammatory rheumatoid disease were ruled out. The common feature identified in all patients was joint irrigation with a chlorhexidine solution (Biseptine®).

Results: Four of the nine patients underwent surgical treatment: a four-bone arthrodesis with scaphoidectomy was used for the three patients with mediocarpal involvement and a shoulder arthrodesis was performed in one patient. The pathology study demonstrated cartilage defects filled with dense strongly hyalinised acellular tissue. Bacteriological specimens were all negative.

Discussion: The chondrolytic effect of chlorhexidine, a member of the biguanide family, was first reported in 1986 with a few cases described with knee involvement. Experimentally, there would be a dose-dependent effect. The mechanism involves a disorganisation of the cell membrane with cartilaginous necrosis and ostocartilaginous resorption. Individual predisposition cannot be ruled out.

Conclusion: In light of these observations, it would be advisable to avoid peroperative joint irrigation with chlorhexidine solution.

Purpose: Reactivation of upper limb function in high-tetraplegia patients requires two successive procedures: restoration of elbow extension, then construction of the key grip. Performing both procedures during the same operative time can reduce the operative time. We compared this combined technique with the classical programme, particular for patients requiring transfer of the brachioradialis to construct the key grip.

Material and methods: The study series included 16 upper limbs in 15 tetraplegic patients. Two distinct operative programmes were used. Group A (nine limbs): transfer of the posterior deltoid to the triceps and active key grip by transfer of the brachioradialis on the flexor pollicis longus. According to the Giens classification there were three group 2, five group 3 and one group 4. Group B (seven limbs): transfer of the biceps on the triceps and passive tenodesis key grip. The Giens classification was five group 2 and two group 3. Five of these limbs exhibited supination attitude of the forearm that was treated initially with isolated osteotomy of the radius. Mean follow-up was ten months. A control group underwent the same surgical programmes but with two distinct operative times.

Results: Mean hospital stay was shortened compared with the control group 4.1±0.8 months versus 10±1.0 months). Elbow extension force according to the BMRC scale was 3.8±0.6 in Group A versus 3.5 for the control group and 3.2±0.5 for Group B compared with 2.8 for the control group. Mean active key grip force was 1.8±0.9 kg for Group A versus 1.9 for controls and 0.9±0.6 kg for the passive key grips in Group B versus 0.9 for controls. Functional independence improved postoperatively, the QIF improved from 40.0±18.0 to 55.2±17.0.

Discussion: This work demonstrated that a single operation shortens hospital stay without affecting the final outcome and that the brachioradial can be transferred on the flexor pollicis longus for reactivation of elbow extension. In our experience, only 46% of the tetraplegic patients starting a functional surgery programme benefit from reactivation of the elbow and hand. Procedures performed during a single operation allow a more systematic approach.

Purpose: Recovery of muscle function after nerve repair remains incomplete despite progress in microsurgical techniques. Potential for muscle recovery could be greatly improved. The purpose of our study was to demonstrate the functional impact of exogenous satellite cells in degenerated muscles.

Material and methods: We used the anterior tibialis muscle (Ta) in rabbits (n=24) as our experimental model. Muscle degeneration was created by bilateral injections of cardio-toxin into the Ta. Five days later, the left Ta was injected with autologous satellite cells (SC) at multiple points. The same volume of culture medium was injected into the right Ta. Two months later, maximal isometric muscle force and stress resistance of the Ta was measured. Histoimmuno-chemical labellings were made.

Results: The volume of cardiotoxin injected created two categories of muscles: recovery of former function was not possible with low dose cardiotoxin injections. Maximal isometric muscle force was less than 35% of the control. Transfer of SC restored nearly normal muscle force. Resistance to stress followed the same pattern. Recovery of maximal muscle force was possible with high-dose cardiotoxin injections. Resistance to stress was greater than the control (+ 35%). Transfer of SC did not modify results.

The weight of the Ta increased for both cardiotoxin doses. There was an increase in the size of the fibres with or without SC transfer.

Discussion: Injection of cardiotoxin induced muscle degeneration. With greater muscle degeneration, regeneration of muscle capacity was greater. Transfer of SC improved the functional result when muscle degeneration was incomplete. Improved resistance to stress after injection of high-dose cardiotoxin could result from changes in muscle myosin and fibrillary structure.

Conclusion: Further studies are needed before clinical application to better understand the underlying mechanisms operating with satellite cell injections. Many applications could be proposed, particularly for surgical nerve repair, ischaemic heart failure, and myopathy.

Purpose: We evaluated submuscular anterior transposition of the ulnar nerve at the elbow with lengthening of the medial epicondylars as described by Dellon in patients with ulnar nerf deficiency due to compression.

Material and methods: A consecutive series of 30 submuscular tranpositions of the ulnar nerve in 28 patients were performed between 1994 and 1998. Four patients had had a prior procedure (two simple neurolyses, two subcutaneous transpositions). Mean age was 52 years. Preoperative EMB confirmed the diagnosis of ulnar compression at the elbow. All patients has sensorial and/or motor deficits. Postoperative immobilisation was maintained for 15 to 20 days.

Results: The patients were reviewed at a mean follow-up of four years two months. There were no cases of paraesthesia. Improved sensorial function was observed in 71% of the cases (normalisation in 50%) with improvement in the Foment sign and grip in 81.5% (normalisation in 48%). Mean elbow extension was −5°, and flexion was 135°. There was not limitation on wrist amplitudes. The thumb finger force on the operated side was 78% to 94% that measured on the healthy side and was a function of the MacGowan grade. The palm-finger force was 80% to 95% of the healthy side. There has been no recurrence at last follow-up.

Conclusion: Submuscular transposition using the Dellon technique in 30 cases of ulnar nerve compression at the elbow in patients with ulnar deficiency provided satisfactory sensorial and motor recovery. The usefulness of lengthening the medial epicondyls lies in removing the tension on the ulnar nerve and the little effect on elbow and wrist mobility. Submuscular transposition is the technique of choice for repeated neurolysis.