Purpose: The radial nerve, originating from C5 to C8 and occasionally T1, is one of the two major nerves in the posterior brachial plexus bundle. Studies on the radial nerve vary regarding the number, arrangement, and emergence of its branches. This study aims to clarify the motor branch layout of the radial nerve to identify the optimal branch for neurotization. Methods: Thirty cadaveric dissections were performed using a posterior approach, spliting the triceps muscle heads. Results: Four distinct motor branches were consistently identified, all emerging before the nerve contacts the radial sulcus. Only the inferior branch to the medial head showed variability, sometimes giving additional branches to the lateral head, sensory branches, or both. Conclusion: We recommend the long head branch for neurotization due to its consistent anatomical position and reliability Level of evidence: IV

BACKGROUND:Carpometacarpal osteoarthritis of the thumb is classically considered a degenerative disease of middle-aged and elderly patients but may present before age 50. In this younger population, surgical decisions are especially challenging: patients have long remaining hand-use expectations, and any operative intervention, regardless of technique, carries a risk of deterioration, failure, or need for revision. This narrative review aims to analyse the specific challenges associated with the management of carpometacarpal osteoarthritis of the thumb in patients under 50 years of age and to introduce the concept of early surgical intervention. This narrative review aims to analyse the specific challenges associated with the management of the first carpometacarpal osteoarthritis of the thumb in patients under the age of 50, to better define the indications and expected outcomes of early surgical intervention, and to situate the decision to undergo surgery within the context of a long-term preventive strategy. METHODS:A narrative review of the literature was conducted, focusing on epidemiology, biomechanics, non-surgical treatment and the main surgical options reported for young or active patients, including arthroscopy, denervation, metacarpal osteotomy, chondrocostal grafting, trapeziectomy, pyrocarbon interposition, total arthroplasty and arthrodesis. RESULTS:The available literature remains heterogeneous and primarily specific to certain techniques, with variable age thresholds and limited data devoted exclusively to patients under 50 years of age. Most procedures can provide pain relief and functional improvement, but each option has specific limitations. Joint-preserving procedures may delay more definitive surgery but depend on the stage of the disease and the morphology of the joint. Trapeziectomy remains reliable for pain relief but may compromise the height and strength of the thumb. "Interposition implants and total joint prosthetic arthroplasty" may allow for a faster recovery and preserve thumb length but require long-term monitoring and expose patients to mechanical failure or revision. Arthrodesis provides stability and strength but sacrifices mobility and may lead to non-union or adjacent joint degeneration. CONCLUSION:In patients under 50 years of age, treatment should not be based solely on anticipated short-term improvement. Surgical indications must be determined upfront, considering disease stage, occupational demands, expected durability, revision risk, and the feasibility and quality of potential salvage procedures.

Post-traumatic forearm nonunion in adults is a rare but formidable complication. Therapeutic objectives must combine bone union with restoration of radial anatomy and pronator curvature, in order to regain pronosupination function and ideal hand positioning. The rate of nonunion in forearm diaphyseal fractures, with or without infection, is in the range of 2-10%. Failed healing of these fractures is often due to an inadequate surgical technique. The objectives of the clinical and diagnostic assessment are to characterize the trauma and its initial management, the nonunion and the patient. AP, lateral and three-quarter radiographs of the forearm, including the wrist and elbow joints, are essential. CT scans of the forearm with MPR and 3D reconstructions provide the details needed to characterize the nonunion and the surrounding bone tissue. If infection is suspected, blood tests should be performed to check for inflammatory syndrome. The extent of segmental bone loss and whether or not the nonunion is infected dictate the treatment options available. The reference internal fixation is a plate. LEVEL OF EVIDENCE: >V; expert opinion.

INTRODUCTION:Epithelioid sarcoma is a little-known malignant tumor that affects young people. Preferentially localized to the hand, it is characterized by a misleading clinical and anatomopathological appearance. The aim of this study was to clarify the clinical and long-term prognostic specificities of this tumor of the hand and upper limb. METHODS:We retrospectively analyzed the clinical databases of 3 sarcoma referral centers for patients with epithelioid sarcoma of the upper limb. The affected areas on each finger were specified. Survival analysis was performed using the Kaplan Meyer method. RESULTS:Eighteen patients were included over a mean period of 5.6 years. The average age of the population was 38.9 years. The hand and wrist were the most affected areas of the upper limb. Involvement of the thumb, index finger and first web space accounted for 86% of the patients. There was no injury of the little finger. All hand lesions were palmar. The tumor size ranged from 5 mm to 150 mm. Recurrence occurred in 59% of patients. Death occurred in 8 patients. All presented with large tumors, proximal localization and distant metastases. The 5-year survival rate was 70.1%, and the 10-year survival rate was 57.4%. CONCLUSION:This study proposes a precise topographical analysis of the epithelioid sarcoma of the hand. A proximal location above the wrist and a large tumor size are important poor prognostic factors. We recommend that any undetermined palmar skin lesion localized to the thumb, index finger or first web space in individuals aged 20 and 40 undergo a systematic biopsy rather than simple surveillance or additional imaging tests. Delayed diagnosis due to these alternative approaches could have serious consequences. LEVEL OF EVIDENCE:IV.

La pseudarthrose antébrachiale post-traumatique de l’adulte est une complication rare mais redoutable. Les objectifs thérapeutiques doivent prioritairement associer une consolidation osseuse avec une restauration de l’anatomie et de la courbure pronatrice radiale afin de récupérer la fonction de pronosupination et le positionnement idéal de la main. Le taux de pseudarthrose des fractures diaphysaires antébrachiales, avec ou sans infection, est de l’ordre de 2 à 10 %. L’échec de la consolidation de ces fractures est par ailleurs souvent dû à une insuffisance technique chirurgicale. Les objectifs du bilan clinique et paraclinique seront de caractériser distinctement le traumatisme et sa prise en charge initiale, la pseudarthrose et le patient. Les clichés radiographiques de face, de profil et de trois-quarts de l’avant-bras incluant les articulations sus- et sous-jacentes sont indispensables. La tomodensitométrie du segment antébrachial avec reconstructions MPR et 3D apporte les détails pour caractériser la pseudarthrose et le tissu osseux limitrophe. Outre une ouverture cutanée lors du traumatisme initial, une suspicion d’infection doit conduire à réaliser un bilan biologique sanguin à la recherche de syndrome inflammatoire. L’étendue de la perte de substance osseuse segmentaire et le caractère infecté ou non de la pseudarthrose dictent les options thérapeutiques. L’ostéosynthèse de référence est aujourd’hui la plaque vissée. En cas de pseudarthrose aseptique avec perte de substance segmentaire inférieure à 5cm, il est recommandé d’utiliser des greffons spongieux ou cortico-spongieux autologues. Les pertes de substances osseuses plus étendues appellent à utiliser une greffe vascularisée autologue ou des greffons spongieux, en deux temps, dans le cadre de la technique de la membrane induite. Une infection évolutive nécessite une phase de débridement, avec documentation bactériologique et utilisation d’un traitement antibiotique adapté suivie d’une phase de reconstruction. Les cas complexes doivent être discutés en centre de référence des infections ostéoarticulaires (CRIOAC). Les pertes de substances non reconstructibles renvoient à la technique du « one-bone forearm » garant d’une continuité osseuse mais sacrifiant la pronosupination. Niveau de preuve V ; avis d’expert.

Ulnar carpal impingement syndrome causes pain on the ulnar side of the wrist. Various surgical techniques have been described. Ulnar shortening osteotomy is now a standard treatment for carpal ulnar impingement syndrome. However, it is associated with complications such as non-union of the osteotomy site.The main objective was to report the rate of radiographic consolidation after ulnar shortening osteotomy with cutting guide.This is a multicenter retrospective series of 30 cases reporting clinical and radiographic criteria with a minimum 6-month follow-up.The non-union rate was 3.4%. One case presented a non-union of the osteotomy site. 87% of patients were satisfied or very satisfied with the procedure. Mean VAS pain was 2.7 (standard deviation 2.4). The QuickDash and PRWE averages were 24.7 (standard deviation 19.2) and 28.6 (standard deviation 25.3). Mean Jamar dynamometer strength was 27.4kg (standard deviation 8.9). One patient developed complex regional pain syndrome. Five patients required plate removal for hardware-related discomfort.The Aptus wrist plate ulna shortening osteotomy provides a standardized approach to the surgical treatment of ulnar impingement syndromes of the carpus. Compared with other series in the literature, this procedure provides a satisfactory consolidation rate and clinical results.The Aptus wrist plate ulna shortening osteotomy provides good outcomes for the treatment of ulnar carpal impingement syndrome.

Le sarcome épithélioïde (SE) est une tumeur maligne du sujet jeune peu connue. Localisée préférentiellement au niveau de la main, elle se caractérise par un aspect clinique et anatomopathologique trompeur. L’objectif de cette étude est de préciser les spécificités cliniques et pronostiques à long terme de cette tumeur à la main et au membre supérieur.Nous avons analysé rétrospectivement les bases de données cliniques de 3 centres experts référents sarcome pour les patients atteints de SE au membre supérieur. Au niveau de la main nous avons précisé les zones atteintes sur chaque rayon digital. L’analyse de la survie a été réalisée selon la méthode de Kaplan Meyer.Dix-huit patients ont été inclus sur une période moyenne de 5,6 ans. La main et le poignet étaient les régions les plus touchées du membre supérieur. L’atteinte du 1er rayon, du 2e rayon et de la 1re commissure représentait 86 % des patients. Aucune atteinte du 5e rayon n’a été constatée. La taille du SE allait de 150mm à 5mm. La tumeur a récidivé chez 59 % des patients. Huit décès sont survenus. Ces derniers sont davantage survenus chez les patients qui présentaient une tumeur volumineuse, une localisation proximale et des métastases à distance. Le taux de survie à 5 ans était de 70,1 % et à 10 ans de 57,4 %.Cette étude est la seule à proposer une analyse topographique précise de la tumeur à la main. Les cas isolés rapportés dans la littérature retrouvent fréquemment une atteinte des 1er et 2e rayons qui semblent être les doigts les plus touchés par le SE. Notre série présente le taux de récidive le plus élevé comparativement aux autres études. Le taux de survie à 5 ans et à 10 ans varie beaucoup dans la littérature. La localisation proximale en amont du poignet et la taille importante de la tumeur semblent constituer un facteur de mauvais pronostic important.La région anatomique et l’envahissement tumoral conditionnent l’espérance de vie du patient. Nous suggérons que toute lésion cutanée palmaire, localisée au niveau du pouce, de l’index ou de la 1ère commissure chez un sujet jeune, doit faire l’objet d’une biopsie systématique et non d’une simple surveillance ou d’examens d’imagerie complémentaires pouvant induit un retard diagnostic aux lourdes conséquences.

IntroductionUlnocarpal impaction syndrome causes pain on the ulnar side of the wrist. Various surgical techniques have been described. Ulnar shortening osteotomy is now a standard treatment. However, it is associated with complications such as non-union of the osteotomy site.The main study objective was to report the rate of radiographic consolidation after ulnar shortening osteotomy with a cutting guide.Material and MethodsThis multicenter retrospective study of 30 cases reported clinical and radiographic criteria at a minimum 6 month’s follow-up.ResultsThe non-union rate was 3.4%. One case presented non-union of the osteotomy site. 87% of patients were satisfied or very satisfied with the procedure. Mean VAS pain rating was 2.7 ± 2.4. Mean QuickDASH and PRWE scores were 24.7 ± 19.2 and 28.6 ± 25.). Mean strength on Jamar dynamometer was 27.4 ± 8.9 kg. One patient developed complex regional pain syndrome. Five patients required plate removal for hardware-related discomfort.DiscussionUlna shortening osteotomy with the Aptus Wrist plate provides a standardized approach to the surgical treatment of ulnocarpal impaction syndrome. Compared with other series in the literature, the procedure provided satisfactory consolidation and clinical results.

Objective: Recurrence after primary ulnar tunnel syndrome surgery is observed in 1.4%-25% of patients. However, the outcome of revision surgery is uncertain and limited. This study aimed to assess the clinical and functional outcomes of neurolysis combined with anterior subcutaneous transposition in cases of recurrence. Patients and methods: This retrospective single-center study included patients who were operated on for iterative ulnar tunnel syndrome at the elbow between January 1996 and December 2020, with a minimum follow-up of 24 months. Demographic data, pre- and post-operative clinical evaluations, surgical details, and satisfaction levels were collected. Results: Twenty-eight patients were reviewed. Mean follow-up was 11.7 years (range, 2.1-26.4 years). The secondary procedure led to significant improvement in mean Quick-DASH score, from 25.3 (range, 11-50) to 20.0 (range, 11-49) (p = 0.023), with a satisfaction rate of 78.5%. Symptoms of pain (p = 0.033), amyotrophy (p = 0.013), hypoesthesia (p < 0.01), and paresthesia (p < 0.001) also showed significant improvement. There were 7 cases of failure (25.0%). Conclusion: The combination of neurolysis and anterior subcutaneous transposition was a reliable technique, improving clinical outcome in recurrent ulnar tunnel syndrome after previous surgery. Level of evidence: IV - retrospective study. (C) 2023 SFCM. Published by Elsevier Masson SAS. All rights reserved.

Le nerf ulnaire, nerf mixte du membre supérieur présente un double intérêt en raison de ses branches motrices à destinée des muscles fléchisseurs, ulnaire du carpe et profond des doigts. La neurectomie sélective de ces branches peut faire partie du traitement chirurgical du membre spastique. Ces branches motrices pourraient être source de nerf donneur d’une neurotisation. Notre étude vient compléter les études effectuées sur le sujet, afin de détailler le nombre, la localisation, la taille et la destinée des branches du nerf ulnaire à l’avant-bras. Nous avons effectué, au laboratoire d’anatomie de la faculté de médecine de Tours, une étude cadavérique sur 30 membres supérieurs frais congelés. Après dissection, il est réalisé une description du nombre de branches émergeant du nerf ulnaire, leurs localisations, leurs longueurs et leurs destinées musculaires. Le fléchisseur ulnaire du carpe (FUC), pour ses deux chefs musculaires ulnaire et huméral, reçoit de façon constante 2 branches nerveuses du nerf ulnaire. La branche à destinée du chef ulnaire émerge du nerf en moyenne à 1,67 cm et celle à destinée du chef huméral à 2,1 cm. Le FUC reçoit une branche motrice supplémentaire dans 53 % des cas et deux branches supplémentaires dans 3 %. L’innervation du fléchisseur profond par le nerf ulnaire est constante. L’émergence de cette branche se situe en moyenne à 4,1 cm. Il est retrouvé une branche supplémentaire dans 6 % des cas. Les résultats semblent concordant avec la tendance décrite par les précédentes études, à savoir la présence d’une innervation proximale du FUC et FP. La principale différence semble venir de la méthode de dissection, qui pour certains désinséraient le chef huméral induisant une translation des émergences par rotation du nerf suivant le muscle retourné. Nous retrouvons de façon constante une branche nerveuse pour chacun des chefs du fléchisseur ulnaire du carpe (FUC) par deux branches distinctes ou un tronc commun ainsi qu’un branche à destinée du fléchisseur profond, sans autre branche dans 47 % des cas. Schéma auquel s’ajoute de façon variable une seconde branche pour le FUC soit par émergence directe d’une branche du nerf ulnaire dans 16 % des cas, soit par une branche émergent du tronc du FP, dans 30 % des cas. Et dans 3 % des cas, le FUC a trois branches, une branche supplémentaire isolée et une branche supplémentaire du tronc du FP. Dans 2 cas, il a été retrouvé deux branches distinctes pour le fléchisseur profond.

S C Introduction: Many surgical techniques have been described to correct the sequelae of chronic mallet fingers (MF), but no clear therapeutic strategy has been defined. We have reported the choice of their management according to the severity of the deformities. Two procedures were compared: Fowler's central slip tenotomy (CST) and arthrodesis of the distal interphalangeal joint (DIP).Hypothesis: The use of our decision tree, based on the severity of deformity (flexion deformity at the DIP and recurvatum at the proximal interphalangeal joint), allows good long-term clinical results to be obtained.Material and methods: Thirty-three patients (34 fingers) were operated on for sequelae of chronic MF either by CST or by DIP arthrodesis. Patients with < 35 & DEG; DIP flexion deformity and < 25 & DEG; proximal interphalangeal (PIP) recurvatum, without DIP joint involvement (osteoarthritis, subluxation, stiffness), were treated with CST. For the others, arthrodesis of the DIP joint was performed.Results: Thirteen patients (13 fingers) were evaluated in the CST group with a mean follow-up of 13 years. There were no postoperative complications and no failures. The mean DIP residual extension lag was 4.23 & DEG; with complete correction of the PIP recurvatum. All patients would redo the intervention in hindsight. The improvement in Quick-DASH was statistically significant (p = 0.01). Twenty patients (21 fingers) were included in the DIP arthrodesis group with a mean follow-up of 10 years. Two failures (9.5%) occurred due to failed correction of the PIP recurvatum. No worsening of the deformities was reported, and they were corrected in 90% of cases. The absence of correction of the PIP recurvatum was more frequent in MF bone (p = 0.01). All except 1 (95%) patient, who reported a lack of mobility of the DIP joint, would repeat the procedure. Quick-DASH was improved for all patients.Discussion: CST is effective in correcting deformities in chronic MFs for < 35 & DEG; DIP flexion deformity and < 25 & DEG; PIP recurvatum without DIP joint involvement. In other cases, it is preferable to perform a DIP arthrodesis by combining, if necessary, a complementary procedure to correct the PIP recurvatum. Level of evidence: IV, retrospective study.& COPY; 2022 Elsevier Masson SAS. All rights reserved.

Background: Posterolateral instability is the most frequent form of both acute and chronic elbow instability. Joint incongruity due to posterolateral unlocking leads to shear and compression stress of the internal aspect of the humeroulnar joint. We carried out long-term analysis of patients with posterolateral elbow instability in order to determine whether, in addition to improving their symptoms, reconstruction of the lateral collateral ligament complex may play a protective role against the development of post-traumatic osteoarthritis. We hypothesized that ligament reconstruction according to the technique of O'Driscoll stabilizes the elbow and also limits the development of osteoarthritis in the long term.Methods: Patients with symptomatic posterolateral instability of the elbow and who underwent ligament reconstruction according to the technique of O'Driscoll from January 1995 to December 2010 were identified and retrospectively included for 2 follow-up evaluations at a mean of 5 and 14 years.Results: Fourteen elbows in 14 patients were included. All had a negative lateral pivot shift test and none reported a new episode of instability. Two patients (14%) had osteoarthritis. The 2 radiographic evaluations showed no progression of osteoarthritis. Osteoarthritis developed in 33% of patients with intra-articular fracture. In simple dislocations, pre-existing osteoarthritic lesions were stabilized and Conclusion: Elbow ligament reconstruction according to the technique of O'Driscoll gives effective posterolateral stabilization and appears to protect against progression to osteoarthritic degeneration in the long term. In the absence of associated lesions, it prevents the development of osteoarthritis or the worsening of pre-existing osteoarthritis.(c) 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

L’arthrodèse totale de poignet (ATP) a pour but d’obtenir un poignet indolore avec une poigne puissante. Son principal inconvénient est de sacrifier la mobilité et elle reste pour beaucoup d’auteurs une intervention de sauvetage. Cependant après une ou plusieurs interventions palliatives l’ATP donne de moins bons résultats. L’objectif de notre étude est d’évaluer à moyen-terme les résultats de l’ATP, et leur stabilité à long terme. Notre hypothèse est que les résultats sont fiables et durables sur la douleur et la force, sans conséquence sur les autres articulations. Il s’agissait d’une série consécutive monocentrique d’ATP réalisées avec une plaque dédiée, hors poignets rhumatoïdes, évaluées à 5,4 et 21,1 ans de recul. Trente poignets ont été évalués lors de la première révision et 17 réévalués au dernier recul. Au recul moyen de 5,4 ans, 93 % des patients se considéraient « très satisfaits » ou « satisfaits » de la chirurgie d’ATP. Aucune complication infectieuse n’était survenue. Au recul moyen de 21,1 ans, tous étaient « très satisfaits » ou « satisfaits » et 88 % d’entre eux estimaient leur résultat stable ou amélioré par rapport à la première révision. L’EVA moyenne était passée de 8,4/10 en préopératoire à 1,8/10 à la première évaluation et à 0,3/10 au dernier recul. Hormis pour un patient opéré des 2 poignets pour lequel la comparaison n’était pas possible, la force du côté opéré était en moyenne 89,7 % de celle du côté controlatéral (de 45 % à 150 %). Le score de Quick DASH moyen était de 30,3 (de 4,5 à 61,4) et le score PRWE moyen était de 32,5 (de 1 à 77). L’ATP par plaque permet d’obtenir d’excellents résultats sur le contrôle de la douleur et la restitution de la force. Les résultats cliniques sont stables dans le temps, et l’arthrodèse à plus de 20 ans de recul, ne semble pas avoir de retentissement sur les autres articulations du membre supérieur. Après chirurgie du poignet, les patients ont pour principal regret la limitation des amplitudes mais pour principal cause d’insatisfaction la persistance de douleurs. L’arthrodèse peut être réalisée en première intention en cas d’indication discutable d’une arthrodèse partielle sur un poignet raide car les résultats d’ATP sont meilleurs en l’absence d’antécédent chirurgical. IV ; étude rétrospective.

Introduction: Total wrist arthrodesis (TWA) aims to obtain a painless wrist with a strong grip. Its main disadvantage is compromised mobility and for many authors it remains a rescue intervention. However, after one or more palliative interventions, TWA confers poorer results. The objective of our study was to evaluate the medium-term results of TWA, and their long-term stability. Hypothesis: Our hypothesis was that the results are reliable and persistent for pain and strength, without repercussions to other joints.Material and methods: This was a single-center consecutive series of TWA performed with a dedicated plate, excluding rheumatoid wrists, evaluated at 5.4 and 21.1 years of follow-up. Results: Thirty wrists were assessed at the first review and 17 reassessed at the last follow-up. At the mean follow-up of 5.4 years, 93% of patients considered themselves "very satisfied" or "satisfied" with the TWA surgery. No infectious complications occurred. At the mean follow-up of 21.1 years, all were "very satisfied" or "satisfied" and 88% of them considered their result stable or improved compared to the first revision. The average VAS had gone from 8.4/10 preoperatively to 1.8/10 at the first evaluation and to 0.3/10 at the last follow-up. Except for a patient with both wrists operated on for whom comparison was not possible, the strength of the operated side was on average 89.7% of that of the contralateral side (from 45% to 150%). The mean Quick DASH score was 30.3 (4.5 to 61.4) and the mean PRWE score was 32.5 (1 to 77).Discussion: TWA using a plate provides excellent results for both pain control and strength restoration. The clinical results remain stable over time, and arthrodesis at more than 20 years of follow-up does not seem to have any impact on the other joints of the upper limb. After wrist surgery, the main complaint of patients is the limited range of motion, but the main cause of dissatisfaction is persistent pain. Arthrodesis can be performed first-line in case of questionable indication of partial arthrodesis on a stiff wrist because the results of TWA are better in the absence of a surgical history. Level of evidence: IV; retrospective study.& COPY; 2022 Elsevier Masson SAS. All rights reserved.

IntroductionLes syndromes de la traversée thoraco-brachiale (STTB) dits neurologiques sont dominés par les formes subjectives. Cette étude ne concerne que les rares formes objectives liées à une compression nerveuse proximale dans la traversée thoraco-brachiale, avec la présence de signes déficitaires neurologiques moteurs (amyotrophie des muscles intrinsèques de la main) et/ou sensitifs (hypoesthésie dans le territoire du nerf cutané antébrachial médial). Les objectifs de cette étude étaient de définir les caractéristiques cliniques, les causes anatomiques et les résultats chirurgicaux de cette pathologie.Patients et méthodeÉtude rétrospective monocentrique incluant 53 cas consécutifs chez 50 patients présentant un déficit clinique objectif, confirmé par examen électroneuromyographique. La population était composée de 47 adultes et 3 enfants, 9 hommes et 41 femmes, d’âge moyen de 39 ans (9–80 ans), dont le diagnostic a été posé entre juillet 1994 et décembre 2019. Un déficit moteur objectif était présent dans 50 cas, et les 3 autres présentaient uniquement un déficit sensitif. Quarante cas ont été opérés, le plus souvent par voie sus-claviculaire, et 13 cas ne l’ont pas été en particulier en raison d’un déficit ancien et non évolutif.RésultatsUn cas opéré a été perdu de vue. Dix-huit cas ont été étudiés sur dossier, dont 15 cas opérés qui, avec un recul de 53 mois (1–162), présentaient une récupération complète dans 4 cas, une amélioration importante dans 9 cas et discrète dans 2 cas. Trente-quatre cas ont été revus en consultation, dont 24 cas opérés et évalués avec un recul de 135 mois (36–284 mois) : la douleur avait disparue dans 21 cas, il persistait dans 17 cas une amyotrophie thénarienne, associée à une déformation en griffe dans 3 cas, et dans 2 cas une déformation en griffe isolée. Les patients étaient très satisfaits de l’intervention dans 15 cas et satisfaits dans 9 cas. Ils évaluaient le bénéfice de la chirurgie à 87,4 % et l’évaluation de leur membre supérieur était passée de 38,3 % (10–60) en préopératoire à 77,2 % (60–100) à la révision.ConclusionPeu d’études dans la littérature portent sur les formes déficitaires de STTB. Le traitement est chirurgical dans les cas évolutifs, une anomalie anatomique est constamment retrouvée. Il permet une disparition de la douleur et une stabilisation voire une récupération au moins partielle du déficit. Malgré un gain objectif modéré, le ressenti de l’amélioration fonctionnelle par les patients est important avec un taux de satisfaction élevé.Niveau de preuveIV, étude rétrospective.

Background: A rare cause of scapular winging is rhomboid muscle paralysis secondary to dorsal scapular nerve (DSN) neuropathy. This paralysis causes winging of the medial border of the scapula with lateral rotation of its inferior angle. We report a series of 4 clinical cases of isolated DSN compression and the results of a specific rehabilitation protocol.Methods: A continuous clinical series of 4 patients with isolated rhomboid muscle deficiency was analyzed. Two patients were men and 2 were women, with a mean age of 40 years (range, 33-51 years). Three patients were right-handed and 1 was left-handed. Scapular winging always affected the dominant side. Two patients had occupations involving heavy physical work. The sports practiced involved exertion of the arms (dancing, boxing, gymnastics, muscle strengthening). A specific rehabilitation protocol was offered to the patients. In addition, 6 fresh cadaver dissections were performed to reveal possible DSN compression. Potential areas of compression were iden-tified, in particular when the arm was raised.Results: The 4 patients presented with isolated DSN neuropathy were confirmed by electroneuromyographic testing. Total correction of scapular winging was not obtained in any patient. Three patients experienced residual pain with a neuropathic pain by the questionnaire for a Diagnosis of Neuropathic Pain (DN4) score of 2. The mean Quick-Disabilities of the Arm, Shoulder and Hand (DASH) score after treatment was 31.8 of 100. The mean ASES score was 56.2. Only 1 patient agreed to rehabilitation in a specialized center and underwent follow-up electroneuromyography. Signs of rhomboid muscle denervation were no longer present and distal motor latencies had become normal. In all cadaver dissections, the DSN originated from the C5 nerve root and did not pass through the middle scalene muscle. We identified a site of dynamic compression of the DSN by the upper part of the medial border of the scapula when the arm was raised.Discussion: DSN compression is conventionally attributed to the middle scalene muscle, but it is noteworthy that our study reveals the possibility of dynamic compression of the nerve by the proximal part of the medial border of the scapula, which occurs when the arm elevation is above 90 degrees.Conclusion: Our study reveals the possibility of dynamic compression of the DSN by the proximal part of the medial border of the scapula, which occurs when the arm is raised above 90 degrees. In the absence of a surgical solution, conservative treatment is fundamental and requires management in a rehabilitation center with intervention by a multidisciplinary team.Level of evidence: Level IV; Case Series; Treatment Study (c) 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Introduction: Neurogenic thoracic outlet syndromes (TOS) are dominated by the nonspecific forms. This study focuses only on the rarer true forms related to proximal nerve compression in the thoracic outlet, with the presence of motor (atrophy of the hand's intrinsic muscles) and/or sensory (hypoesthesia in the territory of the medial antebrachial cutaneous nerve) deficits. The objectives of this study were to define the clinical characteristics, anatomical causes and surgical results of this condition.Patients and methods: Single-center retrospective study of 53 consecutive cases in 50 patients with an objective clinical deficit confirmed by nerve conduction studies. The population consisted of 47 adults and 3 children, 9 males and 41 females, with a mean age of 39 years (9-80 years), diagnosed between July 1994 and December 2019. An objective motor deficit was present in 50 cases, with the remaining 3 having a sensory deficit only. Forty cases underwent surgery, most often via the supraclavicular approach, while 13 cases did not undergo surgery because their deficit was longstanding and non-progressive.Results: One operated patient was lost in follow-up. An analysis of the medical records of 18 cases, including 15 operated cases found complete recovery in 4 cases, significant improvement in 9 cases and small improvement in 2 cases at a mean follow-up of 53 months (1-162 months). Thirty-four cases were reviewed in person, including 24 operated cases and evaluated with a mean follow-up of 135 months (36-284 months): the pain had disappeared in 21 cases, thenar atrophy persisted in 17 cases, which was associated with a claw-hand deformity in 3 cases, while 2 cases had an isolated claw-hand deformity. The patients were very satisfied with the procedure in 15 cases and satisfied in 9 cases. They evaluated the benefit of surgery at 87% and their upper limb function increased from 38% (10-60%) preoperatively to 77% (60-100%) at the review.Conclusion: Few studies in the literature have focused on true neurogenic TOS cases. The treatment is surgical in progressive cases; an anatomical anomaly is always present. Surgical treatment eliminates the pain and helps to stabilize or even partially resolve the deficit. Despite a moderate objective gain, the patients' feeling of functional improvement is important with a high satisfaction rate. Level of evidence: IV, retrospective.(c) 2022 Elsevier Masson SAS. All rights reserved.

Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare soft tissue tumor with a predilection for the distal extremities and a tendency for local recurrence. Morphologically, MIFS consists of spindle and bizarre epithelioid cells resembling virocytes embedded in a fibrous to myxoid stroma with an abundant inflammatory infiltrate. Importantly, the molecular landscape of MIFS is wide and includes: VGLL3 amplification, BRAF fusion/amplification and OGA/TGFBR3 rearrangements. In this study, we describe a variant of MIFS showing a frequent nodular configuration associated with necrosis and recurrent YAP1::MAML2 fusions. The cohort consisted of 7 patients (4 females and 3 males) ranging in age from 21 to 71 years (median: 47 years). Two tumors (28%) occurred in acral locations while the remaining cases were more widely distributed (thigh, n = 2; arm, n = 1; neck; n = 1; chest-wall, n = 1). Tumor size ranged from 10 to 38 mm (median: 20 mm). Histologically, lesions frequently presented as nodules with central areas of necrosis, and were predominantly composed of sheets of epithelioid cells with large vesicular nuclei and prominent nucleoli (Reed-Sternberg-like cells or virocytes). The stroma was mostly fibrous and showed a polymorphous inflammatory infiltrate. Myxoid stromal changes were focally seen in one case, and pseudolipoblasts were absent. The immunophenotype was nonspecific, with only pan-keratin (AE1-AE3) and cyclin D1 expression in a subset of cases. RNA-Sequencing detected YAP1::MAML2 fusions in 3/7 cases; aCGH showed no significant gene copy number variations in 4 tested cases, and FISH analysis showed no VGLL3 amplification in 1 tested case. Follow-up was available for 6 cases, ranging from 7 to 63 months (median: 42 months). Local recurrence and metastasis were not seen and one tumor showed spontaneous regression following initial biopsy. In conclusion, we describe a novel variant of MIFS with distinctive clinicopathological and molecular features for which we propose the term “nodular necrotizing” MIFS.

Background:Posterolateral rotatory instability (PLRI) is the most frequent form of both acute and chronic elbow instability. It is due to mechanical incompetence of the lateral collateral ligament. O'Driscoll et al described treatment of this instability by autologous reconstruction of the lateral ulnar collateral ligament. The aim of our study was to evaluate the medium and long-term clinical, functional and radiological results of patients who were surgically treated for PLRI by this technique. We hypothesized that such ligament reconstruction restores a functional joint complex and durably stabilizes the elbow and limits the long-term risk of osteoarthritis.Methods:All patients treated for symptomatic PLRI by ligament reconstruction since January 1995 and who had a minimum follow-up of 36 months were retrospectively included.Results:Thirty-two patients (32 elbows) underwent clinical and radiological evaluation with a mean follow-up of 112 months (range, 36-265 months). The success rate of the procedure was 97% with one patient requiring revision reconstruction. Twenty-four patients (75%) were free from pain. Pain was significantly greater in patients with associated lesions (P = .03) and those with morbid obesity (body mass index ≥40) (P = .03). Twenty-nine (91%) patients had resumed their previous activities. Twenty-eight patients (87%) were satisfied or very satisfied. The mean Mayo Clinic score was 96/100 and the QuickDash 14.7/100. Two patients (6%) with accompanying lesions developed severe osteoarthritis.Conclusion:Elbow ligament reconstruction by the technique of O'Driscoll et al effectively restores stability and limits progression to osteoarthritis in the long term. The only failure in our series was due to several technical errors. Patients who had dislocation with associated lesions or morbid obesity are at risk of poorer functional results.

Background: Serratus anterior (SA) palsy following mechanical injury to the long thoracic nerve (LTN) is the most common cause of scapular winging. This study aimed to identify the factors influencing the outcome of neurolysis of the distal segment of the LTN. We hypothesized that poor results are due to duration before surgery and to persistent scapulothoracic dysfunction.Methods: A retrospective study was conducted. The inclusion criteria were partial or complete isolated noniatrogenic SA paralysis of at least 4-month duration with preoperative electrophysiologic assessment confirming the neurogenic origin without signs of reinnervation.Results: Seventy-three patients were assessed at 45 days, 6 months, and 24 months after neurolysis of the distal segment of the LTN. At the last follow-up, improvement was excellent in 38 (52%), good in 22 cases (30%), moderate in 6 (8%), and poor in 7 (10%). No patient showed deterioration in outcomes since the beginning of follow-up. Scapular winging was no longer present in 46 cases (63%), while it was minimal in 23 (31.5%). In 4 cases (5.5%), winging was similar to the preoperative condition.Discussion: The best outcomes occurred in patients who presented without compensatory muscle pain and who were treated within 12 months of paralysis. Beyond this time frame, neurolysis can still provide useful functional improvement and avoid palliative surgery. Conclusion: Neurolysis of the distal segment of the LTN is a safe and reliable procedure. This technique allows treatment of SA muscle palsy and corrects scapular winging with excellent or good outcomes in 82% of cases.Level of evidence: Level IV; Case Series; Treatment Study (c) 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.