Arthroscopic grafting of scaphoid nonunion - surgical technique and preliminary findings from 23 cases.

We report our experience with the arthroscopic treatment of 23 cases of scaphoid nonunion. We explain the surgical technique and describe the different steps needed to achieve bone union. We report our initial clinical and radiological results. This was a prospective non-randomized study. Inclusion criteria were a scaphoid nonunion without radiocarpal arthritis, without any time limit and without any selection as to nonunion location. Before the operation, patients underwent an X-Ray and CT scan or MRI. Schernberg's classification was used to evaluate the location of the nonunion. Internal fixation was performed with a screw or K-wires. Bone grafts were taken from the dorsal side of the distal radius using a T-Lok™ bone marrow biopsy needle (Argon Medical Devices, Plano, TX, USA). A CT scan was performed 3 months after the operation to determine whether union was achieved. Pain, strength and range of motion were evaluated before and after the operation. The patients' smoking habits were also documented. The average follow-up was 17.3 months (4-41). There were 20 men and 3 women with an average age of 26 years (17-63). The average duration of nonunion before the operation was 17 months (6-60). Based on Schernberg's classification, there was one type I, 12 type II and 10 type III nonunions. Wrist strength increased from 32 to 41kg. Union was obtained in all patients after an average of 4 months (3-12). Numerous treatments have been described for treating scaphoid nonunion: Matti-Russe, Fisk-Fernadez bone graft, vascularized bone graft, bone substitutes, etc. The success rate varies depending on the technique and study design. We have described an arthroscopic technique for treating scaphoid nonunion with very promising preliminary results. Arthroscopic debridement is needed to ensure good quality bone at the graft site, while preserving extrinsic vascularization. Traction is used during the operation to restore the scaphoid height, once debridement has been completed. Use of the compacted cancellous bone plugs adds stability to the nonunion site and helps to fill the defect. We have yet to encounter a case in which this technique cannot be used (other than the presence of radiocarpal or midcarpal arthritis), whether there is a large bone defect or the nonunion site is very proximal.

[Locking of the metacapophalangeal joint: report of four cases]. / Blocage de l'articulation métacarpophalangienne : à propos de quatre cas.

We report four cases of locked metacarpophalangeal joint. This is a rare and, sometimes, undiagnosed pathology. Locking of the joint is due to a conflict between the head of the metacarpal and one of the collateral ligaments. X-Rays may show an osteophyte or a malformation. Treatment varies from simple traction to surgery. Recurrence is rare.

Spontaneous rupture of the flexor digitorum superficialis tendon of the index and middle fingers: "the pen sign".

We report this case of a flexor digitorum superficialis (FDS) tendon rupture of the second and third fingers of the right hand in a 46-year-old patient. This rupture seems to occur under moderate stress. In this precise situation, the diagnosis was confirmed from the MRI data. Treatment was entirely conservative. However, the clinical presentation of the patient appeared quite original and so misleading to us that we reported this case here and developed the term "pen sign" to describe it. Considering this case, in order to reanimate thumb flexion transferring the fourth finger, FDS would appear to be entirely justified because of the lack of consequent difficulties on fine thumb index finger grasping used when holding pens or fine tweezers. It should also lead us in our everyday surgical practice to attempt to systematically repair the two index flexor tendons when they are damaged.

[Recent scaphoid fractures (within the first three weeks)]. / Fractures récentes du scaphoïde (moins de trois semaines).

Scaphoid fractures are the most common carpal fracture, accounting for 70 a 80% of all fractures of the wrist. The diagnosis of acute fracture of the scaphoid still continues to be missed despite an increasing improvement of imaging techniques. In fact, these fractures are mainly neglected because of minimal early symptoms or quick resolution of initial symptoms. X-ray analysis of acute fractures is rather difficult because of the irregular shape of the scaphoid and its overlapping with other structures. In case of doubtfull or negative initial radiographic views, a technetium 99 bone scan or MR imaging should be consisidered. These fractures occuring in the young and most active members of our society represents a population that doesn't have the patience for traditionnal immobilisation in cast. Thus patients with undisplaced fractures for whom early return to work or sport is a primary concern, percutaneous repair with cannulated screw fixation using fluoroscopy and even aided with arthroscopy represents an increasing option. Nevertheless, in thoses cases, cast immobilisation should always be first considered. If percutaneous internal fixation is the first choice in proximal pole fractures or fractures seen with a delay, in the other cases, it can only be advocated if internal fixation will provide a stable reduction. There is little controversy for the treatment of displaced unstable scaphoid fractures. Open repair and internal fixation with a screw represents the golden standard. Complex displaced or dislocated fractures are often comminuted and associated with bony defect. Accurate reduction may need to perform a bone graft. The ligamentous injuries should also be carefully repaired . Evidence of associated cartilagenous lesions must be asessed with precision, as they always jeopardize the end result.

[Biomaterials in an osteo-articular environment. Report of 129 anatomoclinical cases]. / Biomatériaux en milieu ostéo-articulaire. A propos de 129 observations anatomocliniques.

Actually, there is a range of biomaterials which are synthetic or metallic (or the both). They are employed as prosthesis (biostability property) or as bone graft (bioresorbability property). To understand the interactions between cells and such materials, we studied with human bone cellular cultures the cytologycal, immunohistochemical, cytogenetical and ultrastructural aspects of biomaterials in cell cultures. This paper concerns bioceramics like Pyrost, coral, biosorb, oxbone and polymers like polyethylene and silicones. The aim of this work is to evaluate the efficiency of some biomaterials. We found that porosity is primordial to promote biodegradation of bone substitutes. In fact, the biomaterials is integrated and lead to an osteoconduction, an osteoformation and finally an osteoinduction. Our observations show the implant resorption and ossification occurring in the matrix which penetrate it.

[Operative technique of arthroplastic resection of the three proximal bones]. / Technique opératoire de la résection arthroplastique des trois os de la première rangée.

Proximal row carpectomy is a controversial operative technique for difficult wrist problems. Based upon resection of bones, it represents in fact a reconstructive technique of a new joint. The majors steps of the technique are described in detail.

Roentgenographic examination of the wrist: a systematic study of the normal, lax and injured wrist. Part 1: The standard and positional views.

The precise appearances and relationships of the carpal bones have been studied in 53 normal wrists, 15 lax wrists, and 80 injured wrists, using frontal and lateral projections with the wrist in neutral and in various other positions. The findings are discussed and analysed.

Roentgenographic examination of the wrist: a systematic study of the normal, lax and injured wrist. Part 2: Stress views.

The standard and positional views of 53 normal wrists have been compared to views taken under stress. The stresses applied can be divided into normal and abnormal ones. All the injured wrists with pathological roentgenographic appearances were operated on and thus the findings confirmed. Roentgenographic examination of the wrist under stress appears to be a valuable and reliable diagnostic aid. Two types of laxity of the wrist and a radio-anatomical classification of wrist instabilities are defined.

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.

[Local rotational flap of the nail]. / Lokale Verschiebelappen des Nagels.

An original pattern of nail flap is described. It consists of a longitudinal band of lateral nail matrix and bed associated with its lateral wall. A vascular anatomic study with latex neopren infusion has been performed. The dorsal branch of the medial phalangeal artery could be shown to be the arterial pedicle of the flap. The venous system was shown to be concomitant. Eight nail autoplasties have been performed in eight cases, proving the reliability of the flap. It provides an interesting way of reconstruction of the nail in tumors, black longitudinal nail bands, posttraumatic and also post-infectious lesions of the nail.

[Fracture types and fragment dislocations of the scaphoid bone of the hand]. / Bruchformen und Fragmentdislokationen des Kahnbeins der Hand.

Fractures of the scaphoid bone are nowadays better known and treated. However, the types of fractures and fragment dislocations are not well described. The authors analysed 325 fresh and old scaphoid fractures and describe six basic types, clearly defined by location and direction of the fracture line. In fresh cases, the dislocation is mainly rotational. In older cases there is an additional bone resorption. The six basic types of fracture lines are demonstrated radiologically and the course of untreated cases is shown.

[Real-time ultrasonics: a method of hand imaging]. / L'échographie en temps réel: une méthode d'imagerie de la main.

Seventy-five surgically soft-tissue lesions of the hand were examined prospectively by real-time ultrasound and correlated with surgical and pathological findings. The normal ultrasonic anatomy of the hand is described. The use of real time sonography allowed a reliable diagnosis of the cystic or solid nature of soft-tissue tumors, an accurate estimation of their volume and their precise three-dimensional localization. Sonography facilitates the location of foreign bodies, and appears as a new promising technique for the evaluation of tendons.

Ultrasound examination of the hand.

Twenty-five surgically confirmed soft-tissue lesions of the hand were examined prospectively by real-time ultrasound. Use of sonography enabled a reliable diagnosis of the cystic or solid nature of soft-tissue lesions, an accurate estimation of the volume, and precise three-dimensional localization of the abnormality. Sonography also facilitated the location of foreign bodies. Assessment of anatomic relationships of these lesions to tendons and surrounding structures by real-time sonography during palpation, flexion, and/or extension also aided in the surgical approach.