Background: Braquial plexus injuries are a major indication for shoulder arthrodesis today. Numerous investigations have addressed the optimal position of the extremity for shoulder arthrodesis, and there are still numerous opinions on the ideal position. The present consensus appears to favor less abduction and forward flexion and more internal rotation.

Purposes: Our main goal is to determine the most favorable position for arthrodesis regarding upper limb function and prevalence of periscapular pain. Secondarily we describe the fusion and complications rate as well as patient satisfaction.

Materials and Methods: Between 1997 and 2008 the authors performed a total of 19 shoulder arthrodesis using a pelvic reconstruction plate in patients with braquial plexus injuries. Six were lost to follow-up leaving a total of 11 men and two women with a mean age of 46 years available for review. At a mean follow-up of 101 months [13–149] patients were evaluated clinically using predetermined functional parameters (hand-to-mouth, brachiothoracic grip, etc) and the visual analog pain scale. DASH score and radiological studies were also performed. Three patients that presented no active elbow flexion were excluded of the functional results analysis.

Results: The mean fusion position found was 20° abduction, 32° forward flexion and 44° internal rotation. Abduction ≥ 25° relates to better function as judged by a better hand-to-mouth and brachiothoracic grip ratio as well as a better DASH score (38.8 vs. 45.4) but is also unfortunately related to higher periscapular pain prevalence (VAS pain 3.75 vs. 1.38). Forward flexion ≤ 30° also relates to slightly higher periscapular pain prevalence (VAS pain 2.7 vs. 1.7) and a better DASH score (39.5 vs. 47.7). Exaggerated internal rotation seems to have a negative influence on the functional outcome. Although relating to a surprisingly better DASH score (39.7 vs. 44.9), none of the three patients presenting with internal rotation over 45° was able to reach the mouth with his/her hand. Fusion was obtained in 12 patients. Major complications included one pseudarthrosis, one malpositioning of the extremity that forced a revision surgery to increase internal rotation and one humeral shaft fracture treated conservatively. All but one patient (including those with no active elbow flexion) were satisfied/very satisfied with the final outcome.

Discussion: Our results suggest abduction around 25° and forward flexion of no more than 30° are needed. Higher abduction and lower forward flexion values although relating to better function do so at the expense of more periscapular pain. We agree with the present trend towards increasing internal rotation but found that it should not exceed 45°.

Introduction: Long-term results of radial osteotomy for Kienbock’s disease seldom are seen in the literature. The purpose of this study was to evaluate its outcome.

Material: Fifteen patients submitted to radial osteotomy were followed by a mean period of 9,5 years. Mean age at the time of surgery was 32,1 years. On the basis of the Lichtman classification, one patient had Stage II, eight had Stage IIIA and six had Stage IIIB disease.

Methods: Patients were evaluated clinically for pain, grip and range of motion (ROM); radiologically, according to carpal height ratio, Stahl’s index (lunate colapse), and for sclerotic, cystic and degenerative carpal changes. These data were classified according to the Nakamura Scoring System for Kienbock (NSSK).

Results: Ten patients are asymptomatic and five have mild pain. ROM improved significantly by 20,8°. When compared with the contralateral wrist, mean range of motion was 78% in flexion and 76% in extension and mean grip strength was 82,3%. Carpal height ratio and Stahl’s index improved, as shown by a mean NSSK of 24,3 (ten Excellent and five Good results). There was no progression to wrist arthritis.

Discussion: Pain, ROM and grip strength improved significantly after surgery. Despite the mild radiologic changes, there seems to have been an improvement in inner structure of the ischemic lunate.

Conclusions: These results show that Radial Osteotomy is an effective procedure in improving clinical and functional scores, and in preventing wrist arthritis.

Aims: A previous study demonstrated that negative pressure wound therapy (NPWT) increases tissue pressure. This conflicts with the understanding that these dressings increase perfusion. This randomised case control study investigates the effects that circumferential NPWT has on perfusion in humans and how different suction pressures influence this.

Methods: Ten healthy volunteers were recruited into the study and sequentially randomised to receive suction pressures of either −400 mmHg or −125 mmHg. With both hands placed in circumferential NPWT dressings, suction was only applied to one hand. Perfusion of both hands was then analysed simultaneously using radioisotope perfusion imaging. After allowing one week for complete excretion and decay of the isotope, an identical experiment was done on the same volunteers’, this time using the contralateral hand as the test hand. A total of 20 scans were carried out. Data were analysed using the Wilcoxon and Mann-Whitney tests.

Results: In the hands that received suction pressures of −400 mmHg, there was a highly significant mean reduction in perfusion of 40% (SD 11.5%, p< 0.0005). In the hands that received suction pressures of −125 mmHg there was also a highly significant mean reduction in perfusion (mean 17%, SD 8.9%, p< 0.0005). The reduction in perfusion of the group undergoing NPWT at −400 mmHg was significantly greater than the group undergoing NPWT at −125 mmHg (p< 0.015).

Conclusion: Tissue perfusion beneath circumferential NPWT dressings is significantly reduced when suction is applied, regardless of whether suction pressures of −125 mmHg or −400 mmHg are utilised. There is a significantly greater reduction in perfusion at suction pressures of −400 mmHg, compared to −125 mmHg. This implies that circumferential NPWT should be used with extreme caution, if at all, on tissues with compromised perfusion. This finding represents a paradigm shift in our understanding of the mechanism of action of NPWT.