Arthroscopic arthrodesis of the thumb metacarpophalangeal joint: An anatomical feasibility study.

Conventional open arthrodesis for the thumb metacarpophalangeal joint provides excellent results but can incur complications. The aim of this study was to evaluate the feasibility and safety of resecting the thumb metacarpophalangeal articular surfaces via an arthroscopic approach or a percutaneous approach under fluoroscopic control. This cadaver study was carried out on 14 thumbs. Ten were operated on arthroscopically, and four percutaneously under fluoroscopic control. The efficacy and safety of the respective procedures were evaluated after dissecting soft tissue and opening the joint. Following 2 insufficient resections using the arthroscopic technique, the procedure was modified, providing satisfactory resection in 80% of cases overall and no tendinous or neurovascular lesions. Percutaneous resection under fluoroscopy did not yield satisfactory results, especially on the volar part of the metacarpal articular surface. We believe these results would justify comparative clinical studies to evaluate fusion of the thumb metacarpophalangeal joint with arthroscopic joint surface resection followed by percutaneous fixation. LEVEL OF EVIDENCE: IV.

Tendon transfer surgery for radial nerve palsy.

Palliative tendon transfer is an integral part of radial nerve palsy treatment. It can be considered in the first weeks when the possibility of nerve repair by direct suture or nerve grafting is not feasible or reasonable. Mostly, it is discussed secondarily when it is too late for nerve surgery and motor recovery cannot be expected, or after failure or incomplete recovery after nerve repair. The goal of tendon transfers is to restore wrist, finger and thumb extension. For wrist extension, the use of pronator teres is well accepted. The best tendon transfer for finger extension is debated. This can be restored doing a flexor carpi ulnaris (FCU), flexor carpi radialis or flexor digitorum superficialis (FDS) to extensor digitorum communis transfer. Regarding thumb extension and abduction, a palmaris longus (PL) or one FDS tendon to the rerouted extensor pollicis longus (EPL) transfer can be performed. If a transfer is done on the EPL without rerouting it, abduction can be restored by doing a tendon transfer to the abductor pollicis longus (APL) or an APL tenodesis. The different tendon transfer options are selected based on the surgeon's preference, and most importantly, discussed with the patients to define the objectives together. The transfer is chosen based on the clinical examination (high or low radial nerve palsy, tendon available for transfer like PL, wrist mobility) and based on the patient's needs and expectations (activities requiring the FCU, finger independence, independence of thumb extension or abduction). If the surgical rules and the postoperative instructions for rehabilitation are followed, tendon transfers for radial nerve palsy regularly produce very satisfactory results.

Palliative surgery for foot drop.

Dysfunction of the common peroneal nerve is the most common mononeuropathy in the lower limb and a source of significant disability for patients. The nerve can be damaged at various levels for various reasons (direct or indirect trauma, extrinsic compression, anatomical variant, endocrine, rheumatological, or neurological disease). Clinical evidence of foot drop with steppage gait is very typical. Conservative treatment should be considered as a first step (avoidance of the contributing factors, functional rehabilitation, foot drop brace ± injection). If properly conducted conservative treatment is not successful, palliative surgery is indicated: either tendon transfer using the posterior tibial tendon or ankle arthrodesis.

Indications for amputation after traumatic brachial plexus injury in adults: Case report and review of new prosthetic technologies.

Hand amputation can be discussed after traumatic brachial plexus injury when the patient's hand is non-functional, painful and/or insensitive. That indication is more common in English-speaking countries than in European or Latin countries. New prostheses are now on the market and can be used after hand amputation to improve the functional prognosis in well-selected patients. A 26-year-old male was involved in a road accident in January 2016. He had a traumatic brachial plexus injury and underwent nerve surgery to restore the biceps brachii and triceps brachii. One year after nerve transfer, his hand was insensitive and non- functional. After multidisciplinary consultation, it was decided to amputate his hand to replace it with a myoelectric prosthesis. Shoulder subluxation pain and complications associated with an insensitive and heavy arm were improved after hand amputation. Functional outcomes were improved with this revolutionary myoelectric prosthesis technique. The patient was able to use his prosthesis for many daily activities. Selective amputation indications after traumatic brachial plexus injury are a heavy and stiff arm with shoulder subluxation pain and an unusable claw hand. The patient's motivation must be high.

Palliative surgery: When? Which technique? Basic principles.

Palliative surgery aims to restore or compensate for the loss of a function for which nerve repairs are no longer or not feasible. It includes tendon transfer, tenodesis, arthrodesis and osteotomy techniques. Palliative surgery is based on several well-established principles that are essential to know. The purpose of this introductory chapter is to review the various basic principles before undertaking palliative surgery.

Hand injury without any deficit: Is systematic surgical exploration justified?

Out of 100,000 inhabitants, 700 to 4000 suffer a hand wound each year. Numerous hand wounds that may not have a clinically evaluated deficit, actually have damage to a major structure after surgical exploration in the operating room (OR). The aim of our study was to evaluate the incidence of major structure damage within a population of patients presenting a hand wound with no deficit on the clinical examination. Every patient older than 12 years, consulting for a wound deeper than the dermis with no clinical signs of major structure damage underwent surgical treatment and exploration of the wound under regional anesthesia in the OR. After each surgery, the surgeon filled out an anonymous study form describing the wound characteristics and the potential findings of major structure damage. Of the 145 wounds with normal clinical examination, we found that 58.6% had a major structure damaged. Given that damage to any major structure in the hand can lead to functional sequela, and the fact that a well-conducted clinical examination by a qualified hand surgeon is not sufficient to eliminate major structure damage, we recommend systematic surgical exploration of hand wounds, even when no clinical deficit is evident. LEVEL OF EVIDENCE III.: Type of sudy: diagnostic study.

Simplified internal fixation of fifth metacarpal neck fractures.

BACKGROUND: Fifth metacarpal neck fractures (boxer's fractures) are common injuries that contribute 20% of all hand fractures. Divergent percutaneous pinning (bouquet fixation) as described by Foucher has gained popularity but is challenging and at times arduous, as it requires the insertion of several slender K-wires into a narrow medullary canal. Here, we report on a simplified technique in which a single thick K-wire is inserted. TECHNIQUE: An 18/10 K-wire is bent at one end then mounted on a drill chuck. The incision is performed and the entry hole created using the K-wire, which is then advanced along the medullary canal. After reduction of the metacarpal head using the Jahss manoeuvre, the K-wire is inserted across the fracture site into the subchondral bone. Any persistent rotational malalignment is corrected by rotating the metacarpal around the K-wire. Immobilisation is by buddy taping covered by a resin guard. METHODS: We collected follow-up data for 30 patients treated using our technique, at a mean age of 32 years. RESULTS: 90 days after surgery, the fracture was healed in all patients. No patients had rotational malalignment. Mean operative time was 14minutes. No complications were recorded. DISCUSSION: The use of a single thick K-wire proved simple, effective, reproducible, and rapid. No rotational malalignment occurred. This technique is faster and easier to perform than divergent pinning with multiple K-wires. CONCLUSION: This technique can be used to treat fifth metacarpal neck fractures.

Two-stage extensor tendon graft using the Paneva-Holevitch procedure: A new technique.

Reconstruction of the extensor tendons remains a therapeutic challenge. Tendon transfers and grafts are a potential source of morbidity at the donor site, and the graft stock is limited. In the index finger, the tendon of the extensor indicis proprius can be anastomosed to the tendon of the extensor digitorum, and then the extensor digitorum tendon turned over after being cut at the forearm. We assessed the feasibility of this reconstruction on 12 upper limbs from 6 cadavers and we report the case of a 24-year-old patient who suffered destruction of the extensor apparatus in the index and middle fingers. For the cadaver study, in each case, the tendon could be moved onto the proximal interphalangeal joint, after having done an anastomosis downstream of the extensor retinaculum. The mean graft length was 13cm (9.7-15.2). This method was used in one clinical case with an excellent outcome. This is a simple technique that is without consequences since the tendons used are already cut, therefore saving a tendon graft. This technique should be part of our therapeutic arsenal.

Accessory extensor pollicis longus: A rare tendon anomaly.

This report provides a complete review of a rare anatomical variation, the accessory extensor pollicis longus (EPL) tendon and its clinical significance. We will describe a case of an asymptomatic accessory EPL that was found incidentally during surgery with a tendon located in the fourth extensor compartment. Pulling on it induced extension of the thumb interphalangeal joint. Very few cases of accessory EPL have been previously reported with various muscle origins and tendon insertions. In the literature, three symptomatic cases of accessory EPL were reported with a tendon running in a compartment other than the fourth. Although this variation is asymptomatic in most cases, knowledge of its existence might be useful in routine procedures to avoid inadvertent tendon damage, or during tendon repair.

Short, Medium and Long Term Complications After Total Anatomical Shoulder Arthroplasty.

Total shoulder arthroplasty (TSA) is an effective approach for the treatment of a variety of clinical conditions affecting the shoulder, including osteoarthritis, inflammatory arthritis and osteonecrosis, and the number of TSA implanted has grown exponentially over the past decade. This review gives an update of the major complications, mainly infections, instability and loosening, encountered after TSA, based on a corpus of recent publications and a dynamic approach: The review focuses on the causes of glenoid loosening, which account for 80% of the complication, and underlines the importance of glenoid positioning in the recovery of early shouder function and in the long term survival rate of TSA.

Shoulder Arthroplasty Imaging: What's New.

BACKGROUND: Shoulder arthroplasty, in its different forms (hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty) has transformed the clinical outcomes of shoulder disorders. Improvement of general clinical outcome is the result of stronger adequacy of the treatment to the diagnosis, enhanced surgical techniques, specific implanted materials, and more accurate follow up. Imaging is an important tool in each step of these processes. METHOD: This article is a review article declining recent imaging processes for shoulder arthroplasty. RESULTS: Shoulder imaging is important for shoulder arthroplasty pre-operative planning but also for post-operative monitoring of the prosthesis and this article has a focus on the validity of plain radiographs for detecting radiolucent line and on new Computed Tomography scan method established to eliminate the prosthesis metallic artefacts that obscure the component fixation visualisation. CONCLUSION: Number of shoulder arthroplasties implanted have grown up rapidly for the past decade, leading to an increase in the number of complications. In parallel, new imaging system have been established to monitor these complications, especially component loosening.

Surgical repair of massive rotator cuff tendon tears: Autologous quadriceps tendon graft versus arthroscopic repair.

INTRODUCTION: Massive rotator cuff tear repair results are variable. The main purpose of this study was to compare functional outcome between two procedures: open repair by autologous quadriceps-patella tendon patch, and arthroscopic suture. The study hypothesis was that there is no significant difference in results between the two techniques. MATERIAL AND METHODS: A retrospective study included all patients younger than 70 years operated on from 1995 to 2013 for massive rotator cuff tear. Exclusion criteria comprised history of dislocation, fracture or surgery or osteoarthritis in the affected shoulder, and infra- and supra-spinatus fatty degeneration equal to or greater than stage 3. Two consecutive groups were distinguished: group 1, from 1995 to 2003, comprised 23 patients (24 shoulders; mean age, 55.8 years) treated by open repair using quadriceps tendon autograft; group 2, from 2003 to 2013, comprised 27 patients (29 shoulders: mean age, 60.3 years) treated by arthroscopic repair. RESULTS: Preoperatively, mean Constant score was 42.9 in group 1 and 45.7 in group 2 (P=0.36), pain score 5.5/15 and 7.6/15 (P=0.08), strength 3.0kg and 2.4kg (P=0.30), and subacromial space 6.3 and 6.7mm (P=0.05), respectively. At respectively 58 and 55 months' mean follow-up, Constant score was 71.1 in group 1 and 71.8 in group 2 (P=0.086), pain 11.9/15 and 12.7/15 (P=0.76), gain in strength 1.4kg and 2.3kg (P=0.0006), and subacromial space 7.1mm and 6.3mm (P=0.29), respectively. The complications rate was 70% in group 1 and there were no specific complications in group 2. CONCLUSION: Functional improvement was significant and comparable between the 2 groups. Quadriceps tendon harvesting was associated with high morbidity, but the technique increased subacromial space. LEVEL OF EVIDENCE: IV, retrospective, single-center.

[Nerve injuries associated with distal radius fractures]. / Lésions nerveuses associées aux fractures de l'extrémité distale du radius.

Nerve damage is a common complication of distal radius fractures. It may be a result of the injury event or be iatrogenic. It is the source of disability and potential handicap. There is little published data on this topic and no study has validated the strategies needed to prevent or manage these nerve-related complications. There is no consensus on treatment. Prevention requires a good knowledge of the various surgical approaches and rigorous fracture fixation technique. The objective of this article is to take stock of recent data from the scientific literature.

A rare complication of scaphoid nonunion: Multiple flexor tendon lesions. A case report and review of literature.

This case report describes a patient who presented with a complete rupture of the flexor pollicis longus (FPL) tendon and partial rupture of the flexor digitorum profundus of the index finger, secondary to scaphoid nonunion. This is a rare, late complication that deserves to be described because of the potential diagnostic confusion with anterior interosseous nerve palsy. No case has been reported since 1999 in the literature. The mechanism was an attrition rupture due to sharp osteophytes. The scaphoid osteophytes were removed and the FPL was repaired by tendon transfer. The results were satisfactory at the last follow-up.

Endoluminal minimally invasive surgery for chronic exertional compartment syndrome: a new technique.

INTRODUCTION: Fasciotomy is the usual treatment for chronic exertional compartment syndrome of the lower limb. For esthetic reasons, minimally invasive techniques have been developed but can generate complications. Herein, we report the use of the KnifeLight during minimally invasive anterior and lateral compartment release in view of reducing these complications, within a feasibility study. MATERIAL AND METHODS: This study was conducted on four cadavers (eight legs) and then an athletic patient (two legs). RESULTS: The technique was carried out on all cases with no complications. The patient's result was excellent. DISCUSSION: The KnifeLight can be used to perform a fasciotomy of the leg's anterior and lateral compartments. It seems to provide the operator with additional safety compared to other minimally invasive techniques. CONCLUSION: This is a simple, reliable, and reproducible technique that deserves to be better known.

[Unusual rupture of a flexor profundus tendon in a rock climber]. / Rupture atypique d'un tendon fléchisseur profond chez un grimpeur.

Injuries of the flexor pulleys are common in rock climbers. Ruptures of the flexor profundus tendons are less common and take place almost exclusively in zone I at the level of the distal phalangeal insertion of the tendon. We report the case of a 48 years old rock climber who sustained an uncommon complete rupture of the flexor profundus tendon of the long finger during a monodigital grip. The tear was localized in zone III, immediately distal to the distal edge of the carpal tunnel. Tendon repair by direct suture followed by early active mobilization led to a satisfactory result. To the best of our knowledge, this is the first description of this type of injury in a rock climber.

Novel approach for posttraumatic panarthritis of the wrist using a pyrocarbon interposition arthroplasty (Amandys(®)): Preliminary series of 11 patients.

OBJECTIVES: In case of posttraumatic radiocarpal destruction, failure of first row carpectomy or partial arthrodesis, there are two options, total prosthesis of the wrist or panarthrodesis. Both solutions have limitations. The aim of our study was to evaluate an alternative therapy: interposition arthroplasty with pyrocarbon implant at follow-up of minimum 6months. METHODS: This is a retrospective monocentric study with clinical and radiological evaluation. This study includes 11 patients with a mean age of 55.2years. There were four failures of first row carpectomy, a failure of partial arthrodesis, a case of post-infection osteoarthritis, four cases of stage IV SNAC wrists and one siliconitis after a scaphoid implant. RESULTS: At the average follow-up of 11 months, pain was improved in nine cases. The average flexion was 36.5° and average extension, 35°. The average strength was 8.3kg. Two implant dislocations occurred, only one required second look surgery for implant replacement. However, in this patient, pain remained severe and required panarthrodesis. In another patient, a second panarthrodesis was performed for resistant pain. CONCLUSIONS: The interposition arthroplasty with pyrocarbon seems to give encouraging results as an alternative therapy. It gives satisfactory mobility, pain relief, but moderate strength. It has the advantages of a simple technique and does not preclude manual activities. A long-term validation is, of course, necessary.

[Ultrasonography for hand surgeons (lecture from the 46th meeting of French Society of Hand Surgery)]. / L'échographie pour le chirurgien de la main (conférence d'enseignement XLV(e) congrès de la Société française de chirurgie de la main).

Ultrasound examination is inexpensive, easily accessible and has numerous applications. Its diagnostic or even therapeutic use is developing in the context of hand surgery. The purpose of this work is to review the literature dealing with hand ultrasonograpy by recalling its physical basis and by showing the normal and pathological aspects of different structures and pathologies.