Biomechanical study comparing Pulvertaft suture to step-cut suture.

Tendon grafts are a component of the therapeutic arsenal for managing chronic flexor tendons injuries in the hand, especially during two-stage Hunter reconstruction. The purpose of this anatomical study was to compare the strength of the Pulvertaft weave versus the step-cut suture used for flexor tendon reconstruction to determine their role in early active mobilization. We performed a biomechanical study with cadaver specimens. Thirty-four hands were randomized and the tendons from both hands were equally assigned to each group. A comparison of the Pulvertaft weave (group 1) versus the step-cut suture (group 2) using the flexor digitorum profundus from the fourth finger and the longus palmaris was carried out. The main variable was the failure load in both repair groups. We also evaluated the cross-sectional area (CSA) and the tensile strength of the repairs. Thirty hands were included in our study. There was no significant difference in the failure load between the two groups (116N for group 1 versus 103N for group 2, P=0.2). The CSA was significantly smaller in the step-cut group compared to Pulvertaft group (19.8mm2 versus 35mm2, P<0.01). The tensile strength was significantly higher in the step-cut group than in the Pulvertaft group (5.3N/mm2 versus 3.4N/mm2, P<0.01). Early active mobilization requires a minimum repair strength of 75N. In our study, the step-cut suture appears strong enough and thin enough to decrease the fibrosis, which would lead to better functional results. No other study of this type has been published. The specimens in which the repair strength was less than 75N all involved a thin, weak longus palmaris. Other biomechanical studies should be done to define the anatomical criteria required for use of the palmaris longus tendon. The step-cut suture seems to be strong enough and thin enough to provide sufficient proximal attachment during flexor tendon reconstruction to allow early active mobilization.

Cubital tunnel syndrome: comparative results of a multicenter study of 4 surgical techniques with a mean follow-up of 92 months.

BACKGROUND: Cubital tunnel syndrome is the second most frequent entrapment syndrome. Physiopathology is mixed, and treatment options are multiple, none having yet proved superior efficacy. OBJECTIVES: The present retrospective multicenter study compared results and rates of complications and recurrence between the 4 main cubital tunnel syndrome treatments, to identify trends and optimize outcome. MATERIALAND METHODS: Patients presenting with primary clinical cubital tunnel syndrome diagnosed on electroneuromyography were included and operated on using 1 of the following 4 techniques: open or endoscopic in situ decompression, or subcutaneous or submuscular anterior transposition. Four specialized upper-limb surgery centers participated, each systematically performing 1 of the above procedures. Subjective and objective results and rates of complications and recurrence were compared at end of follow-up. RESULTS: Five hundred and two patients were included and 375 followed up for a mean 92 months (range, 9-144 months); 103 were lost to follow-up and 24 died. Whichever the procedure, more than 90% of patients were cured or showed improvement. There was a single case of scar pain at end of follow-up, managed by endoscopic decompression; there were no other long-term complications. None of the 4 techniques aggravated symptoms. There were 6 recurrences by end of follow-up: 1 associated with open in situ decompression and 5 with submuscular transposition. CONCLUSION: Surgery was effective in treating cubital tunnel syndrome. Submuscular anterior transposition was associated with recurrence. In contrast to literature reports, subcutaneous anterior transposition, which is a reliable and valid technique, was not associated with a higher complication rate than in situ decompression. LEVEL OF EVIDENCE: Level IV. Multicenter retrospective.

[Neurotization of the deep branch of ulnar nerve and the thenar branch of median nerve with the pronator quadratus branch of anterior interosseous nerve by end-to-side transfer. An anatomic study]. / Étude anatomique concernant le transfert du nerf interosseux antérieur innervant le pronator quadratus sur le rameau profond du nerf ulnaire et sur la branche motrice thénarienne du nerf médian par anastomose termino-latérale.

Proximal or middle lesions of median or ulnar nerves are responsible for a great loss of hand motor function. Neurotization of either deep ulnar branch of ulnar nerve (DBUN) or recurrent (thenar) branch of median nerve (RBMN) with the nerve to quadratus pronator (NPQ) from the anterior interosseous nerve (AION) could reduce length of axonal growth and therefore the reinnervation lead-time of hand intrinsic muscles. We studied the anatomy of these three nerves, to help surgeon choosing his (her) technique and approach. Twenty-three cadaver forearms were dissected. End-to-side sutures were performed to mimic these neurotizations. Distances between nerve sutures and ulnar styloid process (USP) or trapeziometacarpal joint (TM) were measured. All the sutures but one RBMN could be done. On average sutures were distant from USP by 44±17mm (neurotization of DBUN), from TM by 62±15mm (neurotization of RBMN). Knowledge of average distance to perform these neurotizations should allow choosing the best reduced approach of RBMN and DBUN. Neurotizations of DBNU and RBMN with NPQ were feasible for lesions located at 6.1cm upstream USP and 7.7cm upstream TM, respectively. End-to-side sutures remain to be clinically evaluated.

[Functional results of homodigital pedicle island flaps for finger-pulp defects. Evaluation of 15 cases]. / Évaluation fonctionnelle après lambeau homodactyle en îlot antérograde pour perte de substance pulpaire des doigts longs. À propos de 15 cas.

OBJECTIVES: Fingertip amputations are very common. The aim of the treatment is to restore the sensibility of the finger pulp, with adequate pulp padding. The homodigital pedicle island flaps are used in zone 2 or 3 of Allen's classification. This study evaluates the functional results of this type of flap. METHODS: Fifteen patients were reviewed. The clinical evaluation noted complications, satisfaction level, use of the finger, cold intolerance and increased sensibility signs. The Weber test and the Semmes monofilaments were used for sensory evaluation. The joint mobility was measured and the Quick-DASH score calculated. RESULTS: The mean time between surgery and the revision was 21 months. The average flap advancement was 12 mm. Six of the patients were very satisfied. The finger use was normal in seven cases, and excluded in only one. The average Quick-DASH was 18.18. Sixty percent of the nails were deformed, 20% were hooked. Eight patients experienced cold intolerance, and five had increased local sensibility. The average Weber score was 7 mm and the monofilaments were at 3.61. The flexion of the joint was limited in six cases. CONCLUSION: For specific indications in finger-pulp amputation, the homodigital pedicle island flaps give satisfying aesthetic and functional results, allowing considerable advancement. Nevertheless, they are often a source of cold intolerance, finger joint stiffness and require long healing periods.

Complications following rotating hinge Endo-Modell (Link) knee arthroplasty.

BACKGROUND: Rotating hinge knee prostheses are indicated in revisions especially when major ligament laxity or substantial AP deformities are present. These situations make ligament balancing difficult with less constrained design implants. Despite its use for nearly 50 years, this type of prosthesis continues to have a poor reputation due to a high complication rate. HYPOTHESIS: Complications are frequent after this type of arthroplasty and the complication rate is similar in primary or revision arthroplasties. The objective of this study is to report the medium-term results of these implants and determine the eventual predictive factors of complications in order to refine operative indications. MATERIAL AND METHODS: In this retrospective study of patients operated on between 1998 and 2006, 85 Endo-Modell (Link) rotating hinge knee prostheses had been used in 61 females and 24 males. The mean age at surgery was 72.4 years (range, 32-92 years). Fifty-two arthroplasties were primary and 33 were revisions either for loosening (24) or deep infections (9). The mean follow-up was 36 months+/-22 (range, 0-75 months). RESULTS: Complications were observed in 24 patients (28.2%): nine deep infections, four patellar complications, and three cases of aseptic loosening. No significant difference was found between the primary arthroplasties and the revisions regarding all complication types. A significant relation was established between the occurrence of a complication and presence of several associated comorbidity factors (obesity, heart disease, diabetes, etc.). DISCUSSION: The use of this type of implant carries a high risk of complications, higher than the one pertaining to unconstrained design prostheses; this fact is noted irrespective of the surgical indication and other comparison elements. The leading criteria to poor functional results appear to be the indication (gonarthrosis with substantial ligament laxity at primary surgery) and the number of associated comorbidities. These prostheses should therefore be restricted to selected indications, notably in view of the fact that less constrained prostheses give superior outcomes. LEVEL OF EVIDENCE: Level IV. Retrospective therapeutic study.

[Thoracolumbar fractures]. / Fractures du rachis thoracolombaire.

Thoracolumbar fractures are frequent and the functional outcomes are sometimes severe. This multicentric study, including five medical centers, was performed to evaluate the long-term outcomes of the patients. One hundred and thirty six patients with thoracolumbar fracture (T11 to L2) was evaluated with a minimal follow-up of two years. Every one had a clinical exam with a score of Oswestry and an X-Ray study (before and after treatment and at revision). Most of them presented compression fractures, the most often at L1 level. On X-rays, a gain was noted on the vertebral kyphosis immediately after surgery, but there is a loss of correction over time whatever the treatment. The clinical outcomes for the patients were great, with an Oswestry average score of 6,4. A correlation was noted between this functional score and vertebral kyphosis. So, an anterior column strengthening (isolated or performed during the surgery) could improve these functional outcomes. Moreover, the Thoraco Lumbar Injury Severity Score (TLISS) seems to be a simple organigram to determine the most appropriate treatment of these fractures, with particular attention to the distraction mechanism or posterior ligamentous complex lesions. However, RMI before surgery is necessary to evaluate these lesions.

[Biomechanical evaluation of posterior instrumentation for lumbar burst fracture: comparison of two internal devices]. / Evaluation biomécanique d'une instrumentation rachidienne postérieure dans une fracture lombaire de type << burst >>: comparaison de deux montages.

PURPOSE OF THE STUDY: Burst fractures generally occur due to trauma to the thoracolumbar spine. Surgery is indicated for unstable fractures. Posterior instrumentation with pedicular screws is generally proposed. In certain circumstances, hooks may be preferred due to excessive risk of insertion of the pedicular screw. The purpose of this study was to compare two posterior instrumentations, one using pedicular screws on either side of the fracture each protected by hoods and a second composed of the same pedicular screws inserted under the fracture hooks above. MATERIAL AND METHODS: Twelve spinal specimens from human cadavers composed of segments T10 to L2 were used. Range of flexion, extension, lateral inclination, and rotation were noted on T10 up to application of 7 Nm. Spinal segments were tested first intact, then in four configurations: 1) instrumented without lesion, 2) lesion simulating burst fracture of L1 without section of the interspinous ligament, 3) and with section of the interspinous ligament, and 4) with L1 corporectomy. Finally a test to rupture was performed by applying a flexion moment up to fracture. RESULTS: Mean flexion-extension of the instrumented spine was limited compared with the intact spine for both instrumentation configurations and irrespective of the lesion. The same behavior was observed for lateral inclination with less pronounced motion with the first instrumentation. For rotation, the range of motion increased clearly with the second instrumentation and this with the first lesion while with the first instrumentation, rotation amplitude remained below that of the intact spine. There was however an increase in the vertical displacement during flexion-extension for both instrumentations. For the rupture test, the mean flexion moment at rupture was 14.4 Nm (10.6-22 Nm) with no difference between the two instrumentations. DISCUSSION: This mode simulating burst fractures of the spine appears to be reproducible and more realistic than corporectomy. Attention should be taken concerning the limits of this type of study since fractures can occur for forces as small as 10.6 Nm. Thus we observed that pedicle screw configurations and also fractures produced mean ranges of motion greater than intact segments irrespective of the type of lesion simulated. However, the net increase in motion was observed during rotation movements when hooks were used, even when they were placed only below the fracture. Putting pressure on the hooks does not prevent them from slipping along the lamina. But neither of these two configurations controls the fracture gap. A vertebral reinforcement might be necessary.

Mycoplasma hominis osteitis in an immunocompetent man.

Mycoplasma hominis has been associated with pelvic inflammatory illness, postpartum and neonatal infections and respiratory tract diseases. It is rarely isolated from patients with other infections. Reported here is a case of tibial osteitis that occurred in a 16-year-old immunocompetent man. Clinical and laboratory findings improved under treatment with clindamycin and fluoroquinolones.

[Scarf osteotomy for the treatment of hallux valgus: a review of 123 cases with 4.8 years follow-up]. / Ostéotomie Scarf dans le traitement de l'hallux valgus: à propos de 123 cas avec un recul moyen de 4,8 ans.

PURPOSE OF THE STUDY: Many different osteotomies can be used for the treatment of hallux valgus. The purpose of this study was to evaluate the Scarf osteotomy associated or not with phalangeal osteotomy and to search for deformation cutoff points beyond which corrections appear to be difficult to achieve. MATERIAL AND METHODS: This retrospective analysis included 87 patients (123 feet) among 130 who underwent hallux valgus surgery between October 1993 and November 2000. Mean follow-up was four years eight months. The serie included 83 women and 4 men. Mean age at surgery was 53.5 years. A Scarf diaphyseal osteotomy was performed in all patients associated or not with phalangeal osteotomy. Each patient was reviewed clinically and radiographically with anteroposterior and lateral views of the foot in the standing position. RESULTS: 84.6% of the patients were satisfied or very satisfied. There was a correlation between the index of satisfaction and clinical symptoms (metatarsalgia, stiff hallux, pain over exostosis). There was a statistically significant decrease in hallux valgus (31.2 degrees to 17.5 degrees ), of metatarsus varus (12.1 degrees to 7.5 degrees ), and articular angle of the distal metatarsus (13.3 degrees to 11.1 degrees ). Patients who had phalangeal osteotomy achieved the best hallux valgus correction (15 degrees versus 21.4 degrees ). Mean shortening of the first metatarsus was 2.2 mm with a decrease in the metatarsus-ground angle (19 degrees versus 20.1 degrees ). Cutoff limits for deformations which are difficult to correct satisfactorily were M1M2 angle > or = 15 degrees and distal metatarsal articular angle > or = 13 degrees . The overall Groulier score showed 70.7% very good and good results, 27.6% fair results and 1.7% poor results. DISCUSSION: The Scarf technique is a reliable method to achieve significant correction of hallux valgus deformation. It requires a rigorous technique with specific attention to the elevation of the first metatarsus and excessive shortening, two factors favoring metatarsalgia. Adding a phalangeal osteotomy can improve the radiological result, but it is very difficult to obtain satisfactory correction if the initial deformations are severe and associated. Rotation of the plantar fragment helps for better orientation of the articular surface of the first metatarsus but limits the correction of the metatarsus varus. Function is the basic objective of hallux valgus surgery and patient satisfaction is related solely to clinical symptoms.