Surgical treatment of ganglions of the wrist by partial excision of the joint capsule. Report on 303 cases.

Histologic examination confirms the nonsynovial nature of cysts of the wrist, generally located on the dorsal surface. There is found a mucoid degeneration of the capsule and surrounding tissue with numerous neighboring microcysts. This is why it is irrational and usually ineffective to treat these cysts by crushing, aspiration or simple excision. These three methods result in frequent recurrences. One hundred and eighty cases were operated by excision of the cyst and all the neighboring involved tissue including in particular a disk 2 to 4 cm in diameter from the capsule of the joint. Almost all were cured, except for 3 recurrences, and any stiffness or weakness found was present preoperatively. A very detailed radiologic study (an average of 9 films per patient) made 3 years or more after operation showed there was no resultant carpal instability. In spite of its radial character this is the operation of choice in view of its efficacy and in cases where treatment is justified because of appearance or interference with function.

[The carpal tunnel syndrome (author's transl)]. / Le syndrome du canal carpien.

The carpal tunnel, a narrow space closed distally by the anterior annular ligament of the wrist, and containing flexor tendons and the median nerve, is the most frequent site of tunnel syndromes, compression in the canal leading to medium nerve lesion. The carpal tunnel syndrome usually affects women aged between 40 and 60 years, and presents typically as parasthesia of the fingers, mainly at night, in the regions served by the median nerve, sometimes associated with hypoesthesia and difficulty in movements. Motor disorders, particularly affecting the thumb, occur during the advanced stages. Electrical tests may confirm diagnosis and enable assessment of severity. More than half the cases are idiopathic in nature, presenting as hypertrophy of the annular ligament and fibrous thickening in the canal, but other forms may be observed including those due to wrist injuries, anatomical anomalies, rheumatic affections, or tumours. Associated disorders may be Dupuytren's disease, cubital nerve compression in Guyon's canal, or nodular tendinitis leading to a trigger finger. Surgical treatment is simple and should be employed when medical measures fail. The nerve should therefore be liberated if parasthesia persists after two or three local corticoid infiltrations. After a wide exploratory incision, the nerve is freed along the total length of the canal and up to the distal extremity of the forearm. Results are excellent, 98 p. cent of patients being relieved of their pain. Persistent motor disorders require surgical intervention before amyotrophy and muscle weakness develops.

Lateral digital rotation flaps in the treatment of forms of Dupuytren's contracture. 141 cases.

Severe contractures of the little finger can be corrected with a rotation flap. It has been used 141 times in a homogeneous series of 522 Dupuytren diseases. This flap brought to the metacarpophalangeal crease to the proximal phalanx can provide a skin lengthening of about 15 mm. The incision can be extended to the palm in order to remove the other fascial lesions. It was used mainly on the little finger (9 times out of 10). A single flap was usually made, but one may use two flaps from contiguous fingers, and even raise two flaps from the same finger. A comparative study with "Z" plasties was carried out. Out of 131 "Z" plasties with an average lack of extension of 126 degrees, the rate of improvement was 57%. The rotation flap was used in 141 cases with an average lack of extension of 140 degrees, and the rate of improvement was 79%. This flap seems to be an interesting procedure in the surgical treatment of severe Dupuytren contractures and seems more efficient than "Z" plasties.

[Pathological study of Kienboeck's disease]. / Etude pathogénique de la maladie de Kienböck.

Besides from diagnosed and undiagnosed fractures of the lunate, one should mainly remember in the pathogenesis of Kienböck disease anatomic propersities and particularly ulnar shortness and relation-ship between the radius and the lunate. These disorders cause an excessive stress on the lunate, producing osteomalacia. Our study of 133 wrists specifies the causative factors.

[Different treatment methods]. / Les différentes méthodes thérapeutiques.

Among all treatments, whether surgical or not, one should remember immobilization in a cast often useful but not sufficient and ulnar lengthening or radius shortening both aiming at widening the lunate cavity and restoring a normal anatomy to the wrist. These are the only valuable methods in the long-term follow-up (30 years or more).

[Shortening of the radius]. / Le raccourcissement du radius.

This procedure provides mainly a widening of the lunate cavity and removes excessive stress. The resection performed through a dorso-lateral approach must be 3 to 5 millimeters wide. From our 17 cases, 12 results were excellent, 2 good, 1 fair and 2 bad. This procedure is particularly indicated when the ulnar variance is important but may also be used when it is normal. It's quite justified when the lunate sharpe is normal but considering the excellent results obtained even when the lunate is deformed we have extended its indications except in cases of additional arthritis.