A comprehensive approach including a new enlargement technique to prevent complications after De Quervain tendinopathy surgery.

The goal of this study was to evaluate the outcome of our surgical approach aimed at preventing complications following surgery for De Quervain tendinopathy. Our stepwise surgical procedure is described in detail. We reviewed 56 cases operated by a senior surgeon over 5years, and re-evaluated them with a minimum 15months' follow-up. Complications mentioned in the literature (poor wound healing, adhesions, nerve injury, incomplete decompression, tendon subluxation) were not present in any of the cases; the satisfaction rate was very high. Slight residual discomfort was noted in 16 cases. Among them, 13 had an associated pathology. In summary, the outcome after the comprehensive approach presented here is highly predictable. Properly applied, good to excellent results can be expected in most patients. Potential postoperative complications are effectively prevented. Some caution is needed in cases of associated pathologies.

Trophically and topographically functionalized silk fibroin nerve conduits for guided peripheral nerve regeneration.

Artificial nerve conduits (NC) can be used as an alternative to autologous nerve grafts to enhance the repair of small nerve gaps. Current NC lack adequate molecular and structural functionalities. Thus, we developed silk fibroin NC (SF NC) that were loaded with glial cell line-derived neurotrophic factor (GDNF) and nerve growth factor (NGF) and topographically functionalized with aligned and non-aligned SF nanofibers. The SF NC were produced from fully functionalized SF membranes on which initial experiments were performed. DRG (dorsal root ganglions) sensory neurons and spinal cord (SpC) motor neurons, both from chicken embryos, exhibited an augmented length and rate of axonal outgrowth parallel to the aligned nanofibers. In addition, glial cells from DRG proliferated and migrated in close association and even slightly ahead of the outgrowing axons. On the contrary, axonal and glial growth was slower and randomly oriented on non-aligned nanofibers. The DRG and SpC explants were also inserted into the lumen of the finished SF NC. The unidirectional orientation of axo-glial outgrowth from the explants evidenced the preservation of the trophic and topographical functionalities in the SF NC. Bioactive GDNF and NGF were released in vitro from SF NC over 4 weeks. Thus, the developed functionalized SF NC hold promise to enhance functional recovery of injured peripheral nerves.

The ECRL bone-tendon ligamentoplasty for chronic ulnar instability of the metacarpophalangeal joint of the thumb.

We report the results of a new bone-tendon ligamentoplasty for the reconstruction of chronic injuries of the ulnar collateral ligament at the metacarpophalangeal joint of the thumb. The mean follow-up period was 36 months. Using the Glickel grading system, seven patients had excellent results and one patient had good results. The mean loss of pinch strength was 10% compared with the contralateral thumb. The mean loss of motion at the MP joint was 8%. This technique successfully restores the desired long lasting stability while maintaining mobility of the thumb's metacarpophalangeal joint.

[MRI evaluation of carpal tunnel morphology after carpal tunnel release by a retinaculum lengthening technique]. / Magnetresonanztomographische Beurteilung der Karpaltunnelmorphologie nach Medianusdekompression mittels einer retinakulumverlängernden Technik.

AIM: The benefits of maintaining the pulley function of the flexor retinaculum in carpal tunnel release by lengthening or reconstructing it have been described. Quantitative MR imaging was used to investigate the morphological changes after open carpal tunnel release by such a retinaculum lengthening technique. METHOD: Ten patients had bilateral carpal tunnel MRI pre- and postoperatively. The MRI examinations were performed with a 1.5 Tesla imaging system and wrist coils. Carpal tunnel volume, carpal arch width, median nerve position and flexor tendon position in relation to the hamate-trapezial axis were recorded . RESULTS: Like other methods of carpal tunnel release with complete division of the flexor retinaculum, the retinaculum lengthening technique showed a significant postoperative increase of carpal tunnel volume. Carpal arch width increased only slightly. There was a significant palmar displacement of the median nerve but not of the flexor tendons. CONCLUSION: The findings support the hypothesis that maintenance of the pulley function of the retinaculum may lead to an early postoperative recovery of grip strength. In spite of some difficulties in application quantitative MR imaging may be a useful tool in evaluating the carpal tunnel morphology.

Minimally invasive fixation versus conservative treatment of undisplaced scaphoid fractures: a cost-effectiveness study.

This study compares the direct and indirect costs of conservative and minimally invasive treatment for undisplaced scaphoid fractures. Costs data concerning groups of non-operated and operated patients were analysed. Direct costs were higher in operated patients. Although highly variable, indirect costs were significantly smaller in operated patients and the total costs were higher in non-operated patients. In conclusion, operative treatment of scaphoid fractures is initially more expensive than conservative treatment but markedly decreases the work compensation costs.

[Interest in early active controlled mobilization and flexion following flexor tendon repair in zone 2]. / Intérêt de la mobilisation en flexion active protégée après suture des tendons fléchisseurs en zone 2.

INTRODUCTION: Primary repair of flexor tendons in zone II of the hand and early post-operative rehabilitation is no longer challenged. However, early rehabilitation methods vary from one unit to another. Although currents techniques such as of Kleinert's and Duran's have brought considerable improvements in functional outcomes, they do not allow early active motion of repaired flexor tendons. METHODS: A promising method of active controlled mobilization has been proposed by the Bordeaux Hand Unit and adopted by our rehabilitation unity since 1995. The aims of this method are: to avoid of proprioceptive inhibition linked to passive methods and prevention of adhesions. This method has been assessed by a prospective study of 22 consecutive patients with average follow-up of 11.8 months. RESULTS: Our rating was based on the Strickland scoring technique. 81% of good and excellent results were observed. Our score rates confirm the results published by others authors who have applied the same active protocols. The results observed in our series tend to confirm the advantages of early controlled active mobilization techniques and lead us to pursue their application in the future.

[Absence of the radial artery: case report and review of the literature]. / Absence d'artère radiale. A propos d'un cas et revue de la littérature.

PURPOSE OF THE STUDY: We report a case of complete unilateral absence of the radial artery in the forearm and reviewed the pertinent literature. CASE REPORT: An 18-year-old girl was admitted for multiple fractures after a car accident. She presented with a comminuted fracture of the left distal humerus, an open grade I fracture according to the Gustilo classification involving the right ulna and radius, a mediodiaphyseal fracture of the right femur and an open grade II fracture of the proximal and distal left tibia. After open reduction and internal fixation of the bones of the right forearm, she presented transient ischemia of her right hand, the radial pulse not being detectable at the end of surgery. An arteriography showed a complete absence of the right radial artery, which was thought to be caused by arterial thrombosis. Surgical exploration evidenced the complete absence of the radial artery. DISCUSSION: Absence of the radial artery is observed in radial preaxial hemimelia, in specific genetic and chromosomal disorders (Fanconi's anemia, Holt-Oram syndrome) and in association with other malformations. Unilateral absence of the radial artery has been described in association with other vascular abnormalities such as a larger anterior interosseous artery or the presence of a medial artery. Our case presented an isolated anatomical variation of the radial artery. This vascular anomaly was asymptomatic and discovered fortuitously. The incidence of this anatomic anomaly may be underestimated in the general population.

Proximal fractures of the fifth metacarpal: a retrospective analysis of 25 operated cases.

The clinical and radiological outcomes of 25 surgically treated fractures of the proximal third of the fifth metacarpal were retrospectively analysed. Many different methods of osteosynthesis were used. At follow-up after a mean of 3.3 years, 15 of 25 patients had no pain. Most patients regained a nearly full range of motion in the adjacent joints and more than 90% of the contralateral grip strength. X-ray signs of degenerative arthritis in the metacarpohamate joint were observed in 10 of 25 patients. Pain was found to be directly correlated with the presence of degenerative changes.

Cross stitch peripheral tendon repair: a mechanical comparison with core stitch techniques.

The purpose of this experimental study was to compare certain mechanical properties of a true epitendineal cross stitch suture with simple and double locking core tendon repairs. Using tensile strength and tendon lengthening until gap formation as measurement parameters, these three types of repair were tested in human flexor and extensor tendons from fresh cadavers. The peripheral cross stitch and the locked core repairs were found to have a greater lengthening capacity than the simple core suture, whereas the latter significantly better withstood axial load. Our findings established that, at least when used as a true epitendinous suture, the cross stitch technique alone was not suited for the repair of severed tendons. However, its design is particularly useful in preventing the suture site from potentially restrictive bulking.

Resorbable filament structures as a scaffold for matrix formation and axonal growth in bioartificial nerve grafts: long term observations.

Gaps, 10 mm wide, in rat sciatic nerves were bridged by bioartificial nerve grafts consisting of a silicone tube containing seven longitudinally placed synthetic filaments, which were expected to serve as a scaffold for axonal growth. The filaments were made of non-resorbable material (polyamide [Ethilon®]) or resorbable material (polydioxanon [PDS®], polyglactin [Vicryl®] or catgut). The purpose was to study the influence of resorbable materials on axonal regeneration and to choose, in the long term, the best filament material among the four. After 3 and 6 months, histological techniques were used to study the regenerated nerve structure. The total axon number in the nerve segment distal to the silicone chamber was counted in all specimens at 6 months. The histological findings were different depending on the filament materials; all the three resorbable materials showing significantly larger numbers of axons than polyamide (non-resorbable). All materials were covered with several layers of more or less flattened cells. These results indicate that resorbable filaments are superior to non-resorbable filaments when used as a scaffold inside a silicone tube, and polyglactin seems ideal for this purpose.

An experimental study of nerve grafting combined with silicone tubes in the rat model: Functional outcome and specificity of muscle reinnervation.

Bridging large defects in mixed nerves is still an unsolved problem in reconstructive microsurgery. Two main aspects may be distinguished: one is to obtain an appropriate substitute for the lost neural tissue, the second to direct fibers toward their previous end-organs with the highest possible specificity. In the present study, sural nerve block grafts were combined with enclosed gaps at one or both ends of the grafts. Functional outcome at the muscle level as well as the number of motor axons and their cross-sectional distribution were assessed after 3 months. The presence of a proximally placed tube was found to decrease significantly the maximal tetanic force of the tibialis anterior muscle, whereas a distally placed one tended to improve it. Morphological data from acetylcholinesterase histochemistry correlated poorly with functional results but they gave some clues about possible roles played by the chambers, according to their position relatively to the grafts. No definitive evidence for an improved regeneration by use of silicone tubes in addition to the conventional grafts could be demonstrated.

[Nerve compression syndromes of the extremities]. / Nervenkompressions-syndrome der Extremitäten.

Peripheral entrapment neuropathies occur in high frequency and present clinically with a wide range of variations. They need to be recognized early enough in order to initiate correct therapy and so to obviate serious nerve lesions and possible neurological sequelae. This paper overviews the essentials of the compression neuropathies as they are encountered in both upper and lower extremities. Pathomechanisms , pathogenesis, evaluation considerations as well as differential diagnosis and basic treatment algorithms are emphasized.

[Should carpal tunnel syndrome be operated in the patient older than 75 years?]. / Faut-il opérer le tunnel carpien chez le patient âgé de plus de 75 ans?

Retrospective study on a continuous series of 37 carpal tunnel syndromes by patients older than 75 years. Particular features of this age-group related to median nerve compression syndrome are given. Paresthesia and loss of cutaneous sensitivity were improved by surgical release of the LAAC respectively in 76% and 61% of cases; on the contrary, grip strength was found to be unaffected in the great majority of cases. Three patients were not improved at all: they all complained first of pain, EMG showed signs of denervation in every case and their mean age was higher than that of the entire group. Caution is mandatory with patients presenting with such a triad. In conclusion, even loss of tactile sense could be alleviated by surgical decompression in the very old patient.

[Injuries of 2 flexor tendons of Verdan's zone II. Multicenter Swiss study]. / Plaies des deux fléchisseurs en zone deux de Verdan. Etude multicentrique suisse.

We report on the results of a swiss multicentric retrospective study collecting 79 complete lesions of both FDP and FDS in zone II and reflecting some variations as well as common habits between the 7 centers when dealing with such settings. After primary repair, striking differences in averaged TAM and TPM motions were observed within the country; some imbalance as nevertheless achieved after tenolysis and other procedures. These proved to be necessary in a relatively high percentage of cases (33%). Thus, it appears that tenorrhaphy still remains a challenging surgical problem.