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: Prolonged denervation resulting from deferred nerve repair or long distance between the muscle and the repaired nerve, leads to major alterations concerning muscle fibre degeneration and their replacement by fibrous or fatty tissue. These structural modifications of the muscle are unfavourable for reinnervation and consequently affect the final functional outcome after peripheral nerve repair with its corollary of reduced muscle force. The purpose of this work was to assess the potential for regeneration of denervated-reinnervated muscles and their improvement with adjuvant cell therapy using in situ transfer of cultured autologus satellite cells.

Material and methods: This work was conducted with the tibialis anterior muscle in different groups of New Zealand rabbits. The experimental model was a sectioned common fibular nerve and immediate or deferred (two months) microsurgical nerve suture. In vivo functional measurements and histomorphological analyses were performed four months after nerve repair.

Results: Reinervation led to loss of mucle weight and maximal force (Fmax) which were greater with longer deferral of repair. Transfer of satellite cells performed immediately after reinervation did not improve muscle properties. Conversely, transfer of satellite cells two months after nerve suture increased Fmax 25% (p < 0.01) and muscle weight 28% (p = 0.005) in comparison with control muscles undergoing reinervation without cell transfer. Furthermore, the morphology of the muscle was improved as demonstrated by anti-myosine labelling studies.

Discussion: Adjuvant cell therapy allows, in certain conditions, an improvement in functional recovery after peripheral nerve injury. Its clinical application still raises a certain number of ethical issues but taking into consideration data currently available, it would be reasonable to propose this therapeutic approach in humans to reduce involution of the denervated muscle and improve its receptivity for regenerating axons after peripheral nerve repair. Better post-operative results could be expected

Purpose: Until recently, evaluation of surgical treatment for brachial plexus palsy has been purely analytic, not taking into account the patient’s overall functional capacity nor his/her quality of life. The unilateral nature of these palsies and the fact that the limb remains healthy requires a global assessment of outcome. We propose here to associate the classical analytical evaluation with a global quality of life evaluation to determine the beneficial effect of surgical treatment for partial or total brachial plexus palsy.

Material and methods: Forty-four patients, mean age 30 years (17–60) were reviewed with a mean follow-up of 34 months. These patients were divided into two groups: C5–C6 ± C7 palsy (n=18), C5-T1 palsy (n=26). In each group, we recorded a complete muscle analysis, a visual analogue scale test of pain, and results of three quality of life questionnaires (DASH, Abilhand, MOS SF-36). We studied for each group the influence of recovered elbow flexion (biceps ≥ M3+), recovered shoulder function (abduction ≥ M3+), and residual pain on quality of life.

Results: The overall analysis did not demonstrate any difference in quality of life between partial and complete palsy. The three questionnaires were correlated with each other (p< 0.03). Residual pain (visual analogue scale ≥ 4 in 59% of the patients) was correlated with quality of life (p< 0.05) while involvement of the dominant side did not have any influence. In the partial palsy group, recovery of shoulder function (61%, n=11) improved significantly all the quality of life scores (p< 0.01). Conversely, recovery of elbow flexion (72%, n=13) did not improve quality of life in patients with a functional shoulder (p< 0.02). In the group with total palsy, recovery of shoulder function (77%, n=20) appeared to be as least as important as elbow flexion on quality of life (p ≤ 0.05).

Discussion: Unlike generally accepted notions, postoperative assessment of quality of life in these brachial plexus palsy patients demonstrates the importance of shoulder function which appears to be as least as important as recovery of elbow flexion. Furthermore, persistent pain appeared as one of the main negative factors affecting quality of life. Appropriate management is necessary.