Strickland's hypothenar fat pad flap for revision surgery in carpal tunnel syndrome: Prospective study of 34 cases.

Several techniques are available for revision surgery of carpal tunnel syndrome (CTS) to preserve a gliding layer and protect the median nerve, including Strickland's pedicled hypothenar fat pad flap. The objective of this single-center, prospective study was to report the results of this flap after a minimum follow-up of two years. Between March 2006 and April 2014, 34 patients were enrolled (mean age 67 years) who had postoperative complications after the primary surgical release of CTS with nighttime paresthesia and/or neuropathic pain and abnormal electromyography findings. All patients were operated on using the same technique: neurolysis of the median nerve in the carpal tunnel with the nerve protected by a Strickland flap. The preoperative and postoperative evaluations consisted of questionnaires (paresthesia, neuropathic pain using the VAS and DN4 score, QuickDASH) and a clinical examination (grip strength, Weber two-point discrimination, atrophy of thenar muscles). Eighteen patients were reviewed in person and sixteen over the telephone. The outcomes were analyzed after at least 24 months' follow-up for all patients and 60 months for 13 patients. At 24 months postoperative, nighttime paresthesia was present in 3 of 34 patients and neuropathic pain in 2 of 24 patients. There was a significant reduction in pain on the VAS in all 34 patients (1.4 versus 6.4), the DN4 score (1.3 versus 5.7) and QuickDASH (60.7 versus 19.8). Of the 18 patients examined, grip strength improved from 72% to 86% of the opposite side (P<0.05), the mean static Weber was 6.4mm (versus 7.1mm preoperatively); nine patients had atrophy of the thenar muscles (versus eight preoperatively). The results observed at two years were maintained at five years' follow-up. This flap appears to improve the subjective neurological signs of CTS.

[The modified Lamberty and Cormack's flap for neuropathies of the ulnar nerve at the elbow]. / Le lambeau de Lamberty et Cormack modifié dans les neuropathies du nerf ulnaire au coude.

Surgical treatment of ulnar nerve syndrome at the elbow gives good results in the majority of cases but there are sometimes incomplete results or recurrences that can lead to iterative procedures. This iterative surgery is responsible for painful neurological sequelae often resistant to pharmacological treatments. In these selected resistant cases, we made the choice of a surgical treatment associating a neurolysis of the ulnar nerve and wrapping with a vascularized flap modified from Lamberty and Cormack. This retrospective study focused on six cases with an average follow-up of 30 months. The results showed an improvement in all patients, especially for the two criteria which best reflect the neuropathic pain: DN4 questionnaire and the visual analog scale of pain. Even if it is a short study, it commits us to continue to apply the principle of covering ulnar neuropathy at the elbow by a vascularized flap.

[Eight days of hand emergencies. Report of the audit carried out at the FESUM centers from June 3 to June 9, 2002]. / Huit jours d'urgences mains. Rapport de l'audit réalisé dans les centres FESUM du 3 au 9 juin 2002.

All the FESUM centers in France, Belgium and Switzerland were invited to participate in this prospective audit, during 1 week in June 2002. In these FESUM centers, the patients are operated by senior hand surgeons or trainees graduated with a microsurgical and a hand surgery University degrees. All acute hand disorders, requiring surgery or not, were to be included. For every case, a standardized form was to be filled. This form included 22 fields concerning the specificities of the patient, the circumstances of the accident, the lesions and initial treatment up to exit of the patient out of the Hand Center. Out of the 43 French centers, 38 (90%) participated in this study, but only 30% in the other French speaking countries. A total of 2360 forms were completed and analyzed, representing a mean of 8 forms per day center (6-147). The population was predominantly active men with a mean age of 31. Manual workers represented 41%, scholars 33%. Most of them came to the Hand Center with a non-specilized vehicle (86%). Emergency medical transportation was required in 130 cases (5.8%). A majority of the patients were treated on an outdoor basis. A 1-day admission concerned 29% of the patients, and 4.6% have been admitted on an indoor basis during several days. Work accident represented 28% of all the cases, while the majority was daily living (62%) or sport (15%) accidents. Closed trauma represented 50% of the cases. Amongst open trauma (974 cases), 862 were simple skin lacerations, 156 skin loss, 140 extensor tendon lacerations, 70 flexor tendon lacerations. A preliminary wound exploration had been performed in a non-specialized center in 124 cases (12%). Complete amputation of some part was observed in 33 cases. In 32%, the initial severity of the lesion led to expect some degree of definitive consequences. Some kind of anesthesia was required in 43% of the cases (local in 41%, troncular in 19%, plexical in 28% and general in 9%). A surgical procedure was performed in 45% of the patients. Microsurgery was necessary in 15%, six of which were replantations. The period between presentation to the Hand Center and treatment was less than 1 day in 95% of the cases. Time of treatment was considered to be delayed in 113 cases (5%). Following this audit, it is considered that the FESUM centers make provision for the care of 120,000 cases per year, 54,000 of which needing a surgical procedure. This may be a small part of the total load of emergency hand surgery throughout the country (generally estimated over 1.4 million), but compares quite favorably with other European studies. We believe that improvement relies essentially on a better orientation of the patients whether they need a simple skill or specialist skill treatment. An information leaflet about orientation of hand trauma has been distributed to non-specialized emergency centers. Hand surgery training must be reevaluated inside the universitary system to avoid a dramatic lack of hand surgeons within a few years. A new audit will be presented next year.

[Hand surgery training]. / La formation du chirurgien de la main.

Training of the hand surgeon HAND SURGEON A CONCEPT: The hand surgeon is supposed to be in charge of all the hand lesions regarding, skeleton, muscles, tendons, nerves and vessels. He has to be able to insure reparation and coverage of all of them. So he is involved in all the structures, which insure integrity and function of the hand. PURPOSE AND WAYS OF TRAINING: To obtain the asked ability, the hand surgeon training has to be global and sustained by two underlying surgical specialities: orthopedic surgery and plastic and reconstructive surgery. From 2000 after many years of dealings, a Right to the Title in Hand Surgery was born. This Right to the Title wants to be the formal recognition of the specific training of the hand surgeon. For the well-recognized ancient hand surgeons they need to be confirmed by one's peers. Now a day the hand surgeon has to satisfy to this specific training: Passed the complete training and exam of the Orthopedic or Plastic surgery board. Spent at least 6 months as resident in the other underlying specialty. Passed a microsurgery examination. Passed one of the four national Hand Surgery diplomas (DIU/Inter-Universitary Diploma). The examinations have been harmonized. A common formation is delivered regarding hand surgery, the way of examination is the same and the formation is 2 years long. The final exam is presented in front of board of examiners where a teacher of one of the other three national diplomas is present. Spent at least 2 years in a formative hand surgery unit, listed by the French College of Hand Surgeons, as senior surgeon. Those requirements are heavy to assume and need a heavy personal involvement. That seems to be necessary to have an ability level as high as possible. Emergency surgery practice is absolutely necessary in this training. All the 17 university formative hand surgery units listed by the French College of Hand Surgeons are members of the FESUM (European Federation of the Emergency Hand Units). Unfortunately it is non-sufficient to train the necessary number of hand surgeons needed in France today. So we try to obtain from the authority the formal recognition of a training period in private practice. Eleven out of the 28 hand units listed as formative by the French College of Hand Surgeons are in private practice and may be recognized as formative in the hand surgeon training. That needs to create an official agreement between university and private Units. This part of the training is yet accepted by the Right to the Title commission for a 6-month training period. But this needs a legal modification or adaptation of the private units legal status so they will be able to offer a quite equivalent conditions of training. Now a days 233 surgeons in France passed the Right to the Title. Among them, the oldest do not have emergency practice any more. So unfortunately, out of 1,400,000 hand injuries a year in France, only few are actually cared by hand surgeons. The emergency training needs at least a three to four senior surgeons team, operating and caring emergencies, 24 h a day, 365 days a year. They need to be surrounded by high-level technical facilities for this type of surgery. Only this type of unit may have a frequent severe hand traumatology practice, especially regarding microsurgery. But on the other hand a less complex hand unit operating only planed surgery and less complicated emergencies, may also be definitively formative. This only depends on the hand surgeon's qualification. It is only with a very demanding and high-level training program that our credibility as hand surgeon may be definitively established. The mainstay of this training is the combined action of the FESUM, the French College of Hand Surgeons and the DIU diploma. The Right to the Title formally confirms that training. For university or private unit, to be a member of the FESUM, must continue to guarantee a high level training regarding emergencies as in number as in complexity. We proposed as minimum level of practice (a year) to be a formative hand surgery unit: 10-15 hand and upper limb replantations; 25-30 very severe hand injuries (revascularization etc.); at least 1000-1500 hand surgery procedures.

[The sensory potential of the ring finger. The value of electromyographic diagnosis of carpal tunnel syndrome]. / Potentiel sensitif de l'annulaire. Intérêt dans le diagnostic électromyographique du syndrome du canal carpien.

Accurate diagnosis of carpal tunnel syndrome relies on electromyography. The usual criteria (sensory conduction velocity and motor latency) fail to identify 10% of cases of carpal tunnel syndrome. The sensory innervation of the ring finger (digit IV) is shared by the median and ulnar nerves. This anatomic feature is the basis of a novel electromyographic test: measurement of the sensory potential of digit IV by an orthodromic method with stimulation of the finger via a ring electrode and recording at the wrist. Analysis of the sensory potential of digit IV in 200 subjects with no median nerve compression afforded an invariably synchronised trace with no error of interpretation since it required no additional measurements. A study of 179 cases in 124 patients suspected of carpal tunnel syndrome showed pathological traces that could be graded into five levels of severity. Comparison with sensory conduction velocity and distal motor latency confirmed its validity and especially its usefulness in mild forms. The sensitivity of the test is excellent since false negatives are theoretically due to anomalies in the sensory innervation of digit IV, the reported occurrence of which varies widely (about 15%). The were no false positives. Its reproducibility, painlessness and sensitivity have led us to make this test compulsory in all patients suspected of CTS in our practice.

[Digital island autograft flaps in pulp defects. 18 cases]. / Le lambeau en îlot homodactyle dans les pertes de substance pulpaire. A propos de dix-huit cas.

Eighteen homodigital island flaps were performed for pulp defects over a period of two years in the Hand Emergency unit. Apart from one failure due to an incorrect indication, the results confirmed the excellent trophicity of the flap and its aesthetic appearance was appreciated by the 17 patients. Discrimination on Weber's test, the possibilities of advancement, and the fact that the size of the flap can be tailored to individual needs make it one of the most attractive alternatives in this type of indication. However, postoperative stiffness of the PIP joint is an almost constant disadvantage requiring an extension splint as soon as possible. The homodigital island flap is an elegant, minimally disfiguring flap indicated in pulp defects or distal palmar or lateral pulp amputations.

Arthroplasty of the rheumatoid wrist with Swanson implant. Long-term results and complications.

Seventy-five patients with Steinbrocker stage III et IV rheumatoid wrists underwent arthroplasty with Swanson implant. Sixty-two implants were reviewed at 5 years postoperatively. Functional criteria, namely pain, mobility and grip proved satisfactory in 66% of cases. Radiological examination revealed 23% radial implant fractures, 50% dislocated or fractured ulnar implants and 29% foreign body synovitis. This high rate of complication is disappointing given the encouraging initial results, and leads us to reconsider the appropriateness of such surgery in severe cases of rheumatoid wrist.

Paralysis of the ulnar nerve in cyclists.

Paralysis of the ulnar nerve in cyclists was first documented ninety years ago. Increase in the number of cyclists has revived interest in this pathology which occurs apparently only amateurs. The authors report three cases to add to the thirty-five previously reported cases of the literature. The onset of symptoms and their specific features are dealt with and the advantage of electromyography is emphasized. Evolution is spontaneously favorable in almost all cases. Cycling can be resumed with certain precautions once symptoms have completely subsided.