Immobilization protocols following trapeziectomy for osteoarthritis of the thumb: 2 weeks versus 4 weeks.

We compared the clinical outcomes of post-trapeziectomy protocols according to their duration. The main hypothesis was that there would be no significant difference in postoperative function whether immobilization duration was 2 or 4 weeks. The secondary hypotheses were that there would be no significant difference in postoperative pain, motion, or strength. 40 trapeziectomies were reviewed. Two weeks' postoperative commissural immobilization was systematic. Patients were then divided in two groups. For the first 20 patients (group I), immobilization stopped at 2 weeks. For the next 20 patients (group II) it was replaced by a splint for further 2 weeks. We compared mean pre- and post-operative (10-20 weeks) function (QuickDASH score), pain (visual analog scale - VAS), thumb opposition (Kapandji score) and strength (palmar pinch test) between the two groups. There was no significant difference between groups in postoperative values or in pre- to post-operative progression. The main hypothesis was confirmed: there was no significant difference in the postoperative function whether the immobilization was for 2 or 4 weeks. The secondary hypotheses regarding postoperative pain, motion and strength were also confirmed.

Organization of outpatient consultations at a hand surgery department in a French university hospital during the COVID-19 lockdown.

The COVID-19 health crisis has greatly impacted the organization of outpatient consultations, especially in hand surgery. Five reorganization stages were described during the crisis (from week 11 to week 21 in 2020): preparatory stage, 1st organizational stage, wait-and-see stage, 2nd organizational stage, and progressive return stage. The number of patients seen on-site decreased 64% in 2020 compared to 2019, while 78% of consultations were canceled. The logistics (teleconsultation, dedicated COVID-19 patient pathways) and human resources (sick leave, telework, reassignment to other departments) were adapted to ensure that patients who are usually seen in our hand surgery department received adequate care.

Comparison of a standard locking screw versus a double-threaded cortical compression screw for fixation of die-punch fragments in distal radius fractures with volar plating.

The aim of this study was to use a compression screw in the epiphyseal medial orifice of a volar plate to reduce and stabilize the die-punch fragment in distal radius fractures (DRF) undergoing open reduction and internal fixation (ORIF). The main hypothesis was that the range of motion (ROM) in supination would be poorer when a standard screw was used. Our case series included 19 patients with an average age of 59 years (24-91) (SD -35.32) (10 male patients and 9 females) who underwent ORIF of DRFs with a volar plate. Group I included 10 patients in which the die-punch fragment was fixed with a standard locking screw and group II included the 9 patients in which the die-punch fragment was fixed with an angle stable compression screw through both cortices. At the 6-month follow-up visit, the average ROM in flexion was 83% in group I and 81% in group II (-2.327 [-13.657; 8.960]), the ROM in extension was 91% and 89% (-2.754 [-13.410; 7.602]), the ROM in pronation was 100% and 102% (+3.178 [-5.242; 11.457]), the ROM in supination 100% and 97% (-3.171 [-10.825; 4.537]), the pain level was 0.6/10 and 1/10 (+0.106 [-0.809; 0.977]), the QuickDASH score was 8.1/100 and 17.17/100 (+5.790 [-2.934; 15.012]), the PRWE was 6.2/100 and 22/100 (+13.109 [4.416; 22.779]) and the grip strength was 95% and 74% of the contralateral side (-12.478 [-24.832; 0.538]). No complications, nonunions or revision surgery were reported in the two groups. One case of secondary displacement of the die-punch fragment occurred in each group. The main hypothesis was not proven. In conclusion, despite what several biomechanical studies have suggested, the use of double-threaded compression screws for die-punch fragment fixation in DRFs does not improve the clinical outcomes compared to standard locking screws.

Arthroscopic scapholunate dorsal capsulodesis: A 30-patient case series comparing postoperative splint immobilization versus immobilization and connected K-wiring.

The aim of this retrospective study was to compare the results of arthroscopic dorsal capsulodesis performed with or without temporary K-wiring to treat patients who had sustained scapholunate ligament injuries. Our case series included 30 patients with an average age of 37 years (range: 19-55) of whom 12 were female. Dorsal scapholunate capsulodesis was carried out in all patients. In 15 patients, splint immobilization only was used (group I). For the remaining 15 patients, supplementary scapholunate and scaphocapitate K-wiring was performed (group II). The outcomes, whether K-wiring was used or not, were not as good as the outcomes of other published studies. In our study, the reported QuickDASH score was on average higher than 20/100, pain score was higher than 2/10, grip strength was less than 70% of the contralateral side. There was one postoperative complication in the first group and three complications in the second group; five cases of DISI were reported in the first group and three in the second group. There were no significant differences between the two groups. Based on our findings, supplementary K-wiring is not necessary when a dorsal scapholunate capsulodesis is performed. The outcomes of our study were not as good as those of other published series, potentially due to a shorter follow-up and the more severe ligament injuries in our case series.

Ultrasound for the diagnosis of pyogenic flexor tenosynovitis.

The usefulness of ultrasound for making the diagnosis of pyogenic flexor tenosynovitis (PFTS) has been demonstrated. The primary goal of this study was to show that the diameter of the flexor sheath near the A2 pulley was larger when PFTS was present compared to the healthy contralateral finger. The secondary goal was to determine the reproducibility of these ultrasound measurements. Our series included 20 patients (12 men and 8 women) operated due to PFTS. The average age was 41.7 years old. The average diameter of the digital sheath measured near the A2 pulley on transverse and longitudinal ultrasound sections was 5.01mm (transverse 5mm, longitudinal 5.03mm) on infected fingers, and 4.17mm on healthy contralateral fingers. Reproducibility, as measured by the intraclass coefficient between transverse and longitudinal values, was 0.910 for infected fingers and 0.928 for contralateral fingers, thus was excellent. Our hypothesis was confirmed. A unilateral increase of more than 20% in diameter of the flexor sheath measured in transverse or longitudinal ultrasound sections near the pulley A2 contributes to the surgical indication when a patient presents with PFTS.

Comparison of proximal interphalangeal arthroplasty outcomes with Swanson implant performed by volar versus dorsal approach.

No study has compared the QuickDASH score after Swanson implant arthroplasty performed by dorsal versus volar approaches. This study compared the outcomes of PIP arthroplasties through a volar approach as described by Schneider versus a dorsal approach as described by Chamay by determining the QuickDASH score, pain and range of motion. Our series included 21 Swanson implant arthroplasty cases in 17 patients aged 62 years on average, among which 12 were females. A volar approach was performed in 9 cases (group I) and a dorsal approach was performed in 12 cases (group II). The difference between the average QuickDASH score preoperatively and at the last follow-up was strong (group I: -16.584; group II: -1.444), the difference between the average pain level preoperatively and at the last follow up was very strong (group I: -2.098; group II: -4.506), the difference in average PIP extension was not different from 0 (group: I -5.805; group II: -11.332), the difference in average PIP flexion was very strong (group I: -2.716; group II: -2.007). There were four recurrences of swan neck deformity (3 in group, 1 in group II) and one implant fracture in each group. For Swanson implant arthroplasty, the volar approach leads to better QuickDASH scores and PIP flexion compared to the dorsal approach. The volar approach did not improve PIP extension, or pain, and did not lead to dysesthesia.

Which surgery should be offered for carpal tunnel syndrome in a patient who was previously treated for recurrence on the contralateral side? Preliminary study of 13 patients with the Canaletto® implant.

There are no published studies on the management of carpal tunnel syndrome (CTS) patients who have already been operated for recurrent CTS on the contralateral side. The aim of this study was to evaluate 13 patients with CTS who underwent primary release using a Canaletto® implant. The 13 patients had all been operated for recurrent CTS previously. On the contralateral side, they all had subjective signs, and two of them already had complications. All were operated with the Canaletto® implant according to Duché's technique, in a mean of 20minutes. After a mean 19.3-month follow-up, paresthesia, pain, and QuickDASH scores were significantly improved, even in one patient who underwent revision at another facility. This preliminary study suggests that use of a Canaletto® implant as first-line treatment for CTS in patients who already underwent revision surgery on the other side is a simple and safe technique, without worsening of symptoms. These findings should be assessed with a prospective randomized controlled trial.

[Correction of an amyotrophic dorsal face of hands due to neurological disease with autologous fat cells transplant: An original case]. / Correction d'une amyotrophie de la face dorsale des mains d'origine neurologique par autogreffe de cellules adipocytaires : à propos d'un cas original.

INTRODUCTION: Autologous fat grafting allows the correction of many volume defects whether natural or post-traumatic. In hand surgery, the most common indication is the rejuvenation of the dorsal aspect of the hands. We present, here, an original case of amyotrophic hands lipofilling due to Charcot-Marie-Tooth disease. PATIENT AND METHODS: The patient had a bilateral and asymmetric amyotrophy of the intermetacarpal spaces responsible of a social handicap. Autologous fat grafting, according to Coleman's procedure, was done at the dorsal aspect of the two hands, three years apart. The adipocyte cells were taken on the medial side of the thighs, knees and on the abdomen. Five and eight years after the procedure, the results were evaluated with satisfactory results for the patient and the surgeon. RESULTS: Autologous fat grafting allowed the filling of the intermetacarpal spaces which last over time. The satisfaction rate was high in the patient and the surgeon. CONCLUSION: Autologous fat cells give an aesthetic correction of neurological amyotrophic hands.

Treatment of unstable distal phalanx fractures by extra-articular DIP pinning: A series of 12 cases.

Unstable distal phalanx fractures are typically treated by pinning of the distal phalanx or the distal interphalangeal joint (DIP). Complications include unstable fixation, K-wire migration, septic arthritis and osteoarthritis. To limit these complications, we wanted to explore the benefits of using locked extra-articular DIP pinning. The cohort consisted of 12 patients (mean age 36.3 years) who had an extra-articular (6 cases) or intra-articular distal phalanx fracture (6 cases). All patients were treated surgically with a construct consisting of two connected K-wires: one was placed inside the shaft of the distal phalanx and the other was placed perpendicular to the middle phalanx. The K-wires were removed after 1 month. After an average follow-up of 19.9 weeks, pain was 0.4/10 and the QuickDASH score was 7.41/100 on average. The range of motion was, on average, 30.0° less than the contralateral uninjured side for active flexion, 8.8° less for active extension, 32.0° less for passive flexion and 4.1° less for passive extension. The overall hand strength averaged 85.2% of the contralateral one. One secondary displacement occurred but there were no infections. In all, these findings suggest that locked extra-articular DIP pinning is a simple and reproducible surgical treatment for distal phalanx fractures. LEVEL OF EVIDENCE: IV.

Arthroscopic interposition in thumb carpometacarpal osteoarthritis: A series of 26 cases.

In 2011, we reported good results after a mean follow-up of 14 months for a series of 25 patients who underwent thumb carpometacarpal osteoarthritis surgery in which a poly-L-lactic acid implant was interposed arthroscopically. The aim of this study was to evaluate the outcomes after a longer follow-up. The new series consisted of 26 patients, whose average age was 60 years, operated with arthroscopy for the interposition of an implant made of poly-L-lactic acid in 12 cases and tendon interposition in 14 cases. After an average follow-up of 20 months, the pain assessed with a visual analog scale was on average 6.61/10 before surgery and 6.03/10 after, the QuickDASH score was 56.36/100 before and 53.65/100 after, grip strength was 15.34kg before and 12.8kg after, pinch strength was 3.7kg before and 2.18kg after, Kapandji thumb opposition score was 8.96/10 before and 8.26/10 after. The radiological stage did not change. We noted one case of type 1 complex regional pain syndrome and 12 poor results, 11 of which were reoperated by trapeziectomy. Given our results and the lack of published studies with a high level of evidence, the value of isolated arthroscopy with interposition in the surgical treatment of thumb carpometacarpal osteoarthritis remains to be demonstrated.

Minimally invasive osteotomy for distal radius malunion: A preliminary series of 9 cases.

UNLABELLED: The rate of malunion after distal radius fractures is 25% after conservative treatment and 10% after surgery. Their main functional repercussion related to ulno-carpal conflict is loss of wrist motion. We report a retrospective clinical series of minimally invasive osteotomies. The series consisted of 9 cases of minimally invasive osteotomies with volar locking plate fixation. All osteotomies healed. The average pain was 5.3/10 preoperatively and 2.1/10 at last follow-up. The mean Quick DASH was 55.4/100 preoperatively and 24.24/100 at last follow-up. Compared to the opposite side, the average wrist flexion was 84.11%, the average wrist extension was 80.24%, the average pronation was 95.33% and the average supination was 93.9%. With similar results to those of the literature, our short series confirms the feasibility of minimally invasive osteotomy of the distal radius for extra-articular malunion. TYPE: Case-series. LEVEL OF EVIDENCE: IV.

Comparison of distal interphalangeal fusion with and without joint preparation in cases of stage IV chondropathy.

UNLABELLED: The main complications in distal interphalangeal (DIP) fusion are non-union and hardware-related symptoms. The primary aim of this study was to show that joint preparation for DIP fusion is not necessary in cases of stage IV chondropathy. The secondary aim was to show that use of buried compression screws decreases the complication rate. This continuous retrospective study included two groups of DIP percutaneous arthrodesis procedures carried out with 1.8mm break-away compression screws: group 1 underwent joint preparation through a dorsal approach and group 2 underwent a percutaneous procedure without joint preparation. Group 1 included 15 patients (18 fingers) with a mean age of 65.3 years, representing nine cases of osteoarthritis, four cases of open trauma, one of gout, and one of rheumatoid arthritis. Group 2 included 18 patients (21 fingers) with a mean age of 58.9 years, representing 16 cases of osteoarthritis, one of rheumatoid arthritis and one of swan-neck deformity. Tourniquet time was longer in group 1 (61min) than in group 2 (24min). The amount of emitted ionizing radiation was not different between groups. Pain and QuickDASH scores were not improved in group 1 but they were in group 2. There was no difference in the fusion time. One non-union was observed in group 1. Our results show that joint preparation for DIP arthrodesis is unnecessary in stage IV chondropathy. No hardware-related complications were observed. LEVEL OF EVIDENCE: III.

Metacarpophalangeal joint arthroscopy in the fingers other than the thumb: Retrospective comparison of horizontal versus vertical traction.

The goal of this study was to compare the advantages and disadvantages of horizontal versus vertical traction by reviewing a small series of metacarpophalangeal (MCP) joint arthroscopy in the fingers other than the thumb. Our series included eight patients operated with traction placed along the axis of the operated finger. In four cases, traction was applied horizontally and in the other four, it was applied vertically. Arthroscopy was performed using dorsomedial and dorsoradial portals. The fluoroscopy unit was placed either vertically or horizontally as required. The average duration of patient set-up was 17.75min in the horizontal traction group and 32min in the vertical traction group. The average tourniquet time was 56.75min in the horizontal traction group and 71min in the vertical traction group. Horizontal traction required an additional procedure that can potentially compromise surgical asepsis. Vertical traction was less comfortable for the surgeon and horizontal placement of the fluoroscope increased the risk of compromised asepsis. Overall, arthroscopy of the MCP joint of the fingers other than the thumb is an easy technique, indicated for trauma-related and chronic lesions, which may be best performed with horizontal traction.

Can ring finger injuries be prevented by pre-weakened rings? Three clinical cases.

Prevention of finger trauma can be directly related to the manufacture of pre-weakened rings. We report on three clinical cases of finger injuries caused by pre-weakened rings. Lesions were less severe than conventional ring finger injuries, such as those caused by iron fences. Surgery was required in all three cases and chronic cold sensitivity was noted in one case. This small series advocates the imposition of a ring manufacturing standard at the European level. Given this lack of consensus, the idea is to prevent injuries by developing rings with intentional weak points that open automatically in case of trauma. These pre-weakened rings have never been subject to clinical study to demonstrate their potential safety.

The MetaHUS(®) fixation system versus pinning and plating in 5th metacarpal neck fractures.

The treatment of fifth metacarpal neck fractures is controversial. The aim of this work was to modify the intermetacarpal pinning technique with an external connector, and to compare the results of this modified technique to those of intramedullary pinning and locking plate techniques. Our series included 56 extra-articular fractures of the neck of the fifth metacarpal treated by intramedullary pinning (group A), locking plate Aptus(®) MEDARTIS™ (group B) and MetaHUS(®) Arex™ (group C); the last one consisted in intermetacarpal percutaneous pinning and connecting the pins externally. There were no statistically significant differences for all criteria except active mobility, which was less important for group B. In groups A and B, 6 complications were noted, in group C, one. Our results showed that blocked intermetacarpal K-wires is a technique of choice for the treatment of displaced fifth metacarpal neck fractures, not only because it is easy to assemble and to remove, but also because it allows immediate active mobilization.

Support for partial lesions of the flexor tendons of the fingers: a retrospective study of 36 cases.

The treatment of traumatic partial injuries of the flexor tendons of the fingers is seldom published. The only published clinical series states that the therapeutic approach depends on the existence or absence of a preoperative trigger. We hypothesized that the therapeutic attitude mainly depends on the percentage of the injured cross-section. Our retrospective series included 36 partial lesions of 31 fingers in 29 patients. The average age was 42 years, there were 19 men. We noted 8 lesions in zones I, 21 in zone II and 2 in zone III. The average percentage of the injured cross-section was 35% and ranged from 10% to 90%. If the lesion was less than 50% (29 tendons), a tangential resection was performed. If the lesion exceeded 50% (seven tendons), a direct suture was performed, supplemented by a running suture. At a follow-up of 34 months, the average pain on a visual analogue scale was 0.7. The average percentage of strength compared to the contralateral side was 93%. The Quick DASH score was 6.2. The range of motion averaged 214° with extremes ranging from 90° to 260°. We observed no cases of hypertrophic callus, neither through the MRI nor through the ultrasonography. Complications such as trigger finger, pseudoblocage or rupture were not observed. Based on our results, in case of partial injury of a flexor tendon, we propose to perform a tangential resection in cross-section lesions up to 50%, and a suture for those which exceeded 50%.

[Assessment of quality of pre- and postoperative information documents about carpal tunnel syndrome]. / Évaluation de la qualité de l'information en fonction du support utilisé avant et après chirurgie du canal carpien.

Before surgery for carpal tunnel syndrome, oral patient information is partially understood and accepted. The objective of this study was to perform a documentation for patients, as recommended by the High Authority in Healthcare (HAS), then to compare the effectiveness of oral information. Our series included 37 patients who received the same information: preoperative shower, pathophysiology, and postoperative instructions. The first 18 (group 1) received only oral information. The following 19 (group 2) received oral, written and visual information. The information in Group 2 followed the methodology of McClune: promoter (Department of Hand Surgery), organizing committee (two teachers from the School of Decorative Arts, two teachers of the School of Medicine), group work (five art students, five medical students), panel of experts (three surgeons, two occupational therapists, one physiotherapist). Four documents were developed: a booklet, a diagram, an animation, a poster. Satisfaction was higher in group 2. Understanding and memorization were better in group 2. Fifty-six percent of patients in group 1 would have liked a paper, 12.5% videos, none went on the Internet. Twelve and a half percent of the patients in group 2 went on the Internet, 18.8% would have liked videos. Our results show that in terms of carpal tunnel syndrome, the written and visual information materials for patients significantly improve the efficacy of oral information. These documents may be extended to other pathologies in Hand Surgery.

[Midcarpal fusion using break-away compression screw]. / Arthrodèse médiocarpienne par vis-broches à compression.

Indication of midcarpal fusion is SNAC or SLAC wrist grade 3. The main complication of circular plate (most common technique) is non-union. In this context, the purpose of our work was to propose the use of break-away compression screws to decrease the rate of non-union. Our series included ten patients. The fusion was fixed using two break-away compression screws (2mm diameter). No bone graft was used. As assessment, subjective (pain, Quick-DASH) and objective (strength, mobility) criteria were reviewed at follow-up. All the criteria were significantly improved after operation except mobility. Among the complications, we noticed one delayed bone-healing with a good outcome and a radiological consolidation. Midcarpal fusion by dorsal approach using break-away compression screws appears to us a technique of interest, not requiring a bone graft, with good cost effectiveness.

Experience of using the bioresorbable copolyester poly(DL-lactide-ε-caprolactone) nerve conduit guide Neurolac™ for nerve repair in peripheral nerve defects: report on a series of 28 lesions.

Synthetic nerve guides are occasionally used to repair nerve defects. The aim of the present work was to analyse the results of Neurolac™ use in a series of 23 patients. We operated on 28 nerve lesions located on various sites: arm (n = 1), elbow (n = 5), forearm (n = 4), wrist (n = 2), palm (n = 5), fingers (n = 11). Defects averaged 11.03 mm and were repaired using Neurolac™. After an average of 21.9 months' follow up (3-45 months), subjective criteria (pain, cold intolerance, Quick DASH) and objective criteria (strength, Weber and Semmes-Weinstein sensitivity tests) were compared with the contralateral side. Average pain score was 2.17/10. Cold intolerance was reported in fifteen cases. Quick DASH averaged 35.37/100. Grip strength averaged 64.62% of the contralateral side. As regards sensitivity, the difference between the two sides was 18.89 on Weber's test, and 46.92 on Semmes-Weinstein. Defect size did not affect the outcomes. We observed eight complications the most serious being two fistulizations of the Neurolac™ device close to a joint and one neuroma. Neurolac™ presents some advantages (resorption, semi-permeability, emergency use, tenseless repair) like other synthetic guides used for nerve regeneration and its transparency constitutes an added benefit. However, some difficulty in its handling and its expensiveness represent real disadvantages. Our results are not in favour of its use in repairing hand nerve defects.